Inquiry Search
Rec-ID | Code | Recommendation |
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REC321-4207 | 25 - Inquiry, audit, lessons management and after action review | We recommend that DELWP reviews its target for the number of fuel hazard assessments conducted and ensures that this measure is evidence based, accurately reflects regional performance, and that the department monitors and reports on each region’s performance against it. |
Rec-ID | Code | Recommendation |
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REC314-3260 | 32 - Doctrine, standards, and reform | Align risk assessment tools and processes to Risk Management Standard ISO 31000 and the National Emergency Risk Assessment Guidelines (NERAG) and communicate these on public-facing platforms. Make Bushfire Management Area Plans (BMAP) accountable for managing and reporting on region-specific risk and identifying critical infrastructure such as mobile phone towers as key risks. |
REC314-3259 | 32 - Doctrine, standards, and reform | Implement previous review recommendations for bushfire management including those relating to the 2009 amendments to the Fire and Emergency Services Act 2005, State Bushfire Coordination Committee operation, State Bushfire Management Plan, as well as urgent completion of Codes of Practice for fuel hazard reduction on all land tenures, and redevelopment of Bushfire Management Area Plans accompanied by effective community engagement to build an understanding of risk. |
REC314-3269 | 32 - Doctrine, standards, and reform | Develop and practice procedures for the CFS, DEW and local governments to access and deploy heavy plant and machinery for fuel reduction operations both before and during bushfires. |
Rec-ID | Code | Recommendation |
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REC302-2395 | 32 - Doctrine, standards, and reform | Remove those policies, guidelines, memoranda of understanding and committees that are made redundant as a result of adopting recommendation #2 while updating any remaining policies that are considered to still be relevant |
Rec-ID | Code | Recommendation |
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REC301-2387 | 32 - Doctrine, standards, and reform | TFS, PWS and STT agree an updated version of the Interagency Fire Management Protocol which maintains the principle that there will be one state-wide point of command for major unwanted fires burning in the State of Tasmania, explicitly recognises the right of each of TFS, PWS and STT to have their objectives prioritised in incident action planning and adequate resources applied to those objectives, and provides a mechanism for executive decision-makers from TFS, PWS and STT to come together and agree objectives and resourcing levels that will then be operationalised by whole-of-State control structures. |
REC301-2385 | 25 - Inquiry, audit, lessons management and after action review | TFS should initiate a policy review (seeking support from government as appropriate) to clearly identify what body or agency is responsible for planning, carrying out and enforcing fuel management on private property at a township level. If current arrangements are unclear or ineffective, TFS should request government to consider making this a statutory responsibility of TFS and provide any additional funding required to support this function. |
REC301-2384 | 36 - Volunteers | TFS should pursue the creation of a cadre of volunteer remote area firefighters. In doing so the TFS should not consider itself limited to upskilling of current volunteer brigade members, but should carry out a cost benefit analysis of creating one or more remote area firefighting units based in urban areas, in order to tap into the potential of those members of the urban-based Tasmanian community who may have advanced knowledge and skills relating to navigation and survival in wilderness areas. |
REC301-2392 | 39 - Disaster Risk Management | TFS should engage in discussions with government about the construction of purpose-built State Control Centre facilities for emergency management in Tasmania. |
Rec-ID | Code | Recommendation |
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REC291-1238 | 32 - Doctrine, standards, and reform | The State Emergency Management Committee to adopt, across all hazards, the doctrine of: · the primacy of life; · the ‘Strategic Control Priorities’ (as documented by the Department of Fire and Emergency Services); and · community warnings that are timely, tailored and relevant. Agencies will reinforce amongst emergency management personnel the importance of this doctrine through briefings and intent statements. |
REC291-1233 | 25 - Inquiry, audit, lessons management and after action review | The State Government to explore options for streamlining the functions and the independence of the State Emergency Management Committee Secretariat and the Office of Bushfire Risk Management with a view to including an inspectorate function, and appointing a person who is dedicated to that role. The purpose is to provide assurance and reporting, and to inquire into, monitor and report transparently on emergency management standards, preparedness, capability, service delivery and investment performance outcomes. Within two years of the establishment of this arrangement the State Government to review and assess whether it is meeting the desired outcomes. |
REC291-1249 | 25 - Inquiry, audit, lessons management and after action review | The Department of the Premier and Cabinet to conduct an independent review of the current arrangement for the management and distribution of the Emergency Services Levy. The review will have the specific purpose of: · seeking input from key entities including the Departments of Treasury, Finance, Fire and Emergency Services, Lands, and Parks and Wildlife, WA Local Government Association, and the Office of Bushfire Risk Management. · ensuring the arrangement has the flexibility and agility to deal with emerging bushfire risk priorities. · establishing a budget process that enables a shift in investment towards prevention, mitigation and building community resilience and capability. |
REC291-1247 | 32 - Doctrine, standards, and reform | The State Government to create a Rural Fire Service to enhance the capability for rural fire management and bushfire risk management at a State, regional and local level. The proposed Rural Fire Service will: · be established as a separate entity from the Department of Fire and Emergency Services or, alternatively, be established as a sub-department of the Department of Fire and Emergency Services; · have an independent budget; · be able to employ staff; · have a leadership structure which, to the greatest degree possible, is regionally based and runs the entity; · be led by a Chief Officer who reports to the responsible Minister on policy and administrative matters; and to the Commissioner for Fire and Emergency Services during operational and emergency response; · have responsibilities and powers relating to bushfire prevention, preparedness and response; and · operate collaboratively with the Department of Fire and Emergency Services, the Department of Parks and Wildlife, Local Government and volunteer Bush Fire Brigades. In creating the Rural Fire Service, the State Government to consider whether back office and corporate support services could be effectively provided by an existing Department, such as the Department of Fire and Emergency Services or the Department of Parks and Wildlife. The State Government to review the creation of the Rural Fire Service two years after its establishment, to assess whether its structure and operations are achieving the intended outcome. |
Rec-ID | Code | Recommendation |
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REC288-1191 | 32 - Doctrine, standards, and reform | The Committee finds that on the evidence presented, that a review and reform of the Fire Services Act 1979 is necessary. An investigation should be undertaken to assess how the legislation can be amended or replaced to best service the organisations subject to the Act and should be undertaken and completed within 12 months. The Fire Services Act 1979 must be reformed or replaced to allow for: (1) A centralised funding model for the State Emergency Services; (2) Streamlined approach to fire fighting between Tasmania Fire Service, Tasmania Parks and Wildlife Service, Forestry Tasmania and other relevant agencies; (3) Resources to be allocated according to the risk and not according to local government municipal boundaries; (4) The continuation of Tasmania having a singular fire service; (5) Clear reporting lines; (6) Improved governance structure; and, (7) Include the fire permit system and inter- agency protocols. |
REC288-1200 | 32 - Doctrine, standards, and reform | The Committee finds that on the evidence presented, that the State Government should establish an independent Chair to govern the State Fire Commission and that this governance arrangement should be included in the reform of the governing legislation. |
REC288-1199 | 36 - Volunteers | The Committee finds that on the evidence presented, that volunteer firefighters are at risk of being undervalued and underrated and that the Government should use best endeavours to ensure the full acknowledgement and recognition of these services. |
REC288-1192 | 32 - Doctrine, standards, and reform | The Committee finds that on the evidence presented, that section 107 of the Fire Service Act should be amended to provide greater clarity in relation to discretionary spending by the Chief Officer or alternatively, the Act should be amended to include the authorisation for the State Fire Commission to directly fund the State Emergency Service. |
Rec-ID | Code | Recommendation |
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REC287-1188 | 25 - Inquiry, audit, lessons management and after action review | The Tasmanian fire agencies commission a review into the efectiveness of aerial firefghting in the 2016 fires, in order to better understand and to document for future reference the cost-efectiveness of specifc fire suppression strategies and tactics in different vegetation types. The Review should include a comparative analysis of fire suppression options whether aerial or ground-based. |
REC287-1185 | 25 - Inquiry, audit, lessons management and after action review | The Tasmanian fire agencies take steps at a national level to share learnings from the 2016 fires about the administration of interstate assistance and support the codifcation of the workings, structure and reporting lines of an Interstate and International Liaison Unit for future complex deployments within Australia and New Zealand. |
REC287-1182 | 32 - Doctrine, standards, and reform | The fire agencies consider how the Regional Fire Operations Centre (RFOC) as a concept adds value once a level 3 IMT is up and running in a region. |
Rec-ID | Code | Recommendation |
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REC275-1174 | 32 - Doctrine, standards, and reform | IGEM recommends that fire agencies consider an earlier classification of Level 3 incident for fires that present significant complexity such as was evident in the Wye River – Jamieson Track event. |
Rec-ID | Code | Recommendation |
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REC273-1145 | 32 - Doctrine, standards, and reform | Review relevant Legislation associated Acts and Plans to establish a consistent approach to fire and emergency management to minimise duplication and risk of contradiction. That the Hazard and Functional area plans be amalgamated and establish a SA Bushfire Plan, under the SEMP, which clearly define role of SACFS. |
REC273-1143 | 32 - Doctrine, standards, and reform | That SACFS in consultation with SAMFS consider adopting common terminology and capability requirements for strike teams being ‘4-5 appliances and a group officer’ in line with other jurisdictions. |
REC273-1133 | 32 - Doctrine, standards, and reform | That a complete review of current naming conventions of personnel and centres, in accordance with the outcomes of the Victorian Bushfire Royal Commission is undertaken, to ensure clarity around command, control and coordination within SA. |
REC273-1129 | 32 - Doctrine, standards, and reform | Incorporating ‘triggers’ within Chief Officers Standing Orders No. 17, which requires the escalation of the State Controller role to the rank of Assistant Chief Officer or greater, depending on the increased risk or activity. |
REC273-1128 | 32 - Doctrine, standards, and reform | Incorporate in operational doctrine the ability for the State Controller to determine the operational readiness levels of the state or regions based on either the predicted and/or actual risk and/or activity to some or all of the regions. |
Rec-ID | Code | Recommendation |
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REC264-1078 | 32 - Doctrine, standards, and reform | The State review and revise the community carbon monoxide response protocol and the firefghter carbon monoxide response protocol, to: |
REC264-1087 | 25 - Inquiry, audit, lessons management and after action review | GDF Suez: • practice and ensures that, by taking a risk management approach, it is suitable for fire prevention, mitigation and suppression in all parts of the Hazelwood mine; and review its ‘Mine Fire Service Policy and Code of Practice’ so that it refects industry best • work plan for the Hazelwood mine. incorporate the revised ‘Mine Fire Service Policy and Code of Practice’ into the approved |
REC264-1077 | 32 - Doctrine, standards, and reform | The State take the lead in advocating for a national compliance standard for PM |
REC264-1086 | 25 - Inquiry, audit, lessons management and after action review | GDF Suez: • consequences of fire in the worked out areas of the Hazelwood mine, and an assessment of the most effective fre protection for the exposed coal surfaces; conduct, assisted by an independent consultant, a risk assessment of the likelihood and • controls are in place to eliminate or reduce the risk of fre; and prepare an implementation plan that ensures the most effective and reasonably practicable • implement the plan |
REC264-1075 | 32 - Doctrine, standards, and reform | The State: • bring forward the commencement date of s.16 of the Mineral Resources (Sustainable Development) Amendment Act 2014 (Vic), to facilitate the requirement that approved work plans specifcally address fre prevention, mitigation and suppression; and • acquire the expertise necessary to monitor and enforce compliance with fre risk measures adopted by the Victorian coal mining industry under both the mine licensing and occupational health and safety regimes. |
REC264-1084 | 32 - Doctrine, standards, and reform | GDF Suez revise its Emergency Response Plan, to: • require an increased state of readiness on days of Total Fire Ban; • require pre-establishment of an Emergency Command Centre; • require pre-positioning of an accredited Incident Controller as Emergency Commander; and • require any persons nominated as Emergency Commander to have incident controller accreditation and profciency in the use of the Australasian Inter-service Incident Management System. |
REC264-1074 | 32 - Doctrine, standards, and reform | The State enact legislation, to: • require Integrated Fire Management Planning; and • authorise the Emergency Management Commissioner to develop and implement regional and municipal fire management plans. |
REC264-1080 | 32 - Doctrine, standards, and reform | The State develop and widely disseminate an integrated State Smoke Guide, to: • incorporate the proposed State Smoke Plan for the management of public health impacts from large scale, extended smoke events; • include updated Bushfre Smoke, carbon monoxide and PM protocols; and 2.5 • provide practical advice and support materials to employers, communities and individuals on how to minimise the harmful effects of smoke. |
REC264-1072 | 25 - Inquiry, audit, lessons management and after action review | The State empower and require the Auditor-General or another appropriate agency, to: • oversee the implementation of these recommendations and the commitments made by the State and GDF Suez during this Inquiry; and • report publicly every year for the next three years on the progress made in implementing recommendations and commitments. |
REC264-1079 | 32 - Doctrine, standards, and reform | The State review and revise the Bushfre Smoke Protocol and the PM Health Protection Protocol, to: 2.5 • ensure both protocols are consistent with each other; and • ensure both protocols include assessment methods and trigger points for specifc responses. |
REC264-1088 | 32 - Doctrine, standards, and reform | GDF Suez adopt and apply the firefghter carbon monoxide response protocol. |
Rec-ID | Code | Recommendation |
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REC257-1543 | 32 - Doctrine, standards, and reform | Range Standing Orders be amended to include a direction that no Defence vehicle is to leave the administration area of Marrangaroo Training Area during a bushfire, except to leave Marrangaroo Training Area itself through the main gate, unless it is a properly equipped bushfire fighitng vehicle havig at least four wheel drive capabiliy and self-protection equipment. |
REC257-1551 | 32 - Doctrine, standards, and reform | The use of Internal and External ranges at MTA for patrolling activities be prohibited. |
REC257-1539 | 25 - Inquiry, audit, lessons management and after action review | Defence Security Authority conduct an investigation into the whereabouts of items of anaccounted explosive ordnance issued to Defence Explosive Ordnance Training School Exercise Marrangaroo. |
REC257-1550 | 32 - Doctrine, standards, and reform | Defence engage with both the Bureau of Meteorology and the Rural Fire Service to determine a more suitable index system. In the interim, Range Standing Orders be amended so that live-firing on the ranges on Marrangaroo Training Area not be permitted where the Forest Fire Danger Index for either the Central Ranges District or Greater Sydney Region is 12, it being the threshold for HIGH Fire Danger Rating or above. put another way, and in a practical sense, Range Standing Orders should, as an interim measure, require the Officer in Charge Practice and the Range Control Officer to consider the Forest Fire Danger Index for both Central Ranges District AND Greater Sydney Region on the day of any given serial. If either index is as 12 or above, live-firing should not be permitted. Any indication in Range Standing Orders or elsewhere that live-firing is permitted on Marrangaroo Training Area when the Fire Danger rating is HIGH should be rescinded. |
REC257-1538 | 32 - Doctrine, standards, and reform | Commanding Officer Defence Explosive Ordnance Training School amend relevant instructions, both generally and specifically, so as to ensure that explosive ordnance used in training serials is logged in real time, in accordance with extant doctrine. |
REC257-1549 | 32 - Doctrine, standards, and reform | Marrangaroo Training Area Range Standing Orders should be reviewed to impose a requirement that the Officer in Charge of any live-firing practice ascertain and consider current weather parameters, temperature, humidity, wind strength and direction, registered at Mt Boyce immediately prior to any demolition serial. The setting of those parameters and their limits should be decided in consulation with the Bureau of Meteorology and Rural Fire Service and inserted into Range Standing Orders. |
REC257-1554 | 32 - Doctrine, standards, and reform | All documents be reviewed to remove ambiguity and perceived inconsistencies. Marrangaroo Training Area Range Standing Orders be subject to further examination, with particular consideration of the bushfire mitigation strategies referred to in the Bushfire Management Plan 2011-2014 before amendments to Chapter 10 are made. the basis upon which Range Standing Orders might fix a cut-off point for live-firing exercises should depend on continued bushfire strategies. Range Standing orders and Marrangaroo Training Area Bushfire Management Plan be reviewed annually. if hazard reduction has not occurred or the fire trails degraded, Range Standing Orders should take into account of heightened risk. |
REC257-1537 | 32 - Doctrine, standards, and reform | Commanding Officer Defence Explosive Ordnance Training School review and enforce Standard Operating Procedures to ensure that appropriate explosive ordnance accounting and handling practices, in accordance with Defence doctrine, are adhered to during all training activities. |
REC257-1548 | 25 - Inquiry, audit, lessons management and after action review | The Regional Director-Defence Support-Northern NSW, make contact with Deputy Commissioner ~~~~~ Director of Operational Services Rural Fire Service, to arrange a headquarters driven bipartite review of the events of 16 October 2013 with a review to mitigation of future fire events generally, and with specific reference to: |
REC257-1553 | 32 - Doctrine, standards, and reform | On matters relating directly to safety or risk, or when live-firing may occur, where there is ambiguity or apparent inconsistency, the most conservative or restrctive order should be followed until formal clarification has been provided. |
REC257-1546 | 25 - Inquiry, audit, lessons management and after action review | Defence undertake a review of its ability to respond to a fire within Marrangaroo Training Area, whether bushfire or structural. The underlying assumption should be that the only response available to fight a fire within Marrangaroo Training Area will be provided by Defence. Further, such response must occur while a fire is in its initial stages. A review must either acknowledge the risk of fire occurring in th future, or upgrade Defence's firefighting capability at Marrangaroo Training Area. |
REC257-1552 | 32 - Doctrine, standards, and reform | Authority be given to the regional Environmental Officer to close a range or impose live-firing restriction in addition to any set out in Range Standing Orders if circumstances so warrant. |
Rec-ID | Code | Recommendation |
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REC247-0898 | 32 - Doctrine, standards, and reform | That the State Special Emergency Plan–Recovery and the emergency management structure for recovery be reviewed. |
REC247-0951 | 25 - Inquiry, audit, lessons management and after action review | That an independent means of monitoring and reporting on the implementation of approved recommendations is established. |
REC247-0870 | 32 - Doctrine, standards, and reform | That Tasmania Fire Service considers adopting a primary tactic of an aggressive first attack on fires. |
REC247-0913 | 32 - Doctrine, standards, and reform | That the State Fire Commission structures its Tasmania Bushfire Safety Policy so policy outcomes are identifiable and progress in achieving outcomes can be evaluated. |
REC247-0876 | 32 - Doctrine, standards, and reform | That Tasmania Fire Service reviews its approach to blacking out and mopping up, including its policies, operating procedures and training. |
REC247-0929 | 32 - Doctrine, standards, and reform | That the State Emergency Management Committee considers structuring the Tasmania Emergency Management Plan in a way that provides more specific guidance, commitment to and accountability for action to be taken. |
REC247-0897 | 32 - Doctrine, standards, and reform | That a standing plan is developed to manage the transition from immediate recovery to medium and long-term recovery, and arrangements are made to ensure this plan can be effectively implemented in a timely way. |
REC247-0950 | 32 - Doctrine, standards, and reform | That resources are committed to developing and implementing approved reforms to the emergency management arrangements. |
REC247-0869 | 32 - Doctrine, standards, and reform | That Tasmania Fire Service ensures that planning for active fires includes a proactive approach wherever possible. |
REC247-0912 | 32 - Doctrine, standards, and reform | That the State Fire Commission finalise its position on the Tasmania Bushfire Safety Policy without further delay. |
REC247-0874 | 32 - Doctrine, standards, and reform | That Tasmania Fire Service reviews operational practices to ensure there is continuity of fire operations when fire suppression action is required. |
REC247-0927 | 25 - Inquiry, audit, lessons management and after action review | That an accountability process be established for managing improvement in the emergency management arrangements, including annual State of Readiness Reports by relevant departments and agencies and on the overall emergency management arrangements. |
REC247-0883 | 32 - Doctrine, standards, and reform | That Tasmania Police ensures planning for emergency operations includes a proactive approach wherever possible. |
REC247-0949 | 32 - Doctrine, standards, and reform | That following any review, the Emergency Management Act 2006 be amended. |
REC247-0864 | 32 - Doctrine, standards, and reform | That Tasmania Fire Service reviews its position on fire ground management to determine whether a unified command model at the fire ground should be adopted. |
REC247-0909 | 25 - Inquiry, audit, lessons management and after action review | That the plans for social recovery be reviewed, and plans and procedures are established ready for implementation. |
REC247-0873 | 25 - Inquiry, audit, lessons management and after action review | If it is considered more information is required on action to suppress the fires in Dunalley and why fire operations did not continue, the Department of Justice should conduct an independent examination of this matter. |
REC247-0926 | 25 - Inquiry, audit, lessons management and after action review | That membership of the State Emergency Management Committee, and other processes to link in appropriate agencies and organisations to emergency management, be included in the recommended review of the emergency management arrangements. |
REC247-0882 | 32 - Doctrine, standards, and reform | That Tasmania Fire Service documents and publishes its operational policies and procedures so they are accessible to and suitable for operational personnel. |
REC247-0941 | 25 - Inquiry, audit, lessons management and after action review | That the Strategic Fuel Management Plan includes measurable targets and they are actively monitored and reported on to the community. |
REC247-0852 | 32 - Doctrine, standards, and reform | That the role and expected duties of the State Controller be clearly defined in the Emergency Management Act 2006. |
REC247-0908 | 32 - Doctrine, standards, and reform | That the State Emergency Management Committee examine whether there are any legal issues associated with continuing recovery operations where the overarching emergency management arrangements have ceased. |
REC247-0872 | 32 - Doctrine, standards, and reform | That Tasmania Fire Service considers what adjustments may be necessary to the promotion and use of the Six Operational Priorities to ensure plans are suitable for the circumstances of each fire. |
REC247-0923 | 25 - Inquiry, audit, lessons management and after action review | That a process be established for the timely implementation of approved recommendations from the 2009 Victorian Bushfires Royal Commission. |
REC247-0881 | 32 - Doctrine, standards, and reform | That Tasmania Fire Service establishes sufficient resources and expertise to research, develop, implement and review its policies and operations. |
REC247-0940 | 32 - Doctrine, standards, and reform | That the Government actively support the timely development and implementation of an ongoing Strategic Fuel Management Plan. |
REC247-0903 | 25 - Inquiry, audit, lessons management and after action review | That the role of Red Cross in emergency management plans and procedures for the activation of Red Cross be reviewed. |
REC247-0871 | 32 - Doctrine, standards, and reform | That Tasmania Fire Service critically reviews the operation of the Six Operational Priorities to determine whether they are appropriate and effective. |
REC247-0914 | 32 - Doctrine, standards, and reform | That the Tasmanian Emergency Management Plan includes a comprehensive all hazards communications policy and plan. |
REC247-0877 | 32 - Doctrine, standards, and reform | That Tasmania Fire Service reviews its approach to fire management operations at night, and develop and effectively implement unambiguous policy and operating procedures. |
REC247-0930 | 32 - Doctrine, standards, and reform | That the State Emergency Management Committee determine suitable risk management tools, such as the Bushfire Risk Assessment Model, and encourages their use in assessing bushfire risk in a consistent manner. |
Rec-ID | Code | Recommendation |
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REC246-0780 | 32 - Doctrine, standards, and reform | TFS develop MOUs with interstate fire agencies and land management authorities to formalise agency to agency resource sharing/mutual aid protocols that ensure the effective deployment of interstate resources for all roles from fire ground to state control, and management of those resources within pre-established criteria. |
REC246-0779 | 32 - Doctrine, standards, and reform | TFS review all areas in which the SFOC has a role and ensure that robust policy and protocols are finalised to ensure that corporate knowledge is widely accessible and is not held solely by individuals. |
REC246-0778 | 32 - Doctrine, standards, and reform | TFS review the Inter-Agency Fire Management Protocol and the Terms of Reference (ToR) of the Multi-Agency Coordination Group (MAC), to ensure that the Inter-Agency Fire Management Protocol accurately reflects the role and functions of the State Fire Operations Centre (SFOC) and clearly establishes and communicates the role and functions of the MAC Group. |
REC246-0777 | 32 - Doctrine, standards, and reform | TFS finalise and sign off the State Fire Protection Plan (SFPP). All the documents named in the SFPP should be finalised and available to relevant stakeholders to support the SFPP. |
REC246-0776 | 32 - Doctrine, standards, and reform | All Tasmanian fire agencies seek to have the State Bushfire Policy finalised and signed-off at the required level of government. |
REC246-0788 | 25 - Inquiry, audit, lessons management and after action review | TFS seek to address the following outstanding items from the recommendations of the Victorian Bushfires Royal Commission. § 45 out of 53 Community Bushfire Response Plans for “at risk” communities have been finalized. The remaining eight should be completed as a priority action. § That TFS progress the development of Community Bushfire Mitigation Plans for the 53 at risk communities, possibly as an action for reactivated Fire Management Area Committees. § TFS, together with other ESOs and local government, should develop a common comprehensive approach to the option of planned evacuation from dangerous or potentially dangerous areas to safer areas and eventual return. § TFS should include factors for consideration for evacuation during a bushfire into their training doctrine for Incident Controllers. § The IAP Template and its application be reinforced as an important operational requirement for IMT’s during the 2013-14 pre-season briefing program. 10 § That TFS review their use of IRMS to ascertain if either its full potential is not being realized through a lack of operator training or it is in fact not providing the required functionality and there is a need to research an improved resource management system which enhances interoperability. § The TFS Publication: Guidelines for Development in Bushfire Prone Areas of Tasmania http://www.fire.tas.gov.au/userfiles/stuartp/file/Publications/BushDeve… s2012.pdf requires an update to reflect the provisions of Planning Directive #5 Bushfire-Prone Areas Code. |
Rec-ID | Code | Recommendation |
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REC228-1614 | 25 - Inquiry, audit, lessons management and after action review | The Emergency Services Agency, in consultation with the ACT Bushfire Council, should conduct a review of the ACT Bushfire Council against its recently developed terms of reference (July 2013) within two years. |
REC228-1607 | 32 - Doctrine, standards, and reform | The Justice and Community Safety Directorate, in managing future amendments to the Emergencies Act 2004, should propose amendments which require the Emergency Services Agency to maintain information on privately-owned assets of public interest that are vulnerable to bushfire without the need to include this information in the Strategic Bushfire Management Plan. |
REC228-1613 | 32 - Doctrine, standards, and reform | The Emergency Services Agency should continue to work with National Land managers and develop a National Land bushfire management framework to address bushfire risks on National Land. |
REC228-1606 | 32 - Doctrine, standards, and reform | The Emergency Services Agency should comply with the Emergencies Act 2004 requirements for the Strategic Bushfire Management Plan by including in this Plan an explicit statement of all resources needed to meet the objectives of the Plan. |
REC228-1612 | 32 - Doctrine, standards, and reform | The Emergency Services Agency should develop a strategy for monitoring the development and implementation of all Government land managers’ operational plans. |
REC228-1611 | 32 - Doctrine, standards, and reform | The Emergency Services Agency should specify preparation and approval requirements for bushfire operational plans, particularly those for lands in the Bushfire Abatement Zone. |
REC228-1621 | 32 - Doctrine, standards, and reform | The Emergency Services Agency should improve its management of the Community Fire Unit Program by: |
REC228-1609 | 25 - Inquiry, audit, lessons management and after action review | The Emergency Services Agency should undertake audits to meet the requirements in the Strategic Bushfire Management Plan for the preparation, sharing and publication of annual progress reports. Annual progress reports should be made available to the ACT Bushfire Council. |
REC228-1620 | 25 - Inquiry, audit, lessons management and after action review | The Emergency Services Agency, in consultation with the Territory and Municipal Services Directorate, should review the Farm FireWise Program, including: |
REC228-1608 | 32 - Doctrine, standards, and reform | The Emergency Services Agency should review the operations of the Strategic Bushfire Management Plan Implementation Working Group to determine if it is the most appropriate mechanism for ‘monitoring the scope and effectiveness’ of the Strategic Bushfire Management Plan. If it is retained, ways to improve its effectiveness should be identified and implemented. |
Rec-ID | Code | Recommendation |
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REC223-0523 | 25 - Inquiry, audit, lessons management and after action review | The Government consider enacting legislation to facilitate the review of all future major incidents, including but not limited to fire, earthquake, storm and marine inundation, and the emergency response to them. |
REC223-0522 | 25 - Inquiry, audit, lessons management and after action review | The response operation to the Margaret River bushfire in November 2011 be the subject of a review with independent oversight. |
REC223-0516 | 25 - Inquiry, audit, lessons management and after action review | The Department of Environment and Conservation review its implementation of the findings of the Ferguson Review conducted in 2010. |
Rec-ID | Code | Recommendation |
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REC201-0247 | 28 - Personal responsibility | Local residents must take a degree of shared responsibility to prepare their properties by reducing the risk of bushfire around their properties and planning for a bushfire emergency. |
Rec-ID | Code | Recommendation |
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REC200-0362 | 32 - Doctrine, standards, and reform | The Fire and Emergency Services Authority immediately comply with the provisions of WESTPLAN BUSHFIRE and formally declare incidents at their appropriate level and document and communicate those decisions in a similar way to the systems used by the Department of Environment and Conservation and the Western Australian Police. |
REC200-0392 | 25 - Inquiry, audit, lessons management and after action review | The State Government review implementation of the Special Inquiry’s Recommendations in two years. |
REC200-1701 | 25 - Inquiry, audit, lessons management and after action review | The Fire and Emergency Services Authority convene a facilitated debriefing session between the families who remained behind to protect their properties, and the incident controllers. |
REC200-1720 | 32 - Doctrine, standards, and reform | The State Emergency Management Committee amend State Emergency Management Policy 4.1 (Operational Management) to: |
REC200-0361 | 25 - Inquiry, audit, lessons management and after action review | The Fire and Emergency Services Authority convene a facilitated debriefing session between the families who remained behind to protect their properties, and the incident controllers. This session should include open discussion and explain the decisions of all parties – including how the incident controllers determined priorities, and why residents chose not follow their advice to evacuate. The learning outcomes should be promulgated across all agencies and incorporated in future level 3 incident controller training programs. |
REC200-0384 | 25 - Inquiry, audit, lessons management and after action review | Emergency Management Western Australia develop mechanisms to calculate the estimated total cost of a fire to the community. |
REC200-1698 | 39 - Disaster Risk Management | The Fire and Emergency Services Authority, the Department of Environment and Conservation and local governments jointly develop a single, integrated system for fuel load assessment and management. |
REC200-1709 | 32 - Doctrine, standards, and reform | The Western Australian Police and the Fire and Emergency Services Authority jointly examine the Traffic Management System developed in response to the 2009 Victorian bushfires and seek its adaptation to use in WA with additional attention to the access and egress by bona fide residents to areas that are evacuated. |
REC200-0341 | 32 - Doctrine, standards, and reform | The State Government give legislative effect to the Planning for Bush Fire Protection Guidelines. |
REC200-0382 | 32 - Doctrine, standards, and reform | Emergency Management Western Australia and the State Emergency Management Committee amend WESTPLAN-BUSHFIRE to require State Emergency Coordination Group meetings to be held at the State Coordination Centre in West Leederville. |
REC200-1696 | 32 - Doctrine, standards, and reform | The State Government reaffirm its 2009 decision to approve DEC exercising greater flexibility in managing smoke within national guidelines, in order to achieve its prescribed burn program. |
REC200-1704 | 32 - Doctrine, standards, and reform | The Fire and Emergency Services Authority review its use of the Australian Interagency Incident Management System to ensure that the most appropriate resources (including aerial resources) are used to respond to an incident. If resources are rejected during an incident either through the decision making process or other grounds, the reason for the decision should be documented. |
REC200-1732 | 25 - Inquiry, audit, lessons management and after action review | The State Government review implementation of the Special Inquiry's recommendations in two years. |
REC200-0339 | 32 - Doctrine, standards, and reform | Emergency Management Western Australia establish an inter-agency working group to continue the development of the new single emergency services Act. |
REC200-0380 | 32 - Doctrine, standards, and reform | The State Emergency Management Committee amend State Emergency Management Policy 4.1 (Operational Management) to: give clear and explicit direction about when and how an incident should be declared clearly articulate the actions to be taken clearly define accountabilities provide detailed criteria for elevating issues and engaging other agencies. |
REC200-1703 | 32 - Doctrine, standards, and reform | The Fire and Emergency Services Authority develop formal procedures for mandating the completion of Incident Action Plans, ensuring the documents are detailed and that they record critical decision making. |
REC200-1722 | 39 - Disaster Risk Management | Emergency Management Western Australia and the State Emergency Management Committee amend WESTPLAN-BUSHFIRE to require State Emergency Coordination Group meetings to be held at the State Coordination Centre in West Leederville. |
REC200-0363 | 32 - Doctrine, standards, and reform | The Fire and Emergency Services Authority develop formal procedures for mandating the completion of Incident Action Plans, ensuring the documents are detailed and that they record critical decision making. |
REC200-1702 | 32 - Doctrine, standards, and reform | The Fire and Emergency Services Authority immediately comply with the provisions of WESTPLAN BUSHFIRE and formally declare incidents at their appropriate level and document and communicate those decisions in a similar way to the systems used by the Department of Environment and Conservation and the Western Australian Police. |
REC200-1721 | 32 - Doctrine, standards, and reform | The State Government amend section 50 of the Emergency Management Act 2005 to allow the Chair of the State Emergency Coordination Group to declare an emergency situation. |
Rec-ID | Code | Recommendation |
---|---|---|
REC193-0223 | 32 - Doctrine, standards, and reform | The State Fire Management Council support the further development of the Bushfire Risk Assessment Model with a view to it becoming the central information source for use by all entities with responsibility for fire management and mitigation. |
REC193-0224 | 32 - Doctrine, standards, and reform | The State Fire Management Council work with all entities with responsibility for bushfire management to develop a state-wide position on performance indicators and promote that view nationally. |
Rec-ID | Code | Recommendation |
---|---|---|
REC183-0107 | 32 - Doctrine, standards, and reform | The DEC Fire Management Policy should be reviewed and updated. |
REC183-0115 | 32 - Doctrine, standards, and reform | The Hazard Management Agency for bushfire has not been defined. Defining the HMA for bushfire should be addressed. |
REC183-0108 | 32 - Doctrine, standards, and reform | DEC should consider publishing a new reference document that describes policy, doctrine and key systems of work of the fire management system. This document would be a “brief case” or “back pack” reference and would be reviewed annually and issued to all senior staff and fire management personnel. |
Rec-ID | Code | Recommendation |
---|---|---|
REC182-0123 | 32 - Doctrine, standards, and reform | FESA implements measures that will ensure unity and clarity of command. |
Rec-ID | Code | Recommendation |
---|---|---|
REC177-3291 | 39 - Disaster Risk Management | Removal of a barrier must be the subject of consultation between licensees and rig operators prior to removal. A proper risk assessment should be carried out and agreed upon, and documented in writing before removal. Joint written certification as to the appropriateness of removal should take place before removal. Senior onshore representatives of stakeholder entities should be involved in that certification process. |
REC177-3314 | 32 - Doctrine, standards, and reform | Secondary barriers (including PCCCs) should only be installed, tested, and removed with a BOP in place unless a documented risk assessment indicates that well control can be maintained at all times. |
REC177-3335 | 32 - Doctrine, standards, and reform | Licensees, rig operators and relevant third party contractors should develop well control competency standards for key personnel in other entities involved in well control operations. |
REC177-3363 | 32 - Doctrine, standards, and reform | DEWHA, in concert with AMSA and with expert input, should develop ‘off the shelf’ monitoring programs that can be speedily implemented following incidents in Commonwealth waters. In this context, the utility of the current Scientific Monitoring program should be peer reviewed to inform future policy. |
REC177-3300 | 32 - Doctrine, standards, and reform | Licensees and rig operators should install an additional barrier whenever (i) there is any real doubt as to the integrity of any barrier; (ii) whenever the risk of flow from a reservoir increases materially in the course of operations; and (iii) where the consequences of a blowout are grave (for example, for reef systems or shorelines). |
REC177-3319 | 32 - Doctrine, standards, and reform | Drilling programs dealing with barrier installation should incorporate relevant aspects of manufacturer’s instructions. |
REC177-3343 | 32 - Doctrine, standards, and reform | The OPGGS Act should be amended to allow for a power to suspend a petroleum production licence (in addition to the current power to cancel a licence or suspend its conditions). |
REC177-3373 | 32 - Doctrine, standards, and reform | Arrangements should be developed to minimise duplication between the EPBC Act and the OPGSS Act Environment Regulation. |
REC177-3280 | 32 - Doctrine, standards, and reform | Well construction and management plans should include provision for an independent compliance review of well integrity (i) in the event of stipulated triggers; and (ii) at least once in the period between perceived achievement of well integrity and production. The independent compliance review should be undertaken by an expert who is not involved in the day‐to‐day drilling operations. Reviews should be completed in sufficient time to enable results to be implemented in a meaningful manner. |
REC177-3307 | 32 - Doctrine, standards, and reform | Any indication of a compromised cemented shoe which cannot be resolved with a high measure of confidence should result in the installation of additional well control barrier(s). |
REC177-3325 | 32 - Doctrine, standards, and reform | Relevant personnel from licensees and rig operators should meet face to face to agree on, and document, well control issues/arrangements prior to commencement of drilling operations. Well control should be regarded as a so‐called SIMOP to signify its critical importance to both licensees and rig operators, and to ensure that they each take responsibility for achievement and maintenance of well control. |
REC177-3354 | 32 - Doctrine, standards, and reform | NOPSA develop a policy of engagement with operators so as to enable experts (including safety experts) to canvas all available options for well control in the event of a blowout. |
REC177-3289 | 39 - Disaster Risk Management | The use/type of barriers (including any change requests relating thereto) must be the subject of consultation between licensees and rig operators prior to installation. A proper risk assessment should be carried out, agreed upon, and documented in writing before installation. Joint written certification as to the appropriateness of the use of particular barriers should take place before installation. Senior onshore representatives of stakeholder entities should be involved in that certification process. |
REC177-3313 | 32 - Doctrine, standards, and reform | Barriers should not be installed or removed off‐line. The derrick should be located over a well at the time of removal and installation of any barrier. This will enable more decisive action to be taken in the event a problem arises. |
REC177-3334 | 32 - Doctrine, standards, and reform | Licensees, rig operators, and relevant third party contractors should develop well control competency standards for their key personnel. Wherever possible, the competencies of key personnel should be benchmarked against their roles and responsibilities. |
REC177-3362 | 32 - Doctrine, standards, and reform | Procedures for the approval of development projects should ensure that conditions of approval are comprehensive and clearly set out the obligations of their proponents in relation to environmental matters (including expected monitoring and remediation obligations). |
REC177-3298 | 32 - Doctrine, standards, and reform | Reliance upon one barrier against a blowout must not take place except with the prior written approval of the relevant regulator and then only in a true emergency situation (see below). |
REC177-3318 | 32 - Doctrine, standards, and reform | Manufacturers should be consulted about how to address non‐routine operational problems affecting their well control equipment. |
REC177-3342 | 32 - Doctrine, standards, and reform | Written (rather than verbal) approval from the DA (or new regulator) should be obtained before the commencement of well activities that lead to a physical change of a wellbore, other than in a true emergency situation (requiring amendment to regulation 17 of the Management of Well Operations Regulations). |
REC177-3370 | 32 - Doctrine, standards, and reform | Environment plans and OSCPs should be made publicly available as a condition of approval of proposals under the OPGGS Act, and should clearly set out Scientific Monitoring requirements in the event of an oil spill. |
REC177-3277 | 32 - Doctrine, standards, and reform | The concept of ‘good oilfield practice’ should be supplemented by the requirement to incorporate into WOMPs non‐exhaustive minimum compliance standards in relation to well control: for example, stipulations as to when BOPs and/or well control systems must be in place and when they can be removed and minimum barrier requirements (a number of other factors that should be stipulated are outlined in other recommendations below). |
REC177-3306 | 32 - Doctrine, standards, and reform | It should be standard industry practice to re‐test a cemented casing shoe (that is, after WOC) whenever the plugs do not bump or the float valves apparently fail. Standard industry practice should require consideration of other tests in addition to a repeat pressure test. |
REC177-3324 | 32 - Doctrine, standards, and reform | The mere fact that the rig is over the platform should not be regarded by licensees or regulators as sufficient justification for reliance on only one barrier. The default position should be that producible wells are shut‐in when a rig is moved on and off a platform, or when a drilling unit is moved between wells on a platform. |
REC177-3353 | 32 - Doctrine, standards, and reform | The regulatory regime should also impose an obligation on an operator to ascertain the availability, and provide details to the regulator, of any potential relief well rigs, prior to the commencement of drilling operations (including prior to each phase of a drilling operation where applicable). |
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. |
REC177-3286 | 39 - Disaster Risk Management | Problems which arise in the course of installing barriers must be the subject of consultation between licensees, rig operators, and contractors (if used). A proper risk assessment should then be carried out and remedial steps (including further testing/verification) should be agreed upon, and documented in writing before the performance of remedial work whenever practicable. Joint written certification as to resolution of the problem should take place before resumption of drilling operations. Senior onshore representatives of stakeholder entities should be involved in that certification process. |
REC177-3312 | 32 - Doctrine, standards, and reform | The BOP and rig should not move from a well until barrier integrity has been verified. |
REC177-3330 | 39 - Disaster Risk Management | Decision‐making about well control issues should be professionalised. Industry participants must recognise that decision‐makers owe independent duties to the public, not just their employer or principal, in relation to well control. Risk management in the context of well control needs to be understood as an ethical/professional duty. Self‐regulation contemplates self‐regulation by the industry, not just by individual licensees and operators. |
REC177-3361 | 32 - Doctrine, standards, and reform | The National Plan should be revised to ensure that it fully comprehends environmental matters and that it recognises the importance of the prompt implementation of Scientific Monitoring to facilitate the assessment of the environmental impacts of an incident. |
REC177-3297 | 32 - Doctrine, standards, and reform | A minimum of two barriers should be in place at all times (including during batched operations) whenever it is reasonably practicable to do so. |
REC177-3317 | 32 - Doctrine, standards, and reform | Any equipment (including PCCCs) used as, or to install, a barrier should be manufactured for that purpose and be generally recognised as fit for purpose. If equipment is designed in‐house by a licensee or rig operator it should not be approved for use unless and until it is subjected to expert external analysis. |
REC177-3341 | 32 - Doctrine, standards, and reform | The definition of ‘good oilfield practice’ in the OPGGS Act is unduly narrow. The current definition is incapable of application except where things ‘are generally accepted as good and safe’. The definition should be amended such that ‘good oilfield practice includes…’. |
REC177-3368 | 32 - Doctrine, standards, and reform | The regulatory framework should provide that in respect of all activities in Commonwealth waters: |
REC177-3276 | 32 - Doctrine, standards, and reform | WOMPs should be comprehensive and freestanding, rather than an overarching document cross‐referencing many other documents (although the Inquiry also recommends a freestanding well control manual; this should be a guide to rig and onshore personnel on good oilfield practice). |
REC177-3305 | 32 - Doctrine, standards, and reform | Cement integrity should be evaluated wherever practicable by way of cement evaluation tests, rather than relying on pre‐operational calculations of cement and displacement fluid volumes. |
REC177-3323 | 32 - Doctrine, standards, and reform | Where multiple wells are drilled, operations and occurrences at one well must be carefully assessed for any implications with respect to well control at other wells. |
REC177-3352 | 32 - Doctrine, standards, and reform | The regulator, rather than the responsible Minister, should be given the power to direct an operator to use a particular rig for the purpose of well control operations, if appropriate in the circumstances, and the power should be used in the future if that rig is the best option available. This would necessarily involve the operator fully compensating for the use of the rig and any other associated costs. The Inquiry suggests that this power could be invoked and given effect as a condition of an operator’s licence. |
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. |
REC177-3285 | 39 - Disaster Risk Management | Pre‐drilling assessments should include a risk assessment of the worst‐case blowout scenario. |
REC177-3311 | 32 - Doctrine, standards, and reform | Horizontal or high angle penetration of a reservoir should be avoided wherever practicable until such time as the apparent problems associated with the cementing of a casing shoe in these situations are satisfactorily overcome. If a casing string does penetrate a well horizontally or at a high angle, standard practice should be to install two secondary barriers in addition to the cemented casing shoe. |
REC177-3328 | 32 - Doctrine, standards, and reform | All communications between on‐rig and onshore personnel relating to well control should be documented in a timely manner. |
REC177-3359 | 32 - Doctrine, standards, and reform | The National Plan should be reviewed to clarify the arrangements to apply in Commonwealth waters regarding key roles and responsibilities, including in relation to the ESC, in the event of an oil spill. This should also address any necessary training required. |
REC177-3296 | 32 - Doctrine, standards, and reform | Use of single strings of intermediate casing to penetrate hydrocarbon bearing zones should be carefully risk assessed. Multiple strings of intermediate casing have the advantage of isolating lost circulation zones and sealing off anomalous pressure zones. If intermediate casing is set in a hydrocarbon zone it should be treated as production casing. |
REC177-3316 | 32 - Doctrine, standards, and reform | Wells should be re‐entered with a BOP in place unless a documented risk assessment indicates that well control can be maintained at all times. |
REC177-3340 | 32 - Doctrine, standards, and reform | To better ensure that ‘risks’ are identified and managed in accordance with sound engineering principles and good oilfield practice, it is recommended that regulation 25(1)(a)(i) and (2)(a)(i) of the Management of Well Operations Regulations, be reworded as follows: ‘A titleholder must not commence / continue a well activity if…a well integrity hazard exists in relation to the well’. |
REC177-3367 | 32 - Doctrine, standards, and reform | Procedures and accountabilities should be established to ensure, in the event of a future incident, that: |
REC177-3275 | 32 - Doctrine, standards, and reform | Well Operations Management Plan (WOMPs) submitted by licensees to the regulator(s) should continue to be the primary framework document for achieving well integrity. |
REC177-3302 | 32 - Doctrine, standards, and reform | Industry, regulators, and training/research institutions should develop standards that address best practices for cementing operations (including liaising, as appropriate, with overseas regulators) with a view to overcoming problems which can effect the integrity of cemented casing shoes, annulus and cement plugs. |
REC177-3322 | 32 - Doctrine, standards, and reform | Batched drilling operations should only be undertaken after careful assessment of the special risks which such operations give rise to; well control must be maintained during the course of batched drilling operations. |
REC177-3350 | 32 - Doctrine, standards, and reform | The recommendations of the Inquiry in relation to suitable ways of achieving well integrity contained in Chapter 3 be included in a guidance manual that is issued for the assistance of industry and regulators. |
REC177-3377 | 32 - Doctrine, standards, and reform | The Minister consider legislative amendments to the OPGGS Act which make clear that |
REC177-3284 | 32 - Doctrine, standards, and reform | Memoranda of Agreement should be entered into between operators in relation to provision of emergency assistance in the event of blowouts. |
REC177-3309 | 32 - Doctrine, standards, and reform | If performance of barrier installation is outsourced by a licensee, the contractor (for example, the cementing company) should be engaged on terms which clearly require the provision of expert advisory services by the contractor with respect to barrier integrity. |
REC177-3327 | 32 - Doctrine, standards, and reform | Information relevant to well control must be captured and communicated within and between licensees and rig operators (and relevant third party contractors), in a manner which ensures it comes to the attention of relevant personnel. In particular, protocols should be developed to ensure that changes in shift and hitch do not operate as communication barriers. |
REC177-3356 | 39 - Disaster Risk Management | The regulator should pre‐assess and review in a generic sense, and in conjunction with the offshore petroleum industry, available options for well control in the event of a blowout. Being ‘match fit’ in this sense will enable a quicker and more effective response in terms of safety assessment, and will ensure that expectations of both operator and regulator are more readily aligned. |
REC177-3292 | 32 - Doctrine, standards, and reform | Licensees should be subject to an express obligation to inform regulators of the proposed removal of a barrier, even if they consider that well integrity is not thereby compromised. The information should be provided by way of special report, rather than included in a standard reporting document (such as a DDR). The information provided should include risk assessment details. Removal of a barrier should not take place without prior written approval of the relevant regulator(s). |
REC177-3315 | 32 - Doctrine, standards, and reform | PCCCs should be installed in a timely manner (for example, to prevent corrosion in the MLS apparatus). Non‐installation in order to park a BOP is not acceptable. |
REC177-3339 | 32 - Doctrine, standards, and reform | The Inquiry supports the objective (rather than prescriptive) approach to regulation now followed in Australia. However, the pendulum has swung too far away from prescriptive standards. In some areas relating to well integrity there needs to be minimum standards. |
REC177-3366 | 32 - Doctrine, standards, and reform | The National Plan should be reviewed: |
REC177-3301 | 32 - Doctrine, standards, and reform | The industry standard of two barriers should be replaced with the concept of ‘two or more barriers’ as a minimum standard. A minimum standard when operations proceed normally should never be regarded as a sufficient standard in other circumstances. |
REC177-3320 | 32 - Doctrine, standards, and reform | Any pro‐formas used by licensees, rig operators and contractors for recording information about installation of barriers should explicitly provide for ‘exception reporting’, that is, the form should include provision for recording any unforseen or untoward events which occur in the course of installation. |
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. |
REC177-3374 | 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. |
REC177-3283 | 32 - Doctrine, standards, and reform | A separate, identifiable barrier manual should be agreed upon and used by licensees, rig operators, and cementing contractors. These manuals should set out best industry practice in relation to achieving and maintaining well integrity. They should describe barrier types, barrier standards, general principles of well integrity, testing and verification methods and technologies, standard operating procedures (including procedures for the capture and communication of relevant information within and between relevant stakeholder entities). Barrier manuals should address blowout control during drilling, completion, re‐entry, tie‐back of casing strings and so on. Barrier manuals should be the subject of expert external review, and should be regularly updated. |
REC177-3308 | 32 - Doctrine, standards, and reform | Volumes of cement used in connection with barrier installation should be calculated with the assistance of a pro‐forma which records all relevant baseline data, which should be verified by onshore personnel. |
REC177-3326 | 32 - Doctrine, standards, and reform | Prior to commencement of drilling operations, senior representatives of the licensee and rig operator should exchange certificates to the effect that their respective key personnel and contractors have been informed in writing of agreed well control arrangements. |
REC177-3355 | 32 - Doctrine, standards, and reform | The Inquiry also supports Bills and Agostini’s recommendation: ‘…in relation to safety case development and compliance overall, that NOPSA revise its approach to interacting with operators prior to the safety case assessment process and subsequently direct more resources into its advisory functions. We further recommend that NOPSA develop and implement a formal plan for supporting and guiding each operator prior to safety case acceptance, as well as for ongoing compliance with that safety case, recognising the unique experience, capabilities and assessed risk of that operator. Each plan needs to include advice, education and liaison meetings with the operators. The plan needs to be continuously reviewed and reassessed based on the latest information, including the interaction with the operator’. |
Rec-ID | Code | Recommendation |
---|---|---|
REC154-3455 | 32 - Doctrine, standards, and reform | Department of Primary Industries (DPI) should broaden the focus of its planning for biosecurity to include a longer term horizon and demonstrate closer alignment with national planning frameworks. To support this DPI should: |
REC154-3460 | 32 - Doctrine, standards, and reform | To support increased effectiveness in EAD (Emergency Animal Disease) response management DPI should: |
REC154-3458 | 32 - Doctrine, standards, and reform | DPI should develop a surveillance strategy with agreed goals and a comprehensive, integrated approach to surveillance across the livestock value chain. The surveillance strategy should: |
REC154-3457 | 32 - Doctrine, standards, and reform | DPI should develop a strategy to deliver an integrated and coordinated approach to prevention and early detection across the livestock value chain. As part of the strategy DPI should: |
REC154-3456 | 32 - Doctrine, standards, and reform | DPI should more closely align planning and risk management processes to support its decision-making and response to changing priorities, capacity, capability and investment. |
Rec-ID | Code | Recommendation |
---|---|---|
REC150-3115 | 32 - Doctrine, standards, and reform | QFRS establish a structured risk management process for rural fire management, which involves regional and area offices, to enhance decision making processes and ensure opportunities are maximised and losses are minimised. This process should be linked to forward planning and incorporate existing processes such as: |
Rec-ID | Code | Recommendation |
---|---|---|
REC134-3521 | 32 - Doctrine, standards, and reform | To improve the management of the National Medical Stockpile, the ANAO recommends that the Department of Health and Ageing develop and implement procedures for: |
REC134-3519 | 32 - Doctrine, standards, and reform | The Australian National Audit Office (ANAO) recommends that the Department of Agriculture, Fisheries and Forestry and Animal Health Australia review: |
REC134-3522 | 32 - Doctrine, standards, and reform | To improve the effectiveness of deployment arrangements for the National Medical Stockpile, the ANAO recommends that the Department of Health and Ageing: |
Rec-ID | Code | Recommendation |
---|---|---|
REC132-3595 | 32 - Doctrine, standards, and reform | Development of framework document investigating future direction of VBIL including its role during incidents and its role in the transition from bushfire preparation to incident to bushfire recovery phases |
REC132-3592 | 32 - Doctrine, standards, and reform | Clarifying protocols for activating VBIL beyond normal working hours and for 24 hour activations |
REC132-3591 | 32 - Doctrine, standards, and reform | Joint development of templates for provision of core incident information by regional Incident Management Teams to CFA and DSE emergency coordination centres as basis for updates to the VBIL and other authorised information recipients |
Rec-ID | Code | Recommendation |
---|---|---|
REC129-3621 | 32 - Doctrine, standards, and reform | We recommend that NSW Health continue with its good work and establish a time table to finalise all emergency and contingency plans. |
REC129-3631 | 32 - Doctrine, standards, and reform | We recommend that NSW Health continue with its good work and continue to develop plans to respond to the surge in demand for diagnostic tests and for laboratory personnel. |
REC129-3630 | 32 - Doctrine, standards, and reform | We recommend that NSW Health continue with its good work and continue to develop systems to bring all the information relevant to the surge in demand for health resources together in real time. |
REC129-3626 | 39 - Disaster Risk Management | We recommend that NSW Health continue with its good work and consider a more structured and systematic approach to the planning and risk assessment of major infectious diseases to assist transparency and decision making. |
REC129-3622 | 39 - Disaster Risk Management | We recommend that NSW Health continue with its good work and consider building on influenza pandemic preparedness planning to develop broader contingency plans to address the emergence of other new, highly transmissible and/or severe infectious diseases. |
REC129-3632 | 32 - Doctrine, standards, and reform | We recommend that NSW Health continue with its good work and develop distinct surge capacity plans within each Area Health Service to manage emergency staffing needs, isolation facilities, intensive care units, assisted ventilation services, hospital beds and medical supplies. |
Rec-ID | Code | Recommendation |
---|---|---|
REC113-3904 | 39 - Disaster Risk Management | FESA should: in addition to its current initiatives, develop and implement structured programs (with clearly identified objectives, target groups and time lines for achievement) aimed at: |
REC113-3903 | 32 - Doctrine, standards, and reform | Government should: establish emergency management legislation which clarifies State and local government responsibilities, and which rectifies the deficiencies in the State’s bushfire Emergency Management Plan, Westplan Wildfire. |
Rec-ID | Code | Recommendation |
---|---|---|
REC112-3919 | 25 - Inquiry, audit, lessons management and after action review | That the model for state funding be reviewed to ensure that DPI can confidently build and maintain a core level of diagnostic expertise and research capability. |
REC112-3912 | 25 - Inquiry, audit, lessons management and after action review | That DPI, as part of the development of the Victorian plant biosecurity strategy, undertake a strategic review of its plant health planning framework so that: • corporate and business unit plans at all levels of the department align to each other and to government policy so that staff have a coherent frame of reference to guide their work • performance indicators are developed, used, reported against and evaluated regularly • all plans (including service agreements with other parts of DPI) are communicated to staff and implemented in their day-to-day activities and responsibilities. |
REC112-3910 | 32 - Doctrine, standards, and reform | That the Agricultural and Veterinary Chemicals (Control of Use) Act 1992, Plant Health and Plant Products Act 1995 and Livestock Disease Control Act 1994 be registered with the Department of Justice’s PERIN system. |
REC112-3932 | 25 - Inquiry, audit, lessons management and after action review | That DPI conducts and documents debriefs after all incursions, and adopts any improvements that are identified through debriefs. |
REC112-3908 | 32 - Doctrine, standards, and reform | That DPI develops a department-wide enforcement policy and specific guidelines for Plant Standards Branch (PSB). |
REC112-3924 | 32 - Doctrine, standards, and reform | That DPI develops diagnostic protocols for high-priority threats, in conjunction with other jurisdictions and industry, as soon as practicable. |
REC112-3907 | 25 - Inquiry, audit, lessons management and after action review | That Department of Primary Industries (DPI), in partnership with the Department of Sustainability and Environment, reviews all legislation relating to plant biosecurity with a view to streamlining the legislative framework. |
REC112-3922 | 25 - Inquiry, audit, lessons management and after action review | That DPI maintains ISO 9000 accreditation for at least one laboratory and seeks NATA accreditation for key diagnostic tests. This should be done in combination with Plant Health Australia’s laboratory accreditation project. |