Inquiry Search
Rec-ID | Code | Recommendation |
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REC325-4321 | 25 - Inquiry, audit, lessons management and after action review | The Inspector-General of Emergency Management recommends this report be returned to the Office of the Inspector-General of Emergency Management to monitor, evaluate, and report on progress and implementation of the recommendations that are accepted in whole or in part by government. |
REC325-4323 | 7 - Inter-agency communication | The Inspector-General of Emergency Management recommends Queensland Fire and Emergency Services adopt measures to achieve a common operating picture between deployed Queensland Fire and Emergency Services assets in disaster management operations by 1 November 2023. |
Rec-ID | Code | Recommendation |
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REC324-4298 | 37 - Funding | Housing and development funding options: That, to empower vulnerable people and communities to avoid significant impacts from flood as well as drive broader investment in adaptation, Government through NSWRA: |
Rec-ID | Code | Recommendation | |
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REC323-4281 | 37 - Funding | That the NSW Government allocate funding to the improvement of the Pitt Town Evacuation Route and other key possible evacuation routes in Sydney's northwest. |
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REC323-4270 | 37 - Funding | That the NSW Government consider entering into a service agreement with an organisation that has the resources and capacity to manage donations and activate quickly during natural disasters. |
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REC323-4272 | 37 - Funding | That the NSW Government ensure that flood affected individuals can continue to access financial assistance for as long as there is demonstrated need. |
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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. |
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REC323-4279 | 37 - Funding |
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REC323-4280 | 37 - Funding | That the NSW Government work with local governments to identify alternative routes to vulnerable roads, and that the NSW and Australian Governments fund the construction of these important routes to improve evacuation and access options in times of disaster. |
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REC323-4261 | 37 - Funding | That the NSW Government advocate through the National Cabinet to widen eligibility under the Disaster Funding Recovery Arrangements to allow local councils to build back better. |
Rec-ID | Code | Recommendation |
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REC313-2508 | 25 - Inquiry, audit, lessons management and after action review | Regularly reviewing these plans to ensure that they reflect the current operating environment. |
Rec-ID | Code | Recommendation |
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REC311-2505 | 25 - Inquiry, audit, lessons management and after action review | This report be returned to the InspectorGeneral Emergency Management to monitor, evaluate and report on progress and implementation of the recommendation(s) that are accepted in whole or in part by government. |
REC311-2504 | 25 - Inquiry, audit, lessons management and after action review | To enable entities in the sector to proactively work to achieve better results for the community, the recommendations and lessons of this review should be evaluated through the lessons management processes of entities involved in dam safety for their value and relevance. |
Rec-ID | Code | Recommendation |
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REC306-2423 | 37 - Funding | We recommend that, in the absence of stand-alone catchment management authorities, the Department of Infrastructure, Local Government and Planning as a matter of priority, establish what funding is reasonably required and complete all elements of the Brisbane River Catchment Flood Studies. |
Rec-ID | Code | Recommendation |
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REC297-1273 | 25 - Inquiry, audit, lessons management and after action review | That the State Emergency Management Committee allocates resources to reviewing all findings and recommendations in the Productivity Commission Report No. 74 relevant to Tasmania and, for those identified as relevant, actions taken and, if none, why not. |
REC297-1264 | 25 - Inquiry, audit, lessons management and after action review | That the Flood Warning Consultative Committee reviews flood classification levels in the Service Level Specifications with BoM specifically relating to flood level triggers on gauges. |
REC297-1259 | 25 - Inquiry, audit, lessons management and after action review | That DPIPWE examines the Forest Practice Code 2015 for relevance of its concepts to farming and other business activities near rivers, streams and naturally occurring dams and makes recommendations to Government accordingly. |
REC297-1258 | 25 - Inquiry, audit, lessons management and after action review | That DPIPWE examines the WMAwater report along with its own, analyses the differences, consults with the Forest Practices Authority and Environment Protection Authority, and proposes an appropriate course of action to Government. |
Rec-ID | Code | Recommendation |
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REC292-2370 | 25 - Inquiry, audit, lessons management and after action review | I recommend that the New South Wales Police Force undertake a formal assessment of alternatives to the TOU’s current soft-point ammunition to determine whether a more appropriate form of ammunition is reasonably available. |
Rec-ID | Code | Recommendation |
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REC286-2091 | 37 - Funding | Investigate the costs and benefits in enhancing the current Tsunami detection buoy network. |
REC286-1460 | 25 - Inquiry, audit, lessons management and after action review | Review seismic monitoring network alert systems to ensure emergency managers are on the contact lists. |
REC286-1442 | 25 - Inquiry, audit, lessons management and after action review | Review legislation relating to Fuel Stove only areas, Fire Permit System and Total Fire Bans to ensure appropriate incentives to modify individuals’ behaviour. |
REC286-2071 | 29 - Operational Health and Safety | Implement a social marking program to promote improved respiratory etiquette and hygiene. |
REC286-2095 | 37 - Funding | Investigate the costs and benefits of delivering a public education and awareness program. |
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. |
REC286-2055 | 29 - Operational Health and Safety | Personal protective equipment (masks, gowns, gloves, goggles) – review fit-testing vs fit-checking. |
REC286-2070 | 25 - Inquiry, audit, lessons management and after action review | Test the Biosecurity Act 2015. |
REC286-2093 | 37 - Funding | Investigate the costs and benefits in enhancing the current Tsunami warning arrangements with signage and audible warning systems at key exposed locations (e.g. Port Arthur and Kingston Beach). |
REC286-2092 | 37 - Funding | Ensure sufficient investment in controls across the PPRR spectrum with a focus on Prevention and Mitigation. |
Rec-ID | Code | Recommendation |
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REC285-2524 | 25 - Inquiry, audit, lessons management and after action review | The report recommends that Ambulance Tasmania investigate why the level of multiple responses had increased. |
REC285-2520 | 25 - Inquiry, audit, lessons management and after action review | The report recommends that Ambulance Tasmania investigate whether the additional resources in the North and North West regions were effective in reducing average response times. |
Rec-ID | Code | Recommendation |
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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. |
REC274-1405 | 37 - Funding | That the Department of Justice & Regulation broadens Budget Paper 3 response time measures to more comprehensively cover emergency responses to fires, rescues and other emergencies. |
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 |
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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. |
REC268-1422 | 25 - Inquiry, audit, lessons management and after action review | The Queensland State Disaster Management Plan is reviewed to: |
Rec-ID | Code | Recommendation |
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REC263-1092 | 29 - Operational Health and Safety | CFA and VICSES should: implement risk management processes within regions, districts, brigades and units to understand and manage the local risks associated with their volunteer workforces |
Rec-ID | Code | Recommendation |
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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. |
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. |
Rec-ID | Code | Recommendation |
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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. |
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. |
REC258-2560 | 29 - Operational Health and Safety | The Civil Aviation Safety Authority devolve to Designated Aviation Medical Examiners the ability to renew aviation medical certificates (for Classes 1, 2, and 3) where the applicant meets the required standard at the time of the medical examination. |
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. |
REC258-2556 | 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. |
REC258-2552 | 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. |
Rec-ID | Code | Recommendation |
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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: |
REC256-1558 | 37 - Funding | Funding to state and territory governments for community recovery should be provided as untied grants, with a transition period pending the development of a framework to assess community recovery costs. During the transition period, the Australian Government should continue to provide funding for community recovery through a reimbursement model. |
REC256-1557 | 37 - Funding | Where asset management plans at the local, state or territory level pre-identify and cost betterment of assets (improving asset resilience to natural disasters), the Australian Government should share 50 per cent of the betterment component of reconstruction costs following damage from a (eligible) natural disaster. |
REC256-1556 | 37 - Funding | The Australian Government should fund natural disaster recovery by: |
REC256-1577 | 37 - Funding | The Australian Government should develop a formula for allocating mitigation funding to state and territory governments on the basis of where such funding is likely to achieve the greatest net benefits, taking into account the future risks of natural disasters. This should be completed within five years and in consultation with state and territory governments. |
REC256-1560 | 37 - Funding | The Australian Government should: |
REC256-1559 | 37 - Funding | The Australian Government should gradually increase the amount of annual mitigation funding it provides to state and territory governments to $200 million. Initially, this funding should be distributed to state and territory governments in accordance with the allocation under the National Partnership Agreement on Natural Disaster Resilience. |
Rec-ID | Code | Recommendation |
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REC252-2563 | 37 - Funding | Western Australia Health should develop and agree with St John Ambulance a new funding model for emergency ambulance services focusing on standards, performance and allocation of risk |
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 |
REC252-2564 | 37 - Funding | Western Australia Health should collate and centrally monitor financial data including the cost to government of IHPT |
Rec-ID | Code | Recommendation |
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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 |
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REC245-2589 | 7 - Inter-agency communication | That TFS and Ambulance Tasmania work together to resolve problems around congestion, particularly during the fire season. |
REC245-2588 | 7 - Inter-agency communication | That Tasmania Police, Tasmania Fire Service (TFS), Ambulance Tasmania and State Emergency Services (SES) investigate ways of providing secure and confidential radio communications. |
REC245-2592 | 37 - Funding | That duplication of infrastructure be costed and taken into account when considering whether to proceed with the Whole of Government network. |
Rec-ID | Code | Recommendation |
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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. |
REC244-2631 | 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. |
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. |
REC244-2601 | 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. |
Rec-ID | Code | Recommendation |
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REC243-0835 | 37 - Funding | That the Government increase the budgets of all emergency services and community safety organisations, including: i. seeking Federal funding where appropriate (and assisting at no cost volunteer organisations with the grants application process); and ii. considering, with full public and cost benefit analysis, reviewing the effectiveness and efficiency of the Emergency Services Levy; and iii. consider including St John Ambulance Australia SA Ltd in the bodies to benefit from the Emergency services Levy if the funding of other Community Safety and Emergency services providers is improved in line with this recommendation. |
REC243-0838 | 37 - Funding | That the Government cease drawing from South Australia Police or other Community safety and emergency service budgets to fund the Directorate and instead merge its work and functions with the pre-existing South Australia Fire and Emergency Services Commission for zero total State and other Community safety and emergency service budget impact. |
Rec-ID | Code | Recommendation |
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REC242-2650 | 37 - Funding | That the Government resume funding for the helicopter surveillance service rather than by fixed-wing aircraft along Adelaide, South Coast and other high-risk coastlines during summer recreational periods for monitoring shark and other rescue situations, to bring the State back into line with interstate best practice. |
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: |
REC242-2648 | 37 - Funding | That the Government adequately fund Community Safety and Emergency Services budgets so that fire-bombing aircraft are available on call for rapid deployment throughout Autumn and Spring at short notice to bomb fires at the earliest and safest possible opportunity. |
REC242-2640 | 37 - Funding | That the Government cease drawing from South Australia Police or other Community safety and emergency service budgets to fund the Directorate and instead merge its work and functions with the pre-existing South Australia Fire and Emergency Services Commission for zero total State and other Community safety and emergency service budget impact. |
REC242-2637 | 37 - Funding | That the Government increase the budgets of all emergency services and community safety organisations, including: |
Rec-ID | Code | Recommendation |
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REC239-2726 | 20 - Role of police | That the Queensland Fire and Rescue Service enters into discussion with the Queensland Police Service regarding the possibility for the Queensland Police Service to assist with prosecutions that may arise out of fire safety matters. |
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. |
REC239-2757 | 20 - Role of police | That the Queensland Police Service executive team reassesses its preparedness to collaborate with other agencies to deliver a whole of Government approach to delivering community safety. |
REC239-2737 | 29 - Operational Health and Safety | That the workplace health and safety reporting system be reviewed to facilitate ease of reporting. |
REC239-2779 | 37 - Funding | That a new business case for Westgate project should be prepared by an independent party. |
REC239-2689 | 20 - Role of police | That, where appropriate, the Commissioner of Police appoints appropriately trained and experienced public service officers to appropriate roles in the disaster management system to support District Disaster Coordinators in their vital roles. |
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. |
REC239-2752 | 20 - Role of police | That the roll-out of the Queensland Police Service digital technology should take into consideration adopting and facilitating new processes including the police response to domestic violence. |
REC239-2753 | 37 - Funding | That the proposed Chief Executive Officer Portfolio Business be responsible for developing a cost attribution model for portfolio agencies, including the Queensland Police Service, as a priority. |
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. |
REC239-2750 | 20 - Role of police | That the Queensland Police Service: |
REC239-2683 | 37 - Funding | That the Office of Portfolio Business follows the same budget processes as other agencies. |
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: |
REC239-2748 | 20 - Role of police | That the Queensland Police Service considers adopting the broader use of ANPR in line with other Australian jurisdictions in consultation with the Privacy Commissioner. |
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. |
REC239-2682 | 37 - Funding | That a budget based on the desired functional accountabilities should be appropriated to the Portfolio Business as part of the Government budget process. |
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. |
REC239-2747 | 20 - Role of police | That as the Queensland Police Service moves to a digital platform the strategy around effective targeting and alternative automated number plate recognition models should form part of the design architecture. |
REC239-2776 | 25 - Inquiry, audit, lessons management and after action review | That the proposed efficiency review of the Queensland Police Service examine whether: |
REC239-2681 | 37 - Funding | That the funding model for the Portfolio Business is not based on fee- for-service arrangements or notional contributions from the operational services. |
REC239-2780 | 37 - Funding | That should the Westgate project proceed, that consideration must be given to opportunities to partner the investment with the private and public sectors. The business case should also consider alternative facilities such as Australian Defence Force sites. |
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. |
Rec-ID | Code | Recommendation |
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REC238-0802 | 25 - Inquiry, audit, lessons management and after action review | Review the NSW state-wide governance arrangements for flood risk management so that broader issues identified by this Review can be most effectively addressed. |
Rec-ID | Code | Recommendation |
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REC237-0834 | 37 - Funding | That the NSW Rural Fire Service apply for funding from the NSW Treasury for the development of a multi-agency business case for a BRIMS replacement that includes internal management, risk communication, community engagement capability and publishing activities on websites. |
REC237-0833 | 37 - Funding | That the NSW Rural Fire Service and the NSW Treasury explore ways to ensure that unspent hazard reduction funds be carried over to the next financial year in a timely manner and to ensure that hazard reduction funding has a seamless transition from one financial year to the next. |
Rec-ID | Code | Recommendation |
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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. |
REC236-2793 | 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. |
REC236-2792 | 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. |
REC236-2806 | 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. |
REC236-2805 | 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. |
REC236-2791 | 37 - Funding | The committee recommends that the government develop a process by which the ATSB can request access to supplementary funding via the minister. |
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 |
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REC234-2812 | 37 - Funding | In order to further build on the value for money review work being undertaken by the National Disaster Recovery Taskforce (on behalf of the Australian Government Reconstruction Inspectorate), the Australian National Audit Office (ANAO) recommends that the Taskforce: |
Rec-ID | Code | Recommendation |
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REC230-2835 | 37 - Funding | The committee recommends that the Australian Government direct an appropriate portion of the proceeds derived from the auction of spectrum to fund the allocation of 20 MHz of spectrum in the 700 MHz band for the purposes of a national public safety mobile broadband network. |
Rec-ID | Code | Recommendation |
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REC227-2849 | 20 - Role of police | I recommend that the AFP takes steps to ensure that there are on Christmas Island at all times appropriately trained AFP officers who have completed the National Police Search and Rescue Manager’s Course and that upskilling should be ongoing to establish a cadre of trained search and rescue personnel. |
Rec-ID | Code | Recommendation |
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REC222-1858 | 29 - Operational Health and Safety | The Ministers for Environment, Police, Child Protection and Emergency Services fund additional chaplaincy services, particularly for staff and volunteers based in rural and regional Western Australia. |
REC222-1852 | 29 - Operational Health and Safety | The Minister for Health immediately establish the road trauma counselling service to be funded by the Road Trauma Trust Account. |
REC222-1869 | 25 - Inquiry, audit, lessons management and after action review | The Ministers for Emergency Services, Environment and Police ensure their departments include provisions for regular external audits of invoices for payment in their next round of Employee Assistance Program contract negotiations. |
REC222-1850 | 29 - Operational Health and Safety | The Ministers for Emergency Services, Environment and Police ensure that their departments develop as a high priority a computer system for tracking their staff and the number of traumatic events they have attended over a particular period. |
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. |
REC222-1849 | 29 - Operational Health and Safety | Departmental chief executives of the Western Australia Police, Department of Environment and Conservation and the Fire and Emergency Services Authority should be made personally responsible for the psychological health (as a result of critical incident trauma) of their staff and volunteers. This obligation should be reflected in their performance agreements. |
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. |
REC222-1848 | 29 - Operational Health and Safety | The Western Australian Government amend current State occupational health and safety legislation so that it includes a definition for ‘health’ that includes psychological health. |
REC222-1859 | 29 - Operational Health and Safety | The Attorney General and the Ministers for Health and Mental Health fund their departments to establish a peer support program by the end of 2013 for their staff undertaking stressful tasks during a disaster or critical incident. |
REC222-1856 | 37 - Funding | The Ministers for Emergency Services, Environment and Police provide additional funds in the 2013-14 Budget so that the State’s emergency response agencies can implement a Psychological First Aid approach to preparing staff to deal with critical incidents and disasters, as is used in other Australian jurisdictions. |
Rec-ID | Code | Recommendation |
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REC217-1845 | 37 - Funding | The state government should provide core, ongoing funding to the responsible authority for the FloodSafe community education program. Funding should be provided for education about prevention, response and recovery phases and include information on rates notices about the height of particular floods. |
REC217-1842 | 37 - Funding | The state government review the current funding approach used for the operation, maintenance and upgrade of river gauges, with a view to improving the river gauge network. |
REC217-1814 | 37 - Funding | The funding model for works on levees and their ongoing maintenance be revised, to be primarily based on the beneficiary pays principle. The state government should give consideration to wholly funding, or contributing to, the initial upgrade of high priority levees to an agreed standard. The construction of any new public levees will be the subject of a cost‐benefit analysis to be undertaken by DSE and the public authority, and be supported by a floodplain management study. Levees deemed low priority will be wholly the responsibility of the beneficiaries. |
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. |
Rec-ID | Code | Recommendation |
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REC210-0743 | 25 - Inquiry, audit, lessons management and after action review | Seqwater should, in creating the new Wivenhoe and North Pine flood mitigation manuals, comprehensively consider: • the amount of discretion that is able to be exercised by the flood engineers and the senior flood engineers, and the description of the circumstances in which such discretion may be exercised • the circumstances in which it might be appropriate to release water in advance of an impending flood on the basis of forecasts from the Bureau of Meteorology • if strategies of the form of strategy W2 and W3 in Revision 7 are included in the revised manual, or any strategy defined as a ‘transition strategy’, when and how those strategies should be implemented • if the concept of ‘urban inundation’ is relevant to the operation of the dam, how it should be defined, and if the definition involves diverse concepts, how those concepts can be related back to the strategies, so that flood engineers can reach a clear understanding of their objectives and primary considerations • if the concept of ‘natural peak flow’ is relevant, how it should be defined. |
REC210-0738 | 25 - Inquiry, audit, lessons management and after action review | Seqwater should ensure that any future peer review process: • is co-ordinated by someone independent of those who wrote the report • entails the provision of all relevant information to the peer reviewers • permits sufficient time for the review • documents all contact between those whose actions are under review and the reviewers. |
REC210-0737 | 25 - Inquiry, audit, lessons management and after action review | The Department of Environment and Resource Management should ensure that an independent and appropriately qualified person immediately starts the task of reviewing the March flood event report to ensure that the review is completed before the start of the 2012/2013 wet season. |
REC210-0773 | 25 - Inquiry, audit, lessons management and after action review | The Department of Environment and Resource Management should prioritise dam safety audits according to risk. The risk assessment should be informed by criteria including: • structure and materials used in construction • age of the dam • time since last inspection • occurrence of a flood event since last audit and the size of that flood event • population at risk if the dam were to fail • experience and capability of dam owner • dam owner compliance history • time since last audit. |
REC210-0736 | 25 - Inquiry, audit, lessons management and after action review | Seqwater should ensure that proper support and oversight mechanisms are put in place around both the substantive and procedural aspects of drafting flood event reports. Seqwater should consider engaging consultants with expertise in the production of reports following significant events to advise on these mechanisms. Measures to be considered should include: • ensuring appropriate systems are in place to ensure the recollections of flood engineers and other parties are recorded immediately after the event, perhaps by engaging an external party to interview the flood engineers and other parties • ensuring that a methodology for writing the report is set out clearly in advance, in writing, and that the final report includes a statement of that methodology • putting in place systems to ensure that members of senior management have sufficient understanding of both the methodology and process by which the report is prepared to allow themselves to be satisfied that these are appropriate. |
REC210-0772 | 25 - Inquiry, audit, lessons management and after action review | Prior to each wet season, the Department of Environment and Resource Management should audit the compliance of each owner of a referable dam with the obligation to have an emergency action plan approved by the Queensland Government. |
REC210-0732 | 37 - Funding | Emergency Management Queensland should develop and implement a new formula for the distribution of its recurrent SES subsidy, which takes into account relevant factors including the size of a local SES contingent and the population, area and natural hazard risk profile of the local government area concerned. |
REC210-0726 | 25 - Inquiry, audit, lessons management and after action review | The Queensland Fire and Rescue Service should require that each region records in writing the results of its risk assessment undertaken as part of its annual review of its special operations functional plan. |
REC210-0762 | 25 - Inquiry, audit, lessons management and after action review | Seqwater should consider commissioning an investigation into the extent of cracking below the level of the upper gallery of Somerset Dam and the impact of any such cracking on the dam’s stability and, in turn, its operation. |
Rec-ID | Code | Recommendation |
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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. |
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 |
---|---|---|
REC207-2877 | 37 - Funding | Explore opportunities to re-phase investments in large scale projects and programs such as the Strategic Radar Enhancement Program, the NexGen Forecast and Warning System Products and the Improving Water Information Program. |
REC207-2893 | 37 - Funding | Explore options to obtain revenue from advertising on the Bureau’s website |
REC207-2892 | 37 - Funding | Apply a consistent cost-recovery model to all services delivered to state/territory fire agencies. |
REC207-2890 | 37 - Funding | Review and rebalance relative investment in long term climate modelling and medium-term seasonal outlook. |
REC207-2889 | 37 - Funding | Review level of investment in research activities to free up budget and reduce pressure on computing capacity |
REC207-2879 | 37 - Funding | Firm up approval processes and funding for any departures from provision of the basic product set |
Rec-ID | Code | Recommendation |
---|---|---|
REC206-1892 | 37 - Funding | The Committee recommends that the Australian Government allocate additional and continuing funding in the 2012–2013 budget to the Insurance Law Service to establish a consumer advisory position at the Financial Services Ombudsman. The position should be co-funded by the Insurance Law Service and the insurance industry. |
REC206-1891 | 37 - Funding | The Committee recommends that the Australian Government and relevant State and territory governments jointly allocate additional and continuing funding in the 2012–13 budget to the Insurance Law Service for the mobilisation of a temporary physical presence in areas of need following natural disasters. The service should be available to all persons in an affected disaster area and not subject to means-testing. |
Rec-ID | Code | Recommendation |
---|---|---|
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: |
REC205-1903 | 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: |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC199-0447 | 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. |
REC199-0453 | 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 |
REC199-0450 | 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 |
REC199-0446 | 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. |
REC199-0445 | 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. |
REC199-0418 | 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. |
REC199-0428 | 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. |
REC199-0458 | 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. |
REC199-0407 | 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. |
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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC189-2912 | 29 - Operational Health and Safety | The review team recommend that the safety case system be strengthened by including provisions for a design notification scheme along the lines of that under the British Offshore Safety Case Regulations. |
REC189-2911 | 29 - Operational Health and Safety | The review team recommend that: |
REC189-2907 | 29 - Operational Health and Safety | a) For the purposes of designing and implementing its regulatory activities, National Offshore Petroleum Safety Authority (NOPSA) should continue to identify priority hazards and risks and their underlying causes, in consultation with the NOPSA Advisory Board and stakeholders (see Theme 9, Stakeholder engagement). |
Rec-ID | Code | Recommendation |
---|---|---|
REC185-1931 | 37 - Funding | The committee recommends that the Commonwealth Grants Commission ensures that as part of the current redesign of its data request, state and territory governments are required to include their past insurance and reinsurance receipts for natural disaster insurance premiums. These data must be taken into account by the Commission in determining the states' GST share. |
Rec-ID | Code | Recommendation |
---|---|---|
REC177-3282 | 29 - Operational Health and Safety | If a risk assessment or compliance review is triggered by the happening of a predetermined event, specific consideration should be given to whether a ‘hold point’ should be introduced such that work must cease until the problem is resolved (and the subject of appropriate certification). |
REC177-3344 | 25 - Inquiry, audit, lessons management and after action review | There should be a review to determine whether it is appropriate to introduce a rigorous civil penalty regime and/or substantially increase some or all of the penalties that can be imposed for breaches of legislative requirements relating to well integrity and safety. |
REC177-3299 | 29 - Operational Health and Safety | Regulatory approval to rely on only one barrier should not be given unless (i) a proper risk assessment is carried out; (ii) exceptional circumstances exist; and (iii) risks involved are reduced to ‘as low as reasonably practicable’. The default position must be that well integrity must be assured. |
REC177-3281 | 29 - Operational Health and Safety | Wellbore gas bubbling should be regarded as a trigger for independent review of well integrity. Industry and regulators should identify and document other triggers. |
REC177-3295 | 29 - Operational Health and Safety | Wells drilled into hydrocarbon zones should be treated as live wells, with the potential to blowout unless a documented risk assessment establishes otherwise. |
REC144-3387 | 25 - Inquiry, audit, lessons management and after action review | In order that the ACT public can be reassured about the project management and financial planning in relation to the Fairbairn site as a proposed centralised accommodation facility for emergency services, the Auditor-General undertake a review of the project from a financial probity and project management perspective. |
REC177-3279 | 29 - Operational Health and Safety | Well construction and management plans, and drilling programs, should include provision for testing and verifying the integrity of all barriers as soon as practicable after installation. |
REC177-3294 | 29 - Operational Health and Safety | Perceived time and cost savings relating to any matters impacting upon well control should be subjected to rigorous safety assessment. |
REC177-3278 | 29 - Operational Health and Safety | Well construction and management plans should include provision(s) for reviewing the integrity of barriers at safety‐critical times or milestones, such as (i) prior to suspension involving departure of the rig from the platform; (ii) prior to re‐entry of a well after suspension; (iii) prior to removal of any barrier. |
REC177-3293 | 29 - Operational Health and Safety | If a dispute arises between a licensee and a rig operator in relation to a well control issue, and is not resolved between them, the matter must be raised with the relevant regulator before discretionary operations proceed. |
REC177-3378 | 25 - Inquiry, audit, lessons management and after action review | In view of the numerous well integrity problems in all of the Montara Oilfield wells, the Minister should commission a detailed audit of all the other offshore wells operated by PTTEPAA to determine whether they too may suffer from well integrity problems. |
REC177-3321 | 29 - Operational Health and Safety | Careful consideration must be given to equipment compatibility as part of well construction design. |
REC177-3288 | 29 - Operational Health and Safety | As soon as a risk of barrier failure arises, no other activities should take place in the well other than those directed to removal of the risk. |
REC177-3374 | 25 - Inquiry, audit, lessons management and after action review | The Minister should, as the JA for the offshore area of the Territory of Ashmore and Cartier Islands, undertake a review of PTTEPAA’s permit and licence to operate at the Montara Oilfield. |
REC177-3364 | 37 - Funding | The funding arrangements that support the National Plan should be reviewed to ensure that the costs associated with both preparedness and response capability are equitably shared between the shipping and offshore petroleum industries. |
REC177-3303 | 29 - Operational Health and Safety | Tracking and analysis of cementing problems/failures should occur to assess industry trends, principal causes, remedial techniques and so on. |
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: |
Rec-ID | Code | Recommendation |
---|---|---|
REC170-0057 | 7 - Inter-agency communication | SEMC and EM WA should: ensure that agencies have a common or compatible crisis information management system in place |
REC170-0062 | 25 - Inquiry, audit, lessons management and after action review | Agencies should: annually assess their capability to respond to emergencies and take measures to address any shortfalls |
Rec-ID | Code | Recommendation |
---|---|---|
REC165-0085 | 20 - Role of police | The Commissioner of Police, through a dedicated Assistant Commissioner (supported by a cohort of Assistant Commissioners to ensure adequate coverage), be assigned responsibility for overall control of each natural Disaster Management event in Queensland as the preferred arrangement. |
REC165-0090 | 7 - Inter-agency communication | The SDMG lead an initiative to integrate and/or inter-connect all of the control centres involved at all levels of the Disaster Management system in Queensland as part of the project to integrate State communications. |
Rec-ID | Code | Recommendation |
---|---|---|
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 |
---|---|---|
REC162-3016 | 37 - Funding | ESWG recommends investigation of options to fund NGERAC’s on-going activities including through AEMO’s funding model. |
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 |
---|---|---|
REC159-3058 | 25 - Inquiry, audit, lessons management and after action review | ACTAS should improve patient care processes by: |
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. |
REC158-3451 | 37 - Funding | That port/channel managers should be able, within the general context of the pricing/cost recovery arrangements established under the Port Services Act 1995 and pricing determinations made by the Essential Services Commission, to recover the reasonable costs of meeting their statutory obligations (as per recommendation 26) through charges for prescribed service applied to port users. |
REC158-3450 | 37 - Funding | That emergency services are responsible for funding the development of the emergency services marine emergency response capacity/capability to meet their statutory obligations. |
REC158-3449 | 37 - Funding | That port/channel managers are responsible for funding the preparation of marine emergency risk assessments and marine emergency response arrangements and ensuring the availability of identified marine resources in support of response to a marine emergency, to meet their statutory obligations. |
Rec-ID | Code | Recommendation |
---|---|---|
REC149-3135 | 29 - Operational Health and Safety | The initial acceptance of a new facility Safety Case should be in conjunction with inspection of a facility upon commencement of operations. |
REC149-3128 | 29 - Operational Health and Safety | National Offshore Petroleum Safety Authority (NOPSA) should develop guidelines in consultation with stakeholders to provide clarity and consistency to the process which ultimately will result in better safety outcomes. |
REC149-3147 | 29 - Operational Health and Safety | As all stakeholders have responsibility for safe outcomes, decisions regarding target subjects for safety promotion need to have the support of all stakeholders including NOPSA and the workforce. Industry, which ultimately has the responsibility for managing risk as well as funding the promotion, should take a leadership role in implementation. |
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. |
REC149-3144 | 29 - Operational Health and Safety | The Safety Case proponent should be allowed some flexibility to involve appropriate experience matched with the proposed workforce competencies to enable the Safety Case to be developed with value adding processes. Subsequent to the hiring of the workforce Final Government Response Offshore Petroleum Safety Regulation Inquiry and 2008 Review of NOPSA Operational Activities and preferably before the commencement of operations a review of the Safety Case should take place with the new workforce to ensure they understand the accepted Safety Case, its risks and Safety Management Plan. |
Rec-ID | Code | Recommendation |
---|---|---|
REC148-3189 | 37 - Funding | The ANAO recommends that, to ensure that grant conditions are satisfied, EMA enhance procedures to monitor the progress of projects and follow up those behind schedule or not fulfilling funding agreement requirements. |
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 |
---|---|---|
REC145-3236 | 37 - Funding | The Committee recommends that the Australian Government provide funding support for the ongoing activities of the Australian Coastal Alliance in providing a national information and communication interface between research organisations and local government authorities and other coastal stakeholders. |
REC145-3232 | 37 - Funding | The Committee recommends that the Australian Government give consideration to establishing a separate funding program for infrastructure enhancement in coastal areas vulnerable to climate change. Such funding should be provided according to a formula requiring contributions, either financial or in-kind, from state governments and relevant local government authorities. |
REC145-3207 | 37 - Funding | To further enhance Australia’s disaster mitigation, preparedness, response and recovery arrangements in the event of possible major coastal disasters, the Committee recommends that the Australian Government establish a grants program, the Coastal Natural Disaster Mitigation Program, to fund natural disaster mitigation projects in the Australian coastal zone. |
REC145-3200 | 37 - Funding | The Committee recommends that the Australian Government: |
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 |
---|---|---|
REC143-3581 | 37 - Funding | That, in tandem with their consideration of local government cost sharing arrangements under WANDRA (refer Recommendation 1), the Fire and Emergency Services Authority and Main Roads Western Australia also establish ‘exceptional circumstances’ criteria to provide for additional assistance to local government where it may be warranted in order to avoid undue financial pressure caused by delays to secure reimbursement. |
REC143-3576 | 37 - Funding | That Fire and Emergency Services Authority of Western Australia and Main Roads Western Australia, in consultation with the Western Australian Local Government Association, investigate a more equitable means of calculating the local government contribution to road and infrastructure restoration costs. In particular consideration should be given to regulations applying in the eastern states i.e. Queensland. |
REC143-3589 | 37 - Funding | That consideration be given to the establishment of a ‘Heritage Reserve Fund’ that might underwrite urgent initial repairs to private heritage listed properties. |
REC143-3586 | 37 - Funding | That the ‘opportunity cost’ for Local Authorities in meeting the 25% contribution to the restoration of eligible public assets damaged by a natural disaster event be considered when FESA and Main Roads Western Australia, in consultation with Western Australian Local Government Authority, investigate a more equitable means of calculating the local government contribution to road and infrastructure restoration costs as recommended in Recommendation 1. |
REC143-3582 | 37 - Funding | That the Department of Treasury and Finance, in consultation with FESA, consider alternative funding arrangements to alleviate the need for FESA to ‘underwrite’ NDRA costs during the year. |
Rec-ID | Code | Recommendation |
---|---|---|
REC140-3552 | 37 - Funding | Department of Health and Human Services (DHHS) to fund 3 Full-Time Equivalent (FTE) Senior Registrar positions at the Royal Hobart Hospital (RHH) for the Tasmanian Medical Retrieval Service (TMRS). One registrar in the Anaesthesia Department, one in the Intensive Care Unit and one in Emergency Department is proposed. |
REC140-3568 | 37 - Funding | The State Medical Retrieval Cost Centre (TMRS and NETS) be formed and be supported by the appropriate administrative and resource accountant expertise. This cost centre should be placed with those responsible for its management. |
REC140-3567 | 37 - Funding | A uniform retrieval charge to the region of referral should be considered. This should be independent of the mode of transport used. |
REC140-3554 | 37 - Funding | DHHS fund the equivalent of 2 FTE Consultant positions for retrieval duties (1.5 FTE existing, 0.5 FTE new) |
REC140-3553 | 37 - Funding | RHH Neonatal Emergency Transport Service receive DHHS funding for a Senior Registrar to assume the responsibilities of retrieval staffing, quality assurance, data collection and reporting demands. |
Rec-ID | Code | Recommendation |
---|---|---|
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 |
---|---|---|
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 |
---|---|---|
REC121-3731 | 29 - Operational Health and Safety | RailCorp should develop a plan to be submitted to ITSRR to address the deficiencies in the safety culture of RailCorp, including: |
REC121-3759 | 29 - Operational Health and Safety | A Safety Reform Program Director (hereafter referred to as SRPD), reporting directly to the Chief Executive of RailCorp, should be retained to manage, as head of a Safety Reform Program Office, any safety reform program being undertaken by RailCorp. The SRPD should work with the Chief Executive and senior management to ensure the implementation of an integrated safety management system and the cultural change required. The SRPD must have qualifications suitable for recognition by the Australian Institute of Project Management as a master program director. He or she should report to and be under the control of the Chief Executive, to ensure that the accountability of the Chief Executive is not reduced. The SRPD should co-ordinate and integrate any existing rail safety reform programs and, in consultation with and with the authority of the Chief Executive he or she should: |
REC121-3768 | 25 - Inquiry, audit, lessons management and after action review | The ITSRR, when considering a re-application for accreditation, should conduct a field audit of the organisation to ensure that it is carrying on its activities in accordance with the basis upon which it seeks accreditation. |
REC121-3737 | 29 - Operational Health and Safety | There must be a minimum of two independent methods of self-initiated emergency escape for passengers from all trains at all times. |
REC121-3682 | 29 - Operational Health and Safety | All new rolling stock should be designed to be compatible with at least level 2 automatic train protection discussed in chapter 7 of this report. |
REC121-3743 | 29 - Operational Health and Safety | All passenger trains operating in New South Wales must have the external emergency door release clearly marked with the words “Emergency Door Release”. |
REC121-3713 | 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. |
REC121-3711 | 29 - Operational Health and Safety | The ITSRR should establish an electronic document control system to enable effective and reliable information to be gathered for monitoring the safety of the New South Wales rail system. |
REC121-3755 | 29 - Operational Health and Safety | The RailCorp Board should require a full review of the safety competence of RailCorp managers to ensure that each has the ability to bring about those safety reforms recommended in this report which are applicable to his or her position. |
REC121-3765 | 25 - Inquiry, audit, lessons management and after action review | The ITSRR should conduct field audits to satisfy itself that all accredited rail organisations conduct their activities in accordance with the safety management system on the basis of which each was accredited. |
REC121-3735 | 29 - Operational Health and Safety | Risk assessments of occupational health and safety issues by RailCorp should include an analysis of broader public safety risks and not be confined to narrow occupational health and safety issues. |
REC121-3681 | 29 - Operational Health and Safety | RailCorp should progressively implement, within a reasonable time, level 2 automatic train protection with the features identified in chapter 8 of this report. |
REC121-3741 | 29 - Operational Health and Safety | The operation of the train doors should have an override facility whereby the train driver or the guard can override an internal passenger emergency door release system if the door release is interfered with when there is no emergency. There should be an alarm, together with an intercom, in the train guard’s compartment so that, if a passenger attempts to initiate an emergency door release, there is an appropriate delay during which time an alarm sounds in the train guard’s compartment and the guard can then, after first attempting to speak via the intercom to the person concerned, if necessary, override the door release, and make an appropriate announcement over the intercom system in the train. |
REC121-3694 | 25 - Inquiry, audit, lessons management and after action review | The ITSRR should conduct random audits of accredited rail organisations for compliance with communications protocols. |
REC121-3709 | 29 - Operational Health and Safety | RailCorp should provide access to electronic versions of safety documentation for all operational staff at their workplace. |
REC121-3754 | 29 - Operational Health and Safety | The RailCorp Board should ensure that RailCorp has an adequate and integrated safety management system, including adequate systems for risk assessment, clearly defined safety responsibilities and accountabilities for persons holding management positions, and specific performance criteria against which evaluations can be made of safety performance and accountability for safety performance of all managers. |
REC121-3758 | 25 - Inquiry, audit, lessons management and after action review | Following completion of any external audit, a corrective action plan to remedy any identified safety deficiencies should be developed by RailCorp, implemented and followed up within the business groups affected, to ensure appropriate and timely completion of the action plan, by a formal examination of the effectiveness of the controls put in place. Senior management personnel should certify that the corrective action plan has been implemented and is effective. Senior management personnel should be accountable for any such certification. |
REC121-3734 | 29 - Operational Health and Safety | RailCorp should integrate its management of occupational health and safety into its overall safety management. |
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. |
REC121-3680 | 29 - Operational Health and Safety | All trains must be fitted with a minimum of two independent engineering defences to minimise the risk of derailment or collision in the event of train driver incapacitation. |
REC121-3740 | 29 - Operational Health and Safety | The internal passenger emergency door release should be fitted with a facility which prevents it from operating unless the train is stationary. |
REC121-3693 | 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. |
REC121-3707 | 29 - Operational Health and Safety | The safety document management system should provide for the distribution of electronic versions of safety documentation to relevant staff. |
REC121-3749 | 29 - Operational Health and Safety | All new rolling stock must be designed with an area of the roof through which emergency services personnel can access a rail car without encountering wiring or other equipment. That access point must be clearly marked with words such as “emergency services cut here”. |
REC121-3757 | 25 - Inquiry, audit, lessons management and after action review | RailCorp should conduct internal and external safety audits to evaluate the adequacy of its safety management system and to ensure that any risk control measures are effective. |
REC121-3733 | 29 - Operational Health and Safety | RailCorp’s approach to occupational health and safety should be proactive and involve the systematic analysis of all current hazards, risks and controls and an assessment of their adequacy to reduce the risk of injury to, or death of, employees to an acceptable level. |
REC121-3739 | 29 - Operational Health and Safety | All passenger trains operating in New South Wales must be fitted with external emergency door releases which do not require any special key or other equipment to operate. |
REC121-3691 | 25 - Inquiry, audit, lessons management and after action review | The ITSRR should audit the RMC to ensure communications protocols are being followed. The sanction for non-compliance with communications protocols should be identical to that in the aviation industry and involve immediate removal from duty. Any RailCorp employee not following communications protocols should be required to undertake further training. If, following return to duties after such training, the officer continues to fail to comply with communications protocols, that officer is not to be employed in communications related work. |
REC121-3706 | 29 - Operational Health and Safety | RailCorp should establish a comprehensive safety document management system. |
REC121-3748 | 29 - Operational Health and Safety | All new rail cars must have appropriate signage and lighting identifying escape routes in the case of emergency. |
REC121-3753 | 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. |
REC121-3732 | 29 - Operational Health and Safety | If ITSRR accepts such a plan as an appropriate response to the existing weak safety culture, ITSRR should approve it and monitor the effectiveness of the plan. |
REC121-3764 | 29 - Operational Health and Safety | The ITSRR should not grant accreditation to any rail organisation unless it has an integrated safety management system in accordance with any safety management system regulation and the guidelines published from time to time by ITSRR. |
REC121-3738 | 29 - Operational Health and Safety | All passenger trains must be fitted with an internal passenger emergency door release. |
REC121-3702 | 29 - Operational Health and Safety | Random alcohol testing should be continued. |
REC121-3747 | 29 - Operational Health and Safety | All trains should have windows available through which passengers can escape. |
REC121-3726 | 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. |
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 |
---|---|---|
REC117-3640 | 37 - Funding | The ANAO recommends that the Attorney-General’s Department better monitor and account for the expenditure of individual exercise costs under the National Capability Development Exercise Programme, through: |
Rec-ID | Code | Recommendation |
---|---|---|
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. |