Inquiry Search
Rec-ID | Code | Recommendation |
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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. |
REC309-2472 | 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. |
REC309-2471 | 17 - Assets and technology | As part of the annual Emergency Action Plan review for the Ross River Dam, consideration should be given to the potential impacts of operating the gate outside automatic mode and whether this event has provided any new information and learnings which can be incorporated into the Emergency Action Plan. This should occur prior to the 2019/20 wet season. |
REC309-2469 | 12 - EM agency and authority | Entities with disaster management responsibilities need to integrate the eight priorities identified within the Emergency Management Sector Adaptation Plan for Climate Change into their disaster management planning cycle. |
Rec-ID | Code | Recommendation |
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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. |
REC295-1325 | 12 - EM agency and authority | Review and reinstate the State Emergency Management Training Officer and State Emergency Management Planning Officer (capability development) positions to operate with a broad, strategic and leadership focus. |
REC295-1300 | 17 - Assets and technology | That the State Emergency Service explores options for providing suitable personal protective clothing to personnel from supporting emergency services during major flooding events and sandbagging operations. |
REC295-1322 | 12 - EM agency and authority | Consider opportunities to identify synergies between the incident management systems used in SA being the, Australasian Interservice Incident Management System (AIIMS) and ICCS Plus. This might include joint training and exercising in roles that are common across both systems. |
REC295-1299 | 17 - Assets and technology | That systems for Automatic Vehicle Location and personnel tracking be implemented within the emergency services sector. |
REC295-1320 | 17 - Assets and technology | Review existing electronic information systems used by emergency services organisations and other government agencies, and: a) establish a single incident information system across the Emergency Services Sector (MFS, CFS and SES), and b) identify opportunities to consolidate incident information systems of other agencies |
REC295-1335 | 12 - EM agency and authority | Explore alternative emergency management models including the alternative model proposed above to establish a South Australian Emergency Management Office and State Relief and Recovery Office within the South Australian Fire and Emergency Services Commission, to ensure that all the objects and guiding principles of the Emergency Management Act 2004, and State Emergency Management Plan are addressed efficiently and effectively. |
REC295-1298 | 12 - EM agency and authority | That the State Emergency Service, in consultation with key stakeholders, identify and implement a robust system and procedures for prioritising, allocating and coordinating multiple tasks. |
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. |
REC295-1328 | 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. |
REC295-1297 | 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. |
REC295-1315 | 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. |
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. |
REC295-1276 | 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 |
Rec-ID | Code | Recommendation |
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REC292-2345 | 12 - EM agency and authority | I recommend that the New South Wales Police Force establish procedures and the technical capability to ensure that phone calls from hostages in sieges or the victims of other ongoing high-risk situations are expeditiously transferred to officers involved in responding to the incident. |
REC292-2355 | 12 - EM agency and authority | I recommend that the New South Wales Police Force review its procedures to ensure that handovers between negotiation teams are staggered so that a fully briefed officer is always available to receive a call from the stronghold. |
REC292-2354 | 12 - EM agency and authority | I recommend that the New South Wales Police Force consider expanding the panel of psychological advisers it retains and the range of disciplines it consults. |
REC292-2349 | 12 - EM agency and authority | I recommend that the New South Wales Police Force review its personnel arrangements and structures for the monitoring of surveillance devices, including the number of officers allocated to a listening or viewing post for monitoring purposes, and the demarcation of roles, including primary monitor, scribe/log keeper, and disseminator. I also recommend that clear communication channels be established for reporting data captured during such surveillance, including via integrated electronic intelligence sharing platforms or applications. |
REC292-2370 | 25 - Inquiry, audit, lessons management and after action review | I recommend that the New South Wales Police Force undertake a formal assessment of alternatives to the TOU’s current soft-point ammunition to determine whether a more appropriate form of ammunition is reasonably available. |
REC292-2348 | 17 - Assets and technology | I recommend that if it has not already done so, the New South Wales Police Force acquires the audio surveillance technology that in similar circumstances would allow a device to be monitored in the Police Forward Command Post and/or the Police Operations Centre and that the organisation ensures that its capacity in this regard keeps pace with technological advances in the area. |
REC292-2357 | 12 - EM agency and authority | I recommend that the New South Wales Police Force review its policy of requiring negotiators to relinquish that role when they are promoted to commissioned officer rank |
REC292-2346 | 12 - EM agency and authority | I recommend that the New South Wales Police Force investigate the development of an integrated intelligence system that allows selected officers secure access to all information platforms and to record and share operational decisions. |
REC292-2356 | 12 - EM agency and authority | I recommend that the New South Wales Police Force review the number, rank and function of the officers comprising the Negotiation Unit |
Rec-ID | Code | Recommendation |
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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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REC272-1415 | 25 - Inquiry, audit, lessons management and after action review | An audit of all local government areas vulnerable to storm tide events is completed and opportunities identified to resolve gaps in evacuation zone planning to ensure consistency with the Queensland Evacuation Guidelines for Disaster Management Groups and neighbouring local government areas. |
REC272-1414 | 12 - EM agency and authority | Queensland Fire and Emergency Services coordinate the development of an integrated risk based approach to disaster management planning for Queensland that is consistent with the Standard and applicable at all levels of the arrangements. |
REC272-1418 | 12 - EM agency and authority | Queensland Fire and Emergency Services should consider examining regulatory provisions to improve disaster management and business continuity planning for aged care providers. |
Rec-ID | Code | Recommendation |
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REC267-1158 | 28 - Personal responsibility | Farm Management Deposits |
Rec-ID | Code | Recommendation |
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REC232-2824 | 41 - Emergency Management exercises | The Australian Department of Health and Ageing consult with members of the general public or representatives of health consumers in the pandemic planning process, including in pandemic exercises designed to test the ability of government to respond to a pandemic event. Consumer involvement should include testing the ability of any communication strategy designed to inform and engage consumers about a pandemic event. |
REC232-2822 | 41 - Emergency Management exercises | The Australian Government test Australia’s ability to respond to a widespread outbreak of infectious disease other than influenza, by undertaking a pandemic exercise across the relevant Commonwealth, state and territory government agencies. |
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. |
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: |
Rec-ID | Code | Recommendation |
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REC177-3329 | 17 - Assets and technology | Logistics management of well control equipment should be conducted in such a way as to operate as a check against deficient well control practices, for example, use of serial numbers to track availability, testing, and deployment of well control equipment. |
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. |
REC177-3290 | 38 - Agency/Department Reporting | The successful installation of every barrier should be the subject of written verification within and between licensees and rig operators; and should be the subject of explicit reporting to the relevant regulator(s). |
REC177-3338 | 12 - EM agency and authority | Licensees and rig operators should be astute in ensuring that corporate systems and culture encourage rather than discourage raising of well control issues. For instance, do performance bonuses or rewards actually encourage or discourage reporting of issues? Is there a system in place to enable anonymous reporting of well control concerns? What whistleblower protections are in place? |
REC177-3287 | 38 - Agency/Department Reporting | Licensees should be subject to an express obligation to inform regulators of problems which arise in the course of installing barriers, 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. |
REC177-3337 | 12 - EM agency and authority | Supervision/oversight of well control operations (within licensees, rig operators and by regulators) must occur without assuming adherence to good oilfield practice. The opposite assumption should prevail: namely adherence to good oilfield practice may well be compromised by the pursuit of time and cost savings. |
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. |
REC177-3336 | 12 - EM agency and authority | Achievement and maintenance of well control should be written into the job responsibilities of key personnel, at every level up to and including CEOs. That is, a functional line of accountability for well control must exist up to, and including, CEOs. |
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. |
REC177-3336 | 12 - EM agency and authority | Achievement and maintenance of well control should be written into the job responsibilities of key personnel, at every level up to and including CEOs. That is, a functional line of accountability for well control must exist up to, and including, CEOs. |
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. |
Rec-ID | Code | Recommendation |
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REC169-2997 | 38 - Agency/Department Reporting | The Department of Premier and Cabinet and Victoria Police, in consultation with departments, should standardise reporting on training exercises conducted under Part 6 of the Act and the CIP framework to promote greater consistency and to enable better identification of lessons learned and continuous improvement. |
REC169-2989 | 38 - Agency/Department Reporting | The Department of Premier and Cabinet should lead the development of a performance management framework for measuring, monitoring and reporting on the implementation of Part 6 of the Act and the CIP framework. The framework should include key indicators, targets and reporting arrangements for assessing the extent to which departments, agencies and industry have fulfilled their obligations, as well as measures for monitoring achievement of joint objectives. |
REC169-2998 | 38 - Agency/Department Reporting | Reports on the training exercises should be retained in an appropriately secured central repository so that consolidated results of the exercises can be drawn together effectively. |
Rec-ID | Code | Recommendation |
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REC154-3459 | 41 - Emergency Management exercises | To improve response preparedness, DPI should clearly link the selection of simulation exercises to the risk management framework to target coverage of high risks. |
REC154-3462 | 41 - Emergency Management exercises | DPI should formalise the approach and framework for evaluating simulation exercises and response to Emergency Animal Disease incidents with guidelines to define the nature of the review process. This should include: |
Rec-ID | Code | Recommendation |
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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. |
REC148-3182 | 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. |
REC148-3154 | 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. |
REC148-3178 | 38 - Agency/Department Reporting | That the officer responsible for the importation of horses prepare a report to the Executive Director of AQIS that: |
REC148-3149 | 38 - Agency/Department Reporting | That there be established the position of Inspector General of Horse Importation, the duties of that position being: |
REC148-3177 | 12 - EM agency and authority | That the officer responsible for the importation of horses ensure that: |
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. |
Rec-ID | Code | Recommendation |
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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. |
REC129-3624 | 41 - Emergency Management exercises | We recommend that NSW Health continue with its good work and formally establish and oversight a comprehensive program of training, testing and evaluation of plans at the state, area and facility level. |
REC129-3623 | 41 - Emergency Management exercises | We recommend that NSW Health continue with its good work and apply the lessons learnt from Exercise Cumpston to further improve preparedness for major infectious disease emergencies. |
REC129-3628 | 41 - Emergency Management exercises | We recommend that NSW Health continue with its good work and continue to develop and test the capability of its contact tracing system to deal with a public health emergency. |
REC129-3627 | 41 - Emergency Management exercises | We recommend that NSW Health continue with its good work and continue to develop and test its surveillance systems for early detection of infectious diseases. |
Rec-ID | Code | Recommendation |
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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. |
REC128-3601 | 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. |
REC128-3619 | 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. |
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. |
REC128-3612 | 12 - EM agency and authority | That the Department of Primary Industries should ensure that it retains the services of a specialist poultry industry liaison officer in the future. |
REC128-3611 | 12 - EM agency and authority | That the Department of Primary Industries should endeavour to improve its knowledge and skills base in the pig industry by recruiting a specialist pig industry liaison officer. |
Rec-ID | Code | Recommendation |
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REC117-3638 | 41 - Emergency Management exercises | The ANAO recommends that the Attorney-General’s Department, in consultation with the Department of the Prime Minister and Cabinet and the National Counter-Terrorism Committee: |
REC117-3637 | 41 - Emergency Management exercises | The ANAO recommends that the Attorney-General’s Department, in consultation with the Department of the Prime Minister and Cabinet and the National Counter-Terrorism Committee, pursue a more strategic and systematic approach to the measurement of performance via the National Capability Development Exercise Programme by: |
REC117-3636 | 41 - Emergency Management exercises | The ANAO recommends that the Attorney-General’s Department, in conjunction with the National Counter-Terrorism Committee’s exercise management advisers, explore options for the incorporation of more contemporary and varied testing and training aids in the National Capability Development Exercise Programme. |
REC117-3634 | 41 - Emergency Management exercises | The ANAO recommends that the Attorney-General’s Department, in consultation with the Department of the Prime Minister and Cabinet and the National Counter- Terrorism Committee, pursue the adoption of a more strategic approach to determining the National Capability Development Exercise Programme so that: |
REC117-3641 | 38 - Agency/Department Reporting | The ANAO recommends that, to ensure the outcomes of evaluations are effectively used to enhance the national counter-terrorism arrangements, the Attorney-General’s Department and the Department of the Prime Minister and Cabinet take appropriate measures to ensure: |
REC117-3633 | 38 - Agency/Department Reporting | The ANAO recommends that, to provide better information to contribute to strategic assessments, decisions and reporting, the Attorney-General’s Department, with input and guidance from the Department of the Prime Minister and Cabinet: |
REC117-3639 | 41 - Emergency Management exercises | The ANAO recommends that the Attorney-General’s Department, in consultation with the National Counter-Terrorism Committee, strengthens the reporting on the National Capability Development Exercise Programme through: |
Rec-ID | Code | Recommendation |
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REC112-3912 | 25 - Inquiry, audit, lessons management and after action review | That DPI, as part of the development of the Victorian plant biosecurity strategy, undertake a strategic review of its plant health planning framework so that: • corporate and business unit plans at all levels of the department align to each other and to government policy so that staff have a coherent frame of reference to guide their work • performance indicators are developed, used, reported against and evaluated regularly • all plans (including service agreements with other parts of DPI) are communicated to staff and implemented in their day-to-day activities and responsibilities. |
REC112-3921 | 17 - Assets and technology | That the recommendations of the 2000 DPI report into the reference collection’s storage facility be implemented, to secure the collection in a purpose-built facility. |
REC112-3909 | 12 - EM agency and authority | That PSB’s enforcement procedures are consistent with those of the rest of the department. |
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. |
REC112-3907 | 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. |
REC112-3917 | 12 - EM agency and authority | That DPI improves monitoring and surveillance of high priority threats and improves the quality of information provided to the Commonwealth. |
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. |
REC112-3915 | 12 - EM agency and authority | That DPI makes arrangements to use contract labour for fruit fly trap monitoring and surveillance before the predicted fruit fly outbreak season. |
REC112-3923 | 12 - EM agency and authority | That DPI negotiates access, as and when required, to an AQIS PC4- accredited laboratory. |
REC112-3914 | 12 - EM agency and authority | That DPI develops a consistent approach to recording and enforcing breaches of the certification and verification system. |
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. |