Inquiry Search
Rec-ID | Code | Recommendation |
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REC325-4330 | 38 - Agency/Department Reporting | The Inspector-General of Emergency Management recommends Queensland Fire and Emergency Services review the Queensland Emergency Alert Manual – M.1.174 in its entirety by 1 November 2023. The manual should specifically address the authorising environment, legislative obligations and the capability and complexities of the Emergency Alert system. |
REC325-4335 | 16 - Training and behaviour | The Inspector-General of Emergency Management recommends Queensland Fire and Emergency Services update and deliver training on the workflow reviewed (as per Recommendation 3) of the current Emergency Alert system to all persons responsible at a local, district and state level by 1 November 2022. Training should address system constraints and system complexities in addition to the process of requesting, composing (including Clear Explicit Translatable Language [CETL]), authorising and issuing Emergency Alerts. |
REC325-4339 | 38 - Agency/Department Reporting | The Inspector-General of Emergency Management recommends that Queensland Fire and Emergency Services review and update the State Disaster Risk Report, including re-evaluating the risk of flooding by all types. Queensland Fire and Emergency Services should publish the updated State Disaster Risk Report by 1 November 2023. |
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. |
REC325-4330 | 38 - Agency/Department Reporting | The Inspector-General of Emergency Management recommends Queensland Fire and Emergency Services review the Queensland Emergency Alert Manual – M.1.174 in its entirety by 1 November 2023. The manual should specifically address the authorising environment, legislative obligations and the capability and complexities of the Emergency Alert system. |
Rec-ID | Code | Recommendation |
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REC324-4295 | 11 - Evacuation and shelters | Roads: That, to improve the planning and protection of road infrastructure and to ensure communities, freight movers, combat agencies and emergency services have appropriate access and egress during and following a flood event, Government, through TfNSW and NSWRA and working with combat agencies and local and federal governments as needed, should: |
Rec-ID | Code | Recommendation |
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REC323-4274 | 11 - Evacuation and shelters | That the NSW Government establish a standing workforce from within the public service to staff evacuation and recovery centres, with this workforce to be trained ahead of time and mobilised as soon as a natural disaster occurs. |
REC323-4278 | 11 - Evacuation and shelters | That the NSW Government ensure that the current review of evacuation centres considers the role, accreditation and support of community evacuation centres, with the outcomes of this review to be made public and incorporated into the update of state emergency plans. |
REC323-4282 | 16 - Training and behaviour | That the NSW Government invest in the required personnel, training and vessels to ensure that all agencies involved in flood rescue can be mobilised to their fullest potential. |
REC323-4268 | 11 - Evacuation and shelters | That the NSW Government accelerate its caravan program and ensure it is made available as an option to all displaced residents from the February-March 2022 floods. |
Rec-ID | Code | Recommendation |
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REC311-2494 | 22 - Role of local Gvt | To increase shared understanding of risks, enable coordinated plans and collaboratively engage with downstream community members, residents listed within a dam EAP be identified by the Local Government Area (LGA) they reside in. |
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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REC309-2472 | 38 - Agency/Department Reporting | A single point of truth be established for accurately capturing and reporting on disaster management group activation levels for any given timeframe. |
REC309-2480 | 22 - Role of local Gvt | Councils should formalise arrangements with entities that have the skills, capability and capacity to effectively manage spontaneous volunteers. These should be documented and integrated into planning and exercising. |
REC309-2470 | 11 - Evacuation and shelters | Evacuation centre plans be revised to better manage vulnerable persons, including the safe storage of medications and providing alternate arrangements for evacuees with additional needs. (e.g. evacuation centre for aged persons). |
REC309-2478 | 25 - Inquiry, audit, lessons management and after action review | The progress of recovery for this event be reviewed incrementally over the next 2 to 3 years, with a formal, independent report provided on the effectiveness of the recovery after 3 years. |
REC309-2476 | 11 - Evacuation and shelters | Energy Queensland and local groups consider establishing formal arrangements that embed measures that assist evacuation plans to increase levels of safety. |
REC309-2474 | 16 - Training and behaviour | The provision of system-wide tools, education, guidance and testing for requests for assistance is strengthened to enhance understanding and outcomes. |
REC309-2473 | 22 - Role of local Gvt | Councils, with the support of stakeholders, continue to develop and promote local disaster dashboards as the ‘point of truth’ for community information and messaging during disaster events. Greater use during recovery should be considered. |
Rec-ID | Code | Recommendation |
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REC306-2424 | 22 - Role of local Gvt | We recommend that the four councils develop floodplain management plans in accordance with Recommendation 2.12 of the Final Report of the Queensland Floods Commission of Inquiry. |
Rec-ID | Code | Recommendation |
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REC002-4012 | 38 - Agency/Department Reporting | Complete sets of daily-report books should be provided, and kept in the mine or office, to be overlooked by the Inspector during his periodical visits. |
REC002-4009 | 16 - Training and behaviour | In gassy mines the Manager should be specially competent, and one possessing a thorough knowledge of the principles and practice of mining, the properties of gases, and systems of ventilation; and, above all, he must be prudent and cautious, yet resolute, possessing sound judgement. He must have absolute and supreme control over the whole operations, and of the men within the mine, to maintain rigid discipline, and be perfectly free and untrammelled by any outside influences. The competency of a manager should be certified by an examination before a specially-appointed Board. The Commission consider that better results may be obtained if such examinations be oral, and probably assume a more practical form than those hitherto conducted in Great Britain for the same object. |
Rec-ID | Code | Recommendation |
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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. |
REC297-1250 | 22 - Role of local Gvt | That in flood-prone municipalities, the respective Municipal Committee develops or reviews flood-related sub-plans within a Municipal Emergency Management Plan at least every two years and submits each sub-plan to the Regional Controller for approval. In addition, that each Municipal Committee maintains a current flood plan, in a standardised format, which at least identifies: • flood-prone parts of their locality, particularly those where lives may be at risk; • required actions to be taken in the event of a flood threat, especially timely evacuation; • trigger points for taking required actions and how those trigger points will be monitored; and • how the community can access flood-plan information |
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. |
REC297-1261 | 28 - Personal responsibility | That heightened awareness and action is needed by communities when BoM issues flood watches and related warnings. Councils and SES need to facilitate this. |
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. |
Rec-ID | Code | Recommendation |
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REC295-1328 | 25 - Inquiry, audit, lessons management and after action review | Update the SEMP Part 3, Annex F ‘Debriefs’ to provide more guidance regarding the types of debriefs, when they are required to be undertaken and at what level and guidance for undertaking and recording debriefs, and implementing lessons identified. |
REC295-1276 | 25 - Inquiry, audit, lessons management and after action review | That SA Health undertake a review of their emergency management arrangements. Health State Controllers should be consulted during this review and arrangements should be consistent throughout the department and across the State and compatible with State emergency management arrangements and information systems |
REC295-1313 | 16 - Training and behaviour | That regular training and exercising is conducted for all State Emergency Centre participants including Liaison Officers. |
REC295-1327 | 25 - Inquiry, audit, lessons management and after action review | Establish a lessons management capability across the SA emergency management sector to collect, analyse and track lessons identified during debriefs and reviews following events and other sources such as interstate and oversees reviews and inquiries. |
REC295-1303 | 16 - Training and behaviour | That the State Emergency Service be provided with resources to enable them to deliver swiftwater awareness training to all first responders including emergency services, SA Police and council crews. |
REC295-1324 | 16 - Training and behaviour | Establish a State incident management and emergency management training capability which provides for: a) consistent training across the State b) personal development and endorsement processes for roles c) identification, recruitment and development of personnel from other government agencies; and d) incident management and State emergency centre functional role training and development across all sectors. e) skills maintenance including upskills, refresher training and exercises f)incident and strategic leadership training g) consistent training for inter-agency liaison officers at all levels |
REC295-1302 | 28 - Personal responsibility | That the State Emergency Service together with the Local Government Association and Country Fire Service establish a plan for coordinated provision of sandbags to the public, including options for what is provided, where and when, and the process for effective communication of availability to the public. |
REC295-1321 | 16 - Training and behaviour | Through the Emergency Management Workforce Project, identify and provide training and development for SA’s emergency management sector personnel (government agencies, and non-government agencies including volunteers). State Emergency Management Committee should consider supporting recommendations from stage two of the project when the project report is tabled. |
REC295-1297 | 25 - Inquiry, audit, lessons management and after action review | Engage an independent business analyst to review the current call, receipt and dispatch process for emergency services i.e. the Metropolitan Fire Service, Country Fire Service and State Emergency Service, from the initial call for assistance through to response of emergency service resources, including the allocation and coordination of multiple taskings. |
REC295-1317 | 25 - Inquiry, audit, lessons management and after action review | Review representation in the State Emergency Centre including: a) determining if there is a more suitable functional support group e.g. the Procurement Functional Support Group, to replace the Logistics Functional Support Group, and if so, Chief Procurement Officer, DPC, has responsibility for the management of this role within the State Emergency Centre. b) That when the State Crisis Centre is not operating from a physical location, a State Crisis Centre liaison officer is attached to the State Emergency Centre. |
REC295-1284 | 16 - Training and behaviour | Deliver consistent and regular training in the use of the SA Government Radio Network to all users to maximise the efficiency and effectiveness of the network in times of emergency e.g. reduce the issues associated with network busy signals. |
REC295-1315 | 25 - Inquiry, audit, lessons management and after action review | That a review of the role and effectiveness of the State Emergency Management Committee (SEMC) including: the legislative functions; membership including the chair; roles and responsibilities; and, SEMC Advisory Groups be undertaken. |
Rec-ID | Code | Recommendation |
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REC281-1205 | 16 - Training and behaviour | Department of Premier and Cabinet Regional Coordinators: Continue to build the capability of the Department of Premier and Cabinet Regional Coordinator role in recovery operations by providing: · on the ground support for Regional Coordinators during recovery operations by REMOs or OEM Recovery Team · training and developmental opportunities for Regional Coordinators to prepare them for working in the disaster recovery environment. |
REC281-1203 | 22 - Role of local Gvt | Impact Assessment Data Sharing The Office of Emergency Management: · with the SEOCON, jointly provides further guidance to Regional Emergency Management Officers about their role in facilitating local council access to the Impact Assessment Data Base · with REMOs and the SEOCON jointly provides further information to local councils about Impact Assessment Data Sharing Arrangements and the data available through this mechanism · includes information about the Impact Assessment Data Sharing Arrangements in the Local Recovery Toolkit · develops a mechanism to allow local councils to have direct access to the collated impact data. |
REC281-1201 | 25 - Inquiry, audit, lessons management and after action review | Preventing Flood Related Fatalities: The NSW Government consider the recommendations from the Preventing Flood Related Fatalities Report when it is released. |
Rec-ID | Code | Recommendation |
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REC272-1421 | 16 - Training and behaviour | In conjunction with the Queensland Fire and Emergency Services review of guidelines, the Public Safety Business Agency should consider reviewing the cyclone shelter management training package to include guidance to the shelter management team on their roles and responsibilities, and powers available under legislation and how these may be exercised. |
REC272-1419 | 22 - Role of local Gvt | Opportunities should be identified through the Local Government Association of Queensland council to council arrangement to share structural engineers to assess potential places of refuge against the Department of Housing and Public Works’ structure classification criteria. |
REC272-1415 | 25 - Inquiry, audit, lessons management and after action review | An audit of all local government areas vulnerable to storm tide events is completed and opportunities identified to resolve gaps in evacuation zone planning to ensure consistency with the Queensland Evacuation Guidelines for Disaster Management Groups and neighbouring local government areas. |
Rec-ID | Code | Recommendation |
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REC271-1530 | 16 - Training and behaviour | Local Disaster Coordination Centre capability and capacity should be reviewed to ensure adequate staffing arrangements are in place to fill key positions, and that operational protocols are known and practiced across all functions to provide redundancy. Assistance for review and necessary training should be sought from key Local Disaster Management Group member agencies. |
Rec-ID | Code | Recommendation |
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REC267-1158 | 28 - Personal responsibility | Farm Management Deposits |
Rec-ID | Code | Recommendation |
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REC258-2541 | 16 - Training and behaviour | The Civil Aviation Safety Authority finalises its Capability Framework and overhauls its training program to ensure identified areas of need are addressed, including: |
REC258-2556 | 25 - Inquiry, audit, lessons management and after action review | The Civil Aviation Safety Authority structures all regulations not yet made with the three-tier approach, and subsequently reviews all other Civil Aviation Safety Regulation Parts (in consultation with industry) to determine if they should be remade using the three-tier structure. |
REC258-2534 | 16 - Training and behaviour | The Civil Aviation Safety Authority develops a staff exchange program with industry. |
REC258-2552 | 25 - Inquiry, audit, lessons management and after action review | The Civil Aviation Safety Authority implements a system of using third-party commercial audits as a supplementary tool to its surveillance system. |
REC258-2528 | 25 - Inquiry, audit, lessons management and after action review | The Australian Transport Safety Bureau investigates as many fatal accidents in the sport and recreational aviation sector as its resources will allow. |
REC258-2551 | 25 - Inquiry, audit, lessons management and after action review | The Civil Aviation Safety Authority assures consistency of audits across all regions, and delivers audit reports within an agreed timeframe. |
REC258-2549 | 25 - Inquiry, audit, lessons management and after action review | The Civil Aviation Safety Authority provides full disclosure of audit findings at audit exit briefings in accordance with international best practice. |
REC258-2542 | 16 - Training and behaviour | The Civil Aviation Safety Authority publishes and demonstrates the philosophy of ‘just culture’ whereby individuals involved in a reportable event are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training. However, actions of gross negligence, wilful violations and destructive acts should not be tolerated. |
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. |
REC250-0791 | 22 - Role of local Gvt | Local Government Victoria should lead the design and implementation of strategies to support councils to further develop social capital needed for recovery. |
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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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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REC236-2799 | 38 - Agency/Department Reporting | The committee recommends that the ATSB prepare and release publicly a list of all its identified safety issues and the actions which are being taken or have been taken to address them. The ATSB should indicate its progress in monitoring the actions every 6 months and report every 12 months to Parliament. |
REC236-2808 | 38 - Agency/Department Reporting | The committee recommends that in relation to mandatory and confidential reporting, the default position should be that no identifying details should be provided or disclosed. However, if there is a clear risk to safety then the ATSB, CASA and industry representatives should develop a process that contains appropriate checks and balances. |
REC236-2795 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that a short inquiry be conducted by the Senate Standing Committee on Rural and Regional Affairs and Transport into the current status of aviation regulatory reform to assess the direction, progress and resources expended to date to ensure greater visibility of the processes. |
REC236-2806 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that the relevant agencies investigate appropriate methods to ensure that information about the incidence of, and variable weather conditions at, Norfolk Island is available to assist flight crews and operators managing risk that may result from unforseen weather events. |
REC236-2793 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that CASA processes in relation to matters highlighted by this investigation be reviewed. This could involve an evaluation benchmarked against a credible peer (such as FAA or CAA) of regulation and audits with respect to: non-RPT passenger carrying operations; approach to audits; and training and standardisation of FOI across regional offices. |
REC236-2805 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that the relevant agencies review whether any equipment or other changes can be made to improve the weather forecasting at Norfolk Island. The review would include whether the Unicom operator should be an approved meteorological observer. |
REC236-2792 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that the investigation be re-opened by the ATSB with a focus on organisational, oversight and broader systemic issues. |
REC236-2801 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that the ATSB review its process to track the implementation of recommendations or safety actions to ensure it is an effective closed loop system. This should be made public, and provided to the Senate Regional and Rural Affairs and Transport Committee prior to each Budget Estimates. |
REC236-2788 | 16 - Training and behaviour | The committee recommends that, as far as available resources allow, ATSB investigators be given access to training provided by the agency's international counterparts. Where this does not occur, resultant gaps in |
REC236-2800 | 38 - Agency/Department Reporting | The committee recommends that where a safety action has not been completed before a report being issued that a recommendation should be made. If it has been completed the report should include details of the action, who was involved and how it was resolved. |
REC236-2787 | 16 - Training and behaviour | The committee recommends that the training offered by the ATSB across all investigator skills sets be benchmarked against other agencies by an independent body by, for example, inviting the NTSB or commissioning an industry body to conduct such a benchmarking exercise. |
Rec-ID | Code | Recommendation |
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REC234-2813 | 38 - Agency/Department Reporting | To strengthen its oversight of Queensland reconstruction progress, the Australian National Audit Office (ANAO) recommends that the National Disaster Recovery Taskforce: |
REC234-2810 | 38 - Agency/Department Reporting | The Australian National Audit Office (ANAO) recommends that the Australian Government Reconstruction Inspectorate and the National Disaster Recovery Taskforce seek to maximise the benefits from their value for money review activities by obtaining more timely and comprehensive information on project progress and completion from the Queensland Reconstruction Authority, to enable the preliminary value for money assessments to be finalised based on the scope and cost of works that were actually delivered (rather than estimates). |
Rec-ID | Code | Recommendation |
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REC232-2827 | 25 - Inquiry, audit, lessons management and after action review | The Australian Government, in consultation with state and territory governments, conduct a comprehensive national audit and mapping exercise to: |
REC232-2818 | 16 - Training and behaviour | The Royal Australian College of General Practitioners provide resources and training to general practitioners on the complex health needs of migrants and refugees, with a focus on identifying infectious diseases which are notifiable in Australia, or diseases which are of specific concern to refugee and migrant communities. |
REC232-2815 | 25 - Inquiry, audit, lessons management and after action review | The Department of Health and Ageing review the existing evidence base to evaluate the cost-effectiveness of its policy to use heat scanners at ports of entry as a measure to mitigate the risk of infectious disease importation. |
REC232-2828 | 25 - Inquiry, audit, lessons management and after action review | The Australian Government, in consultation with state and territory governments, commission an independent review to assess the case for establishing a national centre for communicable disease control in Australia. The review should outline the role of a national centre and how it might be structured to build on and enhance existing systems. It should examine different models, considering a range of options for location, governance and staffing. The review should incorporate a cost-benefit analysis for each of the models presented. |
Rec-ID | Code | Recommendation |
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REC217-1819 | 22 - Role of local Gvt | In consultation with local communities, local councils will develop flood response plans as subplans to their current Municipal Emergency Management Plans. As part of the flood risk assessment process, these plans will be informed by the best available flood mapping and modelling, and will identify agreed activities to be undertaken during floods including, where appropriate, the construction of temporary levees. The condition of levees will be incorporated into such plans to enable improved emergency response. |
REC217-1840 | 25 - Inquiry, audit, lessons management and after action review | The state government implement the Victorian Floods Review recommendation 8, to review the flood gauging network. As part of the review, consideration should also be given to the use of portable telemetered river gauges, and to the replacement of manual gauges with telemetered gauges over time and where appropriate. |
REC217-1825 | 22 - Role of local Gvt | When developing flood mitigation options in lowland areas, local governments should give consideration to the use of temporary levees as an alternative or addition to permanent structures. To maximise the use of these structures and limit flood damage, and aid affordability, consideration should be given by local governments to the sharing of temporary levees among different townships and different council areas. |
Rec-ID | Code | Recommendation |
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REC216-2871 | 22 - Role of local Gvt | Efficient and effective supporting tools and processes: high-quality local/municipal planning. |
Rec-ID | Code | Recommendation |
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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. |
REC210-0651 | 22 - Role of local Gvt | When approving applications for development which involve the manufacture or storage of hazardous materials, councils should not restrict the conditions imposed to ones which are solely reliant on human intervention to remove the materials in the event of flood. |
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. |
REC210-0668 | 22 - Role of local Gvt | Councils should review their assessment processes to ensure that: • the person with primary responsibility for the assessment of the development application considers what expert input is required • where a development application is subject to comment by a number of professionals, the responsibilities and accountability of each contributor are clear • where flood-related information is referred to an expert for advice, the expert is required to comment on the extent of compliance by reference to each relevant assessment criteria and identify and explain any inability to comment. |
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. |
REC210-0630 | 22 - Role of local Gvt | If the Queensland Government does not include a requirement for such an overlay map in the model flood planning controls, councils should include a flood overlay map in their planning schemes. The map should identify the areas of a council region: • that are known not to be affected by flood • that are affected by flood and on which councils impose planning controls (there may be subsets in each area to which different planning controls attach) • for which there is no flood information available to council. |
REC210-0687 | 22 - Role of local Gvt | The Bundaberg Regional Council should investigate the adequacy of the drain and take reasonable steps to ensure the Moore Park area is effectively served. |
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. |
REC210-0650 | 22 - Role of local Gvt | If the Queensland Government does not include such assessment criteria in the model flood planning controls, councils should include assessment criteria in their planning schemes that require that: a. the manufacture or storage of bulk hazardous materials (as defined in State Planning Policy 1/03) take place above a certain flood level, determined following an appropriate risk based assessment, or b. structures on land susceptible to flooding and used for the manufacture or storage of bulk hazardous materials (as defined in State Planning Policy 1/03) be designed to prevent the intrusion of floodwaters |
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. |
REC210-0667 | 22 - Role of local Gvt | If the Queensland Government does not include such a policy in the model flood planning controls, councils should include a planning scheme policy in their planning schemes that sets out the information to be provided in development applications in relation to stormwater and flooding. The policy should specify: • the type of models and maps to be provided • the substantive information required to be shown in the development application • how the assumptions and methodologies used in preparing the models and maps should be presented • the form in which the information on stormwater and flooding is to be presented in the application. |
REC210-0724 | 28 - Personal responsibility | Councils should consider making available to business owners locality specific information that would assist them to develop evacuation plans for commercial premises, for example, any evacuation sub-plan created under Emergency Management Queensland’s disaster evacuation guidelines. |
REC210-0610 | 22 - Role of local Gvt | Councils in floodplain areas should, resources allowing, develop comprehensive floodplain management plans that accord as closely as practicable with best practice principles. |
REC210-0679 | 28 - Personal responsibility | If the Queensland Development Code is amended to include provisions requiring homeowners to install sewage reflux valves, the Queensland Government should develop and make available to homeowners appropriate guidance material to assist them in meeting their responsibilities to maintain reflux valves. |
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. |
REC210-0648 | 22 - Role of local Gvt | Councils should ensure that, when applications for environmentally relevant activities are approved by a council, the details of those activities, including their nature and location, are provided to the Department of Environment and Resource Management. |
REC210-0769 | 22 - Role of local Gvt | Toowoomba Regional Council and the Department of Environment and Resource Management should continue to co-operate to assess the referable dam status of existing detention basins and any future detention basins constructed in the West Creek and East Creek catchment areas. |
REC210-0663 | 22 - Role of local Gvt | If the Queensland Government does not include such assessment criteria in the model flood planning controls, councils should consider including assessment criteria in their planning schemes that address: • the prospect of isolation or hindered evacuation • the impact of isolation or hindered evacuation. |
REC210-0723 | 28 - Personal responsibility | Councils should support and encourage business owners to develop private flood evacuation plans by providing the following to business owners in areas known to be affected by flood: • information about the benefits of evacuation plans • contact details of relevant council and emergency service personnel for inclusion in evacuation plans. |
REC210-0608 | 22 - Role of local Gvt | Elected representatives from all agencies involved in a flood study should be informed of recommendations made for future work, and determine, on a risk basis, whether that further work is to be completed. |
REC210-0671 | 22 - Role of local Gvt | Councils should consider providing advice to development applicants during pre-lodgement meetings, and at the time of receiving a development application, about the way in which the development will be assessed for flood risk and what flood information council will be relying on to make this assessment. |
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. |
REC210-0643 | 22 - Role of local Gvt | If the Queensland Government does not include such assessment criteria in the model flood planning controls, councils should include assessment criteria in their planning schemes that require the impact of flood on commercial property to be minimised. |
REC210-0768 | 22 - Role of local Gvt | Toowoomba Regional Council should engage external consultants to carry out failure impact assessments on the detention basins along East Creek. |
REC210-0655 | 22 - Role of local Gvt | If the Queensland Government does not include such assessment criteria in the model flood planning controls, councils should consider including assessment criteria in their planning schemes which require that works in a floodplain: • do not reduce on-site flood storage capacity • counteract any changes the works will cause to flood behaviour of all floods up to and including the acceptable defined flood event by measures taken within the subject site (for example, use of compensatory works, detention basins or other engineering mechanisms), and • do not change the flood characteristics outside the subject site in ways that result in: – loss of flood storage – loss of/changes to flow paths – acceleration or retardation of flows, or – any reduction in flood warning times elsewhere on the floodplain. |
REC210-0607 | 22 - Role of local Gvt | Elected representatives from councils should be informed of the results of each flood study relevant to the council’s region, and consider the ramifications of the study for land planning and emergency management. |
REC210-0670 | 22 - Role of local Gvt | Councils should not rely on a condition requiring an evacuation plan as the sole basis for approving a development susceptible to flooding. |
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. |
REC210-0641 | 22 - Role of local Gvt | If the Queensland Government does not include such assessment criteria in model flood planning controls, councils should include assessment criteria in their planning schemes that require community infrastructure (including the types of community infrastructure which are identified in the Sustainable Planning Regulation 2009 and which the community needs to continue functioning, notwithstanding flood) to be located and designed to function effectively during and immediately after a flood of a specified level of risk. |
REC210-0698 | 22 - Role of local Gvt | Councils should consider implementing a property buy-back program in areas that are particularly vulnerable to regular flooding, as part of a broader floodplain management strategy, where possible obtaining funding from the Natural Disaster Resilience Program for this purpose. |
REC210-0766 | 16 - Training and behaviour | Wide Bay Water should, in addition to its usual wet season preparations and maintenance, undertake the following activities in advance of each wet season: Queensland Floods Commission of Inquiry | Final Report 29 Complete list of Final Report recommendations • conduct training for personnel on dam operation, including contingency plans for the situation in which one or more of the gates is inoperable • hold meetings of key personnel of Wide Bay Water involved in the operation of the dam during floods, which: – in addition to any other matters, inform staff about the current status of the gates, dam operation strategies and contingency plans for the situation in which one or more of the gates is inoperable – are recorded in minutes which document the information provided and are made available to all operational staff. |
REC210-0653 | 22 - Role of local Gvt | Councils (particularly Brisbane City Council) should consider including in their planning schemes more stringent standards for the design and construction of prescribed tidal work than those in the code for development applications for prescribed tidal work in the Coastal Protection and Management Regulation 2003. |
REC210-0775 | 16 - Training and behaviour | The Department of Environment and Resource Management should conduct periodic dam safety information and education sessions with emergency management personnel including those from Emergency Management Queensland, local and district disaster management groups and local councils. Priority should be given to sessions if the Bureau of Meteorology forecasts a wet season with a greater than 50 per cent chance of above median rainfall. |
REC210-0605 | 22 - Role of local Gvt | As far as is practicable, councils should maintain up-to-date flood information |
REC210-0669 | 22 - Role of local Gvt | Councils should take care when imposing conditions to ensure that each condition has purpose; standardised conditions should not be included where they have no application to the development in question. |
REC210-0734 | 16 - Training and behaviour | Emergency Management Queensland should simplify the process by which SES members gain recognition for prior qualifications so that unnecessary duplication of training can be avoided. |
REC210-0632 | 22 - Role of local Gvt | If the Queensland Government does not include such a code in the model flood planning controls, councils should include in their planning schemes a flood overlay code that consolidates assessment criteria relating to flood. |
REC210-0688 | 22 - Role of local Gvt | All councils should periodically conduct risk assessments to identify areas at risk of backflow flooding. In respect of such areas, councils should consider how such risks can be lessened, including in that process consideration of the installation of backflow prevention devices. Backflow devices should not, however, be installed unless and until a full risk based assessment has been undertaken. |
Rec-ID | Code | Recommendation |
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REC208-0526 | 25 - Inquiry, audit, lessons management and after action review | That OEH’s testing procedures for determining the impact of pollution incidents incorporate additional requirements for the checking and verification of results before those results are released. |
Rec-ID | Code | Recommendation |
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REC199-0463 | 16 - Training and behaviour | the state: • ensure an appropriate regime of regular emergency management training and exercising is introduced. This must be ‘all hazards’ and multi-agency focused and include all relevant stakeholders • designate an accountable officer to hold ongoing responsibility for conducting such exercises; and • designate the Emergency Services Commissioner as holding ongoing responsibility for auditing and reviewing this training and exercising. |
REC199-0415 | 16 - Training and behaviour | the state ensure that all personnel who are likely to become involved in incident management teams for floods receive basic flood awareness training prior to such involvement. |
REC199-0462 | 16 - Training and behaviour | the state introduce a joint emergency management leadership training program that will deliver critical core competencies for all levels of management of major emergencies. Future appointments to senior operational emergency management positions should require successful accreditation at the appropriate level. |
REC199-0486 | 22 - Role of local Gvt | the state, following the completion of the Municipal Association of Victoria Improving Emergency Management in Local Government program, work with municipalities to revise the role and responsibilities of local government in emergency management. The issue of capability and capacity of each local government should be addressed in all related emergency management arrangements. |
REC199-0414 | 16 - Training and behaviour | the state ensure that all personnel who, because of their particular flood expertise, are likely to be potential participants in an Incident Control Centre are familiar with the requirements of the Australasian Inter-service Incident Management System structure |
REC199-0450 | 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 |
REC199-0482 | 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. |
REC199-0407 | 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. |
REC199-0448 | 16 - Training and behaviour | the state ensure that sector wide familiarity and understanding of the various systems for incident management is developed and maintained. Primarily, this should be achieved through multi-agency emergency management training and exercising involving usage of the various agency incident management systems. |
REC199-0475 | 16 - Training and behaviour | the Department of Planning and Community Development review the volunteer register and examine additional options to support councils in volunteer management, including the development of tools and staffing support. |
REC199-0401 | 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. |
REC199-0445 | 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. |
REC199-0468 | 22 - Role of local Gvt | municipal councils undertake a risk assessment of caravan parks and decide if any should be included in the list of facilities where vulnerable people may be located. |
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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC164-0075 | 16 - Training and behaviour | SERCon consider development of an education program for other government and non-government agencies (with |
REC164-0073 | 25 - Inquiry, audit, lessons management and after action review | SERCon consider that the proposed State Recovery Committee provide an interim report to government on these and |
Rec-ID | Code | Recommendation |
---|---|---|
REC158-3428 | 38 - Agency/Department Reporting | That the nominated marine safety authority, in consultation with the Emergency Services Commissioner and senior emergency services personnel, is responsible for monitoring the implementation and auditing against appropriate performance standards, risk management guidelines and good practice guidelines. |
REC158-3452 | 25 - Inquiry, audit, lessons management and after action review | That the nominated marine safety authority undertakes a further assessment to determine the recommendations from this Review that may also be applicable to State waters outside commercial port waters. |
REC158-3429 | 38 - Agency/Department Reporting | That the nominated marine safety authority is required to ensure that incident notification and data recording requirements for Victorian commercial ports are consistent and adhered to. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC149-3138 | 38 - Agency/Department Reporting | The current KPI measures used by the Regulator and industry need to be reassessed and the performance indicators need to be related to the risk profiles of the industry. The industry needs to develop the indicators, which need to be agreed and measured by the industry in discussion with other stakeholders. The KPI's selected should be published in comparison with the worldwide offshore industry and with other industries. NOPSA should continue discussions with Australian Safety and Compensation Council (ASCC) with a view to adopting their goals. |
REC149-3137 | 16 - Training and behaviour | As professional competency is one of the key pillars of any Safety Case, commitment to training for current and future needs remains a fundamental requirement for achieving best practice outcomes in safety. Industry should be encouraged to build on its training commitment now being made to achieve a competent and fully accredited workforce over the next five years. |
REC149-3136 | 16 - Training and behaviour | There is a need for industry in consultation with NOPSA to establish a priority programme of accredited education modules in the Safety Case regime targeting stakeholders in the regime at their respective levels to improve the understanding of the Safety Case and correspondent responsibilities. |
Rec-ID | Code | Recommendation |
---|---|---|
REC148-3175 | 25 - Inquiry, audit, lessons management and after action review | That the officer responsible for the importation of horses arrange for Biosecurity Australia to review, at least once every two years, the operating procedures to ensure that they adequately identify and manage the risk of entry and spread of equine influenza associated with the importation of horses into Australia. The outcome of each such review should be the subject of a written report and recommendations to the person responsible for the importation of horses and the Executive Director of AQIS. A determination should then be made as to whether any, and if so what, changes should be made to the operating procedures. |
REC148-3170 | 25 - Inquiry, audit, lessons management and after action review | That the officer responsible for the importation of horses arrange for Biosecurity Australia to conduct within six months, an inspection and review of the process of horse importation from the time horses arrive in Australia until the completion of their post-arrival quarantine in order to: |
REC148-3167 | 25 - Inquiry, audit, lessons management and after action review | That the facilities at Eastern Creek and Spotswood Quarantine Stations be reviewed by AQIS in consultation with experts in biosecurity and interested parties including state and territory governments, import agents, veterinarians, farriers, operators of private quarantine stations, and representatives of horse owners, horse racing organisations and equestrian organisations. There should in any event be constructed without delay, an adequate supply of hygienic, modern showering facilities and places of entry and exit to the stations and the horse sections of them that can be supervised and monitored continually. There should also be provided at those stations as soon as is practicable suitable means of electronic surveillance, including closed-circuit television; a secure place to store chemicals, drugs, instruments and equipment for use by people attending the quarantined horses, and a set of horse stalls and yards separate from the main stalls and yards to enable isolation of horses suffering from contagious or infectious diseases. These reviews should also consider the desirability of separate areas in quarantine stations to hold horses forming part of a single quarantine intake but that have been imported from different regions or have undergone pre-export quarantine in different places. The reviews should be carried out without delay, and the two quarantine stations should be upgraded in accordance with the recommendations of the reviews. |
REC148-3154 | 25 - Inquiry, audit, lessons management and after action review | That the officer responsible for the importation of horses arrange for Biosecurity Australia or another qualified body to inspect and review the activities and events that occur from the time horses enter pre-export quarantine until the time they arrive at an airport in Australia, in order to identify any biosecurity risks and recommend any necessary changes to import conditions or other requirements. This inspection and review shall be performed without delay for each country or region from which horses are imported to Australia, and it should take account of my other recommendations and comments in this report. |
REC148-3182 | 25 - Inquiry, audit, lessons management and after action review | That Biosecurity Australia review that formal import risk analysis at least once every two years to take into account any relevant developments in scientific knowledge—specifically testing methods, vaccines, vaccination procedures and other matters that affect biosecurity. Reports on the reviews should be provided to the officer responsible for the importation of horses and should contain recommendations for any necessary changes to policies for importation. |
REC148-3149 | 38 - Agency/Department Reporting | That there be established the position of Inspector General of Horse Importation, the duties of that position being: |
REC148-3178 | 38 - Agency/Department Reporting | That the officer responsible for the importation of horses prepare a report to the Executive Director of AQIS that: |
Rec-ID | Code | Recommendation |
---|---|---|
REC137-3532 | 16 - Training and behaviour | I recommend that CASA reconsider the introduction of measures to ensure the efficiency of training and checking organisations for air transport operations. I recommend that this include the way in which particular training needs of an air operator’s flight crew are to be identified (including recurrent training and CRM training) and how those needs are to be met by approved or certified training and checking organisations. |
REC137-3530 | 16 - Training and behaviour | I recommend that Civil Aviation Safety Authority (CASA) expedite the introduction of mandatory crew resource management training. |
Rec-ID | Code | Recommendation |
---|---|---|
REC129-3625 | 38 - Agency/Department Reporting | We recommend that NSW Health continue with its good work and establish a performance management framework with targets and indicators to assess progress in preparing for infectious disease emergencies. |
Rec-ID | Code | Recommendation |
---|---|---|
REC128-3601 | 38 - Agency/Department Reporting | That, as a matter of principle, the NSW Government provide public reports on the lessons learned from emergency exercises which it manages or in which it participates. If necessary, such reports should exclude material which might jeopardise security. |
REC128-3609 | 16 - Training and behaviour | That the Department of Primary Industries be conscious of its responsibilities in maintaining the continued enthusiasm of Industry Liaison Officers and offer training and refresher training as required. |
REC128-3598 | 25 - Inquiry, audit, lessons management and after action review | That the Department of Primary Industries incorporates reviews of plans and operating procedures as a result of emergency incidents and exercises and ensures that there is adequate commitment from all participants in the review process. |
REC128-3608 | 16 - Training and behaviour | That emergency animal health training be included in induction programs for newly recruited District Veterinarians and all District Veterinarians be encouraged to maintain their skills by attending regular refresher training as appropriate. |
REC128-3607 | 16 - Training and behaviour | That the Department of Primary Industries should continue efforts to develop the skills of private sector veterinarians to increase the level of resources available in emergency responses. |
REC128-3605 | 38 - Agency/Department Reporting | That the Department of Primary Industries make every effort to meet its targets for the TSE program and encourage public and private sector veterinarians across the State to submit samples. The Department should include reports on its performance against these targets in annual reports. |
REC128-3602 | 38 - Agency/Department Reporting | That the Department’s performance against tactical and strategic benchmarks be regularly reported in annual reports or animal and plant health emergency evaluation reports and compared to other jurisdictions where possible. |
REC128-3619 | 38 - Agency/Department Reporting | That the Department of Primary Industries should ensure the roles and capacities of Rural Lands Protection Boards and industry are effectively monitored to enable assessment of the effectiveness of animal health programs. |
Rec-ID | Code | Recommendation |
---|---|---|
REC125-3901 | 22 - Role of local Gvt | That councils formulate, track and report on measures that show their performance in managing drainage assets. |
REC125-3899 | 22 - Role of local Gvt | That councils implement a condition assessment and monitoring program conforming to best practice principles. |
REC125-3898 | 25 - Inquiry, audit, lessons management and after action review | That agencies develop a detailed improvement plan and commit resources to its implementation. |
REC125-3896 | 22 - Role of local Gvt | That councils plan for, and implement, formal consultation arrangements with stakeholders to set drainage goals and objectives, and desired service levels. |
REC125-3894 | 22 - Role of local Gvt | That councils develop flood risk management practices consistent with best practice risk management, and that these incorporate: |
Rec-ID | Code | Recommendation |
---|---|---|
REC121-3693 | 25 - Inquiry, audit, lessons management and after action review | ITSRR should ensure that, as a condition of accreditation, each of these recommendations is carried into effect and should audit against them to enforce compliance. |
REC121-3744 | 16 - Training and behaviour | All RailCorp operational personnel should be trained in the location and operation of external emergency door release mechanisms. |
REC121-3713 | 25 - Inquiry, audit, lessons management and after action review | Recommendations one to seven of the final report of the Special Commission of Inquiry into the Glenbrook Rail Accident should be fully implemented, save that the random auditing referred to in recommendations five and seven should be carried out by ITSRR. |
REC121-3757 | 25 - Inquiry, audit, lessons management and after action review | RailCorp should conduct internal and external safety audits to evaluate the adequacy of its safety management system and to ensure that any risk control measures are effective. |
REC121-3669 | 16 - Training and behaviour | All operational rail staff should be trained by RailCorp in the action check list relevant to each. |
REC121-3718 | 16 - Training and behaviour | Training should be based upon a needs analysis, to determine what skills a particular person will require to carry out the tasks of any position safely and efficiently, and instruction and practice, to acquire and demonstrate those skills. |
REC121-3775 | 38 - Agency/Department Reporting | The Minister for Transport Services must table in Parliament, each such quarterly report by ITSRR. |
REC121-3691 | 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. |
REC121-3729 | 38 - Agency/Department Reporting | All reports of the Chief Investigator of OTSI should be delivered, upon completion and without being reviewed, to ITSRR and the Minister for Transport Services. |
REC121-3712 | 38 - Agency/Department Reporting | RailCorp and ITSRR should co-operate with national programs for the collection, collation, trend analysis and dissemination of safety critical information. |
REC121-3756 | 16 - Training and behaviour | RailCorp should ensure that where the safety competency of any manager is deficient such manager is required to undertake professional development courses to raise his or her safety competency level to an adequate standard. |
REC121-3654 | 16 - Training and behaviour | All train guards should be trained by RailCorp in the use of the Metronet radio and instructed to use it in any emergency. |
REC121-3717 | 16 - Training and behaviour | RailCorp must establish a task analysis for particular categories of employees, to identify the specific skills and responsibility of those employees or groups of employees, and thereafter undertake a training needs analysis, to develop the skills required in particular areas. |
REC121-3774 | 38 - Agency/Department Reporting | The ITSRR must provide a quarterly report to the Minister for Transport Services on the progress made by RailCorp in implementing these recommendations, including: |
REC121-3677 | 16 - Training and behaviour | A training centre for emergency services personnel should be established by RailCorp. The emergency services personnel should be required to undertake training at such a centre, which should be equipped with features replicating railway infrastructure and rolling stock. |
REC121-3726 | 25 - Inquiry, audit, lessons management and after action review | The OTSI should continue to conduct rail accident investigations on behalf of ITSRR and report directly to the Chief Executive of ITSRR. |
REC121-3704 | 28 - Personal responsibility | RailCorp should continue its system of voluntary self-identification and rehabilitation of employees with alcohol or drug related problems. |
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. |
REC121-3650 | 16 - Training and behaviour | Staff at the Rail Management Centre (RMC) should receive training from RailCorp to enable them to quickly and accurately assess that an emergency has occurred and to provide precise and reliable information to emergency response personnel about the location of the emergency, the available access to the site and the resources necessary. |
REC121-3716 | 16 - Training and behaviour | Train driver and guard training should encourage teamwork and discourage authority gradients. |
REC121-3768 | 25 - Inquiry, audit, lessons management and after action review | The ITSRR, when considering a re-application for accreditation, should conduct a field audit of the organisation to ensure that it is carrying on its activities in accordance with the basis upon which it seeks accreditation. |
REC121-3675 | 16 - Training and behaviour | All rail employees should be trained by their employer to commence any emergency communication with the words “Emergency, emergency, emergency”, thereafter to identify themselves, the train, its location, what has occurred, the approximate passenger load and whether death or injuries have occurred. |
REC121-3723 | 38 - Agency/Department Reporting | All ATSB accident investigation reports should be made public. |
REC121-3697 | 38 - Agency/Department Reporting | All train drivers’ defects reports should be entered by RailCorp into a computerised record and tracked to finalisation. |
REC121-3751 | 16 - Training and behaviour | RailCorp should make it a condition of employment that all level 2 managers have or obtain a formal qualification in system safety management. |
REC121-3715 | 16 - Training and behaviour | RailCorp should use its simulators to train drivers and guards in methods of dealing with degraded operations on the rail network. |
REC121-3765 | 25 - Inquiry, audit, lessons management and after action review | The ITSRR should conduct field audits to satisfy itself that all accredited rail organisations conduct their activities in accordance with the safety management system on the basis of which each was accredited. |
REC121-3672 | 16 - Training and behaviour | All emergency response personnel should be specifically trained in the features of railways which are relevant to their work, such as the location and means of operation of all emergency door releases on trains, the location and use of signal telephones, the methods by which electrical power can be isolated and the means by which they can readily identify and obtain information from the on-site rail commander. |
REC121-3722 | 38 - Agency/Department Reporting | The ATSB should deliver any report of any such rail accident which it investigates to the Board of any rail organisation involved in the accident, ITSRR and the Minister for Transport Services. |
REC121-3694 | 25 - Inquiry, audit, lessons management and after action review | The ITSRR should conduct random audits of accredited rail organisations for compliance with communications protocols. |
REC121-3746 | 16 - Training and behaviour | All emergency services personnel should be trained in the location and operation of emergency door release mechanisms on all rail cars. |
REC121-3714 | 16 - Training and behaviour | RailCorp should use its simulators in an interactive manner. |
REC121-3758 | 25 - Inquiry, audit, lessons management and after action review | Following completion of any external audit, a corrective action plan to remedy any identified safety deficiencies should be developed by RailCorp, implemented and followed up within the business groups affected, to ensure appropriate and timely completion of the action plan, by a formal examination of the effectiveness of the controls put in place. Senior management personnel should certify that the corrective action plan has been implemented and is effective. Senior management personnel should be accountable for any such certification. |
REC121-3670 | 16 - Training and behaviour | The RailCorp emergency response plan should be provided to all emergency response agencies. The officers of each emergency service should be trained in any rail specific features of the plan, so as to better ensure inter-agency co-ordination in the circumstances of an emergency. |
REC121-3719 | 16 - Training and behaviour | The position of team leader should be created by RailCorp to be responsible for a group of approximately 30 train drivers, with responsibility to ensure that each train driver’s training needs are being met and that any safety concerns of train drivers are being properly addressed. The team leaders are to have direct access to the Chief Executive of RailCorp if any safety concerns they have are not addressed. |
REC121-3776 | 38 - Agency/Department Reporting | The Minister for Transport Services should retain, independently of ITSRR, safety auditors to provide a report to the Minister confirming or qualifying the contents of each such ITSRR quarterly report. |
Rec-ID | Code | Recommendation |
---|---|---|
REC112-3922 | 25 - Inquiry, audit, lessons management and after action review | That DPI maintains ISO 9000 accreditation for at least one laboratory and seeks NATA accreditation for key diagnostic tests. This should be done in combination with Plant Health Australia’s laboratory accreditation project. |
REC112-3919 | 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. |
REC112-3916 | 16 - Training and behaviour | That DPI reviews the work of entry level graduates to ensure career paths are clear and encourage the retention of staff. |
REC112-3932 | 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. |
REC112-3912 | 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. |
REC112-3931 | 16 - Training and behaviour | That DPI ensures that AIIMS training includes information to ensure that everyone understands their role, and how information will be managed internally and externally, in the event of an incursion. |
REC112-3907 | 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. |
REC112-3930 | 16 - Training and behaviour | That DPI provides plant incursion-specific AIIMS training for anyone who might be involved in, or providing resources for, an incursion response. This includes senior management, field and research staff, contractors and industry participants. |
Rec-ID | Code | Recommendation |
---|---|---|
REC008-3990 | 16 - Training and behaviour | The Commission recommends that more than one means of exit should be provided in every mine from every level of it to the surface; and that the miners should be kept informed where they are situated. |
REC008-3984 | 16 - Training and behaviour | The Commission recommends that the live parts of resistances should be fixed so that no unprotected combustible material is within 6ins of the frames or cases containing them or within 24ins measured vertically above. |