Inquiry Search
Rec-ID | Code | Recommendation |
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REC322-4223 | 5 - Hazard reduction burns | The Inspector-General Emergency Management recommends the Department of Environment and Science implements the proposed treatments for fire identified in the Queensland Parks and Wildlife Service K’gari Compliance Strategy. |
REC322-4240 | 25 - Inquiry, audit, lessons management and after action review | The Inspector-General Emergency Management recommends the next review of the Queensland State Disaster Management Plan examines and provides guidance in respect to the application of Queensland’s disaster management arrangements to support hazard specific events such as bushfire. |
REC322-4246 | 25 - Inquiry, audit, lessons management and after action review | The Inspector-General Emergency Management recommends the Interagency Protocol for Fire Management be reviewed by all relevant entities, including representatives of the Butchulla people, and be updated as a matter of priority. Entities responsible for the protocol should implement a process for regular review and evaluation of its effectiveness. This review process should be conducted after a major bushfire event, or to reflect any material change to applicable legislation and policy. It should also consider pre-arranged approvals and a range of agreed fiscal protocols between the agencies. |
REC322-4218 | 25 - Inquiry, audit, lessons management and after action review | The Inspector-General Emergency Management recommends this report be returned to the IGEM to monitor, evaluate and report on progress and implementation of the recommendations that are accepted in whole or in part by government. |
REC322-4248 | 5 - Hazard reduction burns | The Inspector-General Emergency Management recommends the prescribed burn program for K’gari be developed by the Department of Environment and Science, in collaboration with the Locality Specific Fire Management Group and the Butchulla people, based on the principles of the National Position on Prescribed Burning. This program should incorporate a process for monitoring and evaluation of outcomes and integration of evolving fire management practices. |
REC322-4219 | 25 - Inquiry, audit, lessons management and after action review | The Inspector-General Emergency Management recommends should a Queensland Government Action Plan be considered, clarity about the intent of the recommendations be sought from the Inspector-General Emergency Management to assist in informing this process. |
REC322-4252 | 25 - Inquiry, audit, lessons management and after action review | The Inspector-General Emergency Management recommends Queensland Fire and Emergency Services regularly review and evaluate the effectiveness of the Queensland Bushfire Plan with land managers and stakeholders, including disaster management groups. A review should occur in line with any material change to the Queensland State Disaster Management Plan, the Disaster Management Act 2003, the Prevention Preparedness Response and Recovery Guideline, or after major bushfire events, to ensure appropriate alignment and currency. |
REC322-4220 | 25 - Inquiry, audit, lessons management and after action review | The Inspector-General Emergency Management recommends Queensland Fire and Emergency Services and the Department of Environment and Science monitor the progress of relevant improvement activities resulting from the K’gari (Fraser Island) Bushfire Review, through their respective lessons management programs. |
Rec-ID | Code | Recommendation |
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REC314-3272 | 10 - Infrastructure | Clarify business continuity and restoration of critical infrastructure in the planning and response phases to facilitate water replenishment, fireground remediation and access to businesses (including farming properties). |
REC314-3262 | 10 - Infrastructure | Invest in upgrading and integrating ICT platforms to eliminate manual data transfers, and ensure IT and radio communication interoperability across the agencies, together with a dedicated focus on the development of a coordinated risk intelligence capability to provide all stakeholders with a common operating picture and rapid damage assessments. |
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. |
Rec-ID | Code | Recommendation |
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REC308-2449 | 25 - Inquiry, audit, lessons management and after action review | Queensland should implement and maintain a system-wide lesson management program. |
REC308-2458 | 39 - Disaster Risk Management | A strategy should be developed to improve the availability of information to decision-makers and other audiences. Information should be searchable, more specific, timely, and allow stake-holders to find what they want. |
REC308-2454 | 10 - Infrastructure | Local disaster management groups should focus on the business continuity of local critical infrastructure and its integration with other plans. |
REC308-2452 | 39 - Disaster Risk Management | Planning and warnings for storm tide should be based on modelling that shows the chances of an event occurring (probabilistic). |
Rec-ID | Code | Recommendation |
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REC307-2436 | 39 - Disaster Risk Management | The outputs of these capabilities should be shared and actively inform the disaster management sector, including response operations and the creation of warnings and public messaging. |
REC307-2428 | 39 - Disaster Risk Management | The future risk of bushfires to Queensland communities should be re-evaluated as part of the 2020 State Risk Assessment in light of recent and emerging science, events and lessons. |
Rec-ID | Code | Recommendation |
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REC296-1352 | 10 - Infrastructure | A monthly testing regime needs to be developed that will allow the generator to be tested at full essential load capacity and to ensure that 4 hour monthly testing can be done every month. |
REC296-1357 | 10 - Infrastructure | Monthly test results need to be accurately recorded. |
REC296-1362 | 10 - Infrastructure | Carry out a detailed audit of the current Hospital essential loads to determine the current load requirements of the Hospital. |
REC296-1351 | 10 - Infrastructure | From the above assessment determine the existing generator load requirements and provide a new generator to meet those loads. |
REC296-1356 | 10 - Infrastructure | Accurate records need to be provided as to what is done for each service. |
REC296-1361 | 10 - Infrastructure | Prepare and carry out a testing regime and testing strategy and ensure testing of the generator is done every month for 4 hours over that month and under full Hospital load with test result recorded every 15 minutes. |
REC296-1350 | 10 - Infrastructure | Remove any loads that do not need to be on essential power. |
REC296-1355 | 10 - Infrastructure | Replacement of all original pipes and hoses not yet done. |
REC296-1360 | 10 - Infrastructure | Carry out regular load bank testing on the generator with a load bank large enough to fully load the generator to 110% which will clean out the engine and also identify whether the generator is capable of providing full load for a sustained length of time. |
REC296-1349 | 10 - Infrastructure | Conduct an assessment of the current essential loads and determine if there are loads that should not be on essential power. |
REC296-1354 | 10 - Infrastructure | Monthly and annual maintenance servicing needs to be scheduled for the generator to DPTI or CHSA schedule requirements. |
REC296-1359 | 10 - Infrastructure | Renegotiate the maintenance contract at the end of the current contract and have DPTI through AGFMA take on the maintenance contract. |
REC296-1353 | 10 - Infrastructure | Regular annual testing at 100% on a load bank needs to be scheduled into a maintenance schedule. |
REC296-1358 | 10 - Infrastructure | If the existing generator is capable of providing the current essential power requirements then the generator needs a major inspection and overhaul all items that may need to be replaced due to age and condition. This includes checking compression, oil pressure, coolant pumping and all other critical components and may actually require providing a temporary generator while the Hospital generator receives a major inspection and possible re build. A ball park figure to do this would be $50,000.00 plus cranage and transport to Detroit workshop probably another $10,000.00 then a temporary generator would need to be hired and installed which could run into $10’s of thousands of dollars depending on how long the engine was out of service. For the money that would be spent checking and rebuilding the existing engine it would be recommended to replace the generator with a new generator. |
REC296-1363 | 10 - Infrastructure | Due to the age of the generator, reliability and reparability risk due to age and the apparent under capacity of the generator it is recommend to replace the generator with a new generator and associated control system designed for the current load requirements and allowance for some future expansion. |
Rec-ID | Code | Recommendation |
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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 |
REC295-1317 | 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. |
REC295-1315 | 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. |
REC295-1297 | 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. |
REC295-1286 | 10 - Infrastructure | That the Attorney General’s Department consult with local government regarding potential for them to provide logistical support associated with backup power supply to SA Government Radio Network towers in the event of an emergency. |
REC295-1328 | 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. |
REC295-1279 | 10 - Infrastructure | Install UPS on traffic lights on main Central Business District (CBD) and arterial roads to allow an effective movement of traffic during a loss of power. |
REC295-1327 | 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. |
Rec-ID | Code | Recommendation |
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REC284-1369 | 10 - Infrastructure | Review all generator locations for arrangements for temporary generator installation, including design of modifications as required for electrical connections and spatial requirements at installation locations, to be documented in an emergency procedure. |
REC284-1374 | 10 - Infrastructure | Provide walls around critical electrical infrastructure within the main plant area to provide security and protection from catastrophic water system failures. |
REC284-1368 | 10 - Infrastructure | Improvements to installation to be implemented as follows: - Lighting within the generator enclosure and immediately adjacent to be emergency battery-backed type. - Improvements to the spatial layout within the main generator enclosure should be investigated, including allowance for the control panel door to open 180o (only 90o currently); moving the fuel pumps to a more accessible location, and ensuring clear access to the day tank for manual filling if required. - Improvements to communications facilities between critical areas, including fixed phone line connections between the main control room, main generator control panel in the P (energy) Building, and the generator enclosure, and allowing link to offsite specialist advice. - Where generator maintenance requires operations outdoors (not applicable to main generator, but applicable to others), a shelter over the relevant area should be provided to allow safe work during wet or hot weather. - Written emergency procedures to be prepared covering credible failure scenarios with step by step checklists and recommended actions. |
REC284-1373 | 10 - Infrastructure | Review generator installations details as noted in report and implement physical improvements where possible. |
REC284-1367 | 10 - Infrastructure | Add to generator test procedure a checklist at the end of testing which includes checking that all systems are back to normal positions and includes a requirement to leave the day tank full where there is a bulk tank/day tank arrangement. |
REC284-1372 | 10 - Infrastructure | As part of the electrical master plan update recommended above, a complete and consistent set of single line diagrams describing the electrical distribution network be prepared. Relevant diagrams to be laminated and displayed in the main substations. Labelling to all main electrical equipment be reviewed and updated in accordance with the final documents. |
REC284-1366 | 10 - Infrastructure | A detailed review of the fuel control and BMS systems (for all generators) be carried out and actions taken to: 1) Ensure that the fuel alarm system is operational and properly calibrated, and ensure that the alarms are connected to the BMS. 2) Ensure that the BMS transmits these alarms effectively to the maintenance staff. 3) If this review demonstrates risk of fuel control systems not adequately reporting alarms, consider an independent day tank level switch to be installed in each generator fuel tank, directly connected to the BMS. 4) Consider the feasibility of adding a “fuel system not in auto” or “fuel system fault/fail safe watchdog” or “pre-alarm identifying that the generator is about to shut down without intervention” feature to current systems – subject to details of each individual generator system. |
REC284-1371 | 10 - Infrastructure | Generator dual redundant starter systems should be considered. |
REC284-1365 | 10 - Infrastructure | The electrical master plan for the site should be updated to include planning for the scheduled replacement or refurbishment of those parts of the infrastructure that have not been renewed in the last 10 years. This planning to consider other upgrades or plans for the FMC overall. |
REC284-1370 | 10 - Infrastructure | Review control system for the main generator normal/essential changeover system and ensure that it has effective backup/manual or redundant operations, and suitable testing facilities. The Essential board that supplies the main generator power to Blocks A, B, C (except theatres), D, E (except certain critical engineering plant) (MD-1-4P-10E), is a potential single point of failure of a significant portion of the emergency power system and as part of the Master Plan update should be considered as a priority. |
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. |
Rec-ID | Code | Recommendation |
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REC241-0994 | 5 - Hazard reduction burns | That the Rural Fire Service Queensland needs to provide greater emphasis and acknowledgement of the use of fire as a tool in sustainable land management. |
REC241-1030 | 25 - Inquiry, audit, lessons management and after action review | That Rural Fire Brigades only be required to conduct an audit of finances if the Brigades income exceeds $5,000 for a financial year. RFSQ District offices should investigate options for savings on the costs of auditing Brigades in their district through either an in-house or external provider. Legal Status of Brigades |
REC241-0997 | 5 - Hazard reduction burns | That the electronic fire permit system used in the Mackay District be made available across the state for Fire Wardens who wish to use it. |
REC241-0996 | 5 - Hazard reduction burns | That Section 66 (2) of the Fire and Rescue Service Act 1990 relating to the exemption for issuing of permits to burn in State Forests, National Parks and Reserves is withdrawn and Departments must work within the District Fire Management Plan. |
REC241-0995 | 5 - Hazard reduction burns | At the next reprint of the ‘Permit to Light Fire’ book, the requirement to notify neighbours when applying for a permit is reinstated to properly reflect the requirement under the Fire and Rescue Service Act 1990. |
Rec-ID | Code | Recommendation |
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REC153-1777 | 5 - Hazard reduction burns | That the Minister for Emergency Services and the Minister for Local Government consider the enactment of legislation that would empower Local Government to require the owners or occupiers of rural land to create fire breaks on the land of a kind that Local Government may determine and/or to require the removal of flammable materials from the land, as measures for preventing the outbreak of a bushfire, or for preventing the spread or extension of a bushfire. |
Rec-ID | Code | Recommendation |
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REC150-3125 | 38 - Agency/Department Reporting | QFRS introduce a system to collate and analyse performance information for use in management reporting and to support effective decision making processes. |
Rec-ID | Code | Recommendation |
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REC139-3551 | 39 - Disaster Risk Management | The SA Country Fire Service to analyse the Coroner’s Report into the Wangary Bushfire 2005, and consider the relevant recommendations from this report in the implementation of the Ministerial Bushfire Management Review recommendations. |
REC139-3549 | 39 - Disaster Risk Management | The SA Country Fire Service investigates the establishment of a Minister’s Bushfire Risk Management Reward Scheme. |
Rec-ID | Code | Recommendation |
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REC136-3523 | 38 - Agency/Department Reporting | This Report should be considered for publication so that the insights, data, conclusions and recommendations are available within Queensland and other jurisdictions to assist with disaster management issues in the future. |