Inquiry Search
Rec-ID | Code | Recommendation |
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REC325-4321 | 25 - Inquiry, audit, lessons management and after action review | The Inspector-General of Emergency Management recommends this report be returned to the Office of the Inspector-General of Emergency Management to monitor, evaluate, and report on progress and implementation of the recommendations that are accepted in whole or in part by government. |
REC325-4331 | 41 - Emergency Management exercises | The Inspector-General of Emergency Management recommends Queensland Fire and Emergency Services conduct annual exercises with every local disaster management group and district disaster management group to confirm the process for developing, approving and issuing of an Emergency Alert, including the use of pre-formatted polygons and messages. Upon completion of the initial statewide exercise, Queensland Fire and Emergency Services will furnish an exercise evaluation report to the Office of the Inspector-General of Emergency Management by 1 November 2023. |
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. |
Rec-ID | Code | Recommendation |
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REC324-4299 | 1 - Land-use and building regs | Relocating communities most at risk with good homes and amenities: That, to empower vulnerable people and communities to relocate, Government through the NSWRA: |
REC324-4300 | 1 - Land-use and building regs | Simplify the planning system disaster provisions: That, to simplify and improve the state planning processes especially when anticipating and recovering from a disaster, Government: |
REC324-4303 | 39 - Disaster Risk Management | Risk-based approach to calculating flood planning: That, to take account of greater knowledge of climate change, Government reinforce its adoption of a risk-based approach to calculating the flood planning level for planning purposes and, through the NSWRA, immediately start a process of revising all flood planning level calculations in the state’s high-risk catchments. Flood planning level re-determinations for all high-risk catchments should be completed within 3 years. These revised flood planning levels will need to be factored into all development applications (in-progress and new) in those high-risk catchments. The risk profile of high-risk catchments should be revisited at appropriate time intervals to check that levels are current. A review should take place if there has been a significant trigger event (i.e. changed rainfall, development) or at least every 5 years. As well as reviewing the flood planning level, this 5-yearly review should include reviewing any floodplain lease conditions and adjusting them as necessary in the light of better knowledge of climate change impacts. In working out a tolerable, risk-based flood planning level, consideration should be given to the PMF, 1% AEP, 0.02% AEP, existing development, approved but not yet constructed developments, and existing and approved but not yet constructed evacuation routes. |
REC324-4304 | 1 - Land-use and building regs | Landholders can access information on previous disasters: That, to ensure there is a single source of ground truth to prepare for and respond to emergencies, and to provide people with a better understanding of their individual property and community risk exposure, an online visualisation tool be developed to display, for all land parcels (land titles) in NSW, the extent of known disasters that have affected each piece of land in NSW in the past. This information should be made available through the Planning Portal and, particularly in light of climate change, the data involved should be revised and updated at least every two years and after each major natural disaster. |
REC324-4305 | 39 - Disaster Risk Management | Cost benefit framework:That, to enable a more systematic prioritisation of investment options in risk mitigation before, during and immediately following a natural disaster event, Government adopt and utilise a Disaster Cost Benefit Framework. This Framework will enable Government to estimate the investment required for any given disaster, starting with flood events, and will enable the fast allocation of funding based on detailed and rapid analysis of flood and property modification, mitigation, preparation, response and finance related options including: |
REC324-4296 | 1 - Land-use and building regs | Caravan parks and manufactured home estates: That, to ensure that permanent residents of caravan parks and mobile housing estates are protected from flood, Government: • prohibit permanent residency in caravan parks and mobile housing estates situated below the risk-based flood planning level. Caravan parks for holiday makers could still be on the floodplain with the provision that, if a flood is imminent, they need to be evacuated • address the issues raised in the 2015 Discussion Paper (Improving the regulation of manufactured homes, caravan parks, manufactured home estates and camping grounds). |
REC324-4310 | 41 - Emergency Management exercises | Task Force Hawk: That, to ensure disaster readiness, Government establish a high-level Government standing committee, Task Force ‘Hawk’, comprising key Cabinet Ministers, Secretaries and Commissioners that meets, trains and exercises to ensure Government is prepared to respond to any emergency. Task Force ‘Hawk’ should resonate with the community in difficult times to ensure the highest level of confidence in Government’s response. |
Rec-ID | Code | Recommendation |
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REC323-4257 | 1 - Land-use and building regs | That the NSW Government work with local government, industry and sustainable planning experts, including the Government Architect, on policy initiatives in the New South Wales planning system that will help deliver more resilient and sustainable homes, buildings and places. |
REC323-4258 | 39 - Disaster Risk Management | That the NSW Government significantly increase its investment in flood mitigation and preparation, including its support of local governments to do the same, by: • increasing ongoing, long term funding and access to technical guidance and assistance for local councils • ensuring that land-use planning and development takes a risk-based approach. |
REC323-4266 | 1 - Land-use and building regs | That the NSW Government review the provision of temporary and long term housing options provided to those affected by the February-March 2022 floods, with a view to: • ensuring a range of options are identified and embedded within emergency and recovery plans, so that solutions can be implemented as soon as possible after a natural disaster • ensuring that housing options meet individual and community needs • removing planning impediments that prevent those from accessing more safe and secure housing in times of crisis. |
REC323-4267 | 1 - Land-use and building regs | That the NSW Government consider investing in supporting relocations, land swaps and providing fair and adequate compensation for landowners who wish to relocate from severely flood-impacted areas. |
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. |
REC323-4290 | 20 - Role of police | That the NSW Government embed into its emergency plans the appointment of a senior police officer with combat experience to lead recovery efforts following natural disasters. |
Rec-ID | Code | Recommendation |
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REC311-2493 | 41 - Emergency Management exercises | To increase shared understanding of risks and enhance capability integration and collaborative planning, both Local Disaster Management Group (LDMG) participate in the exercising of the Paradise Dam Emergency Action Plan. |
REC311-2499 | 39 - Disaster Risk Management | To ensure enhanced capability integration and enable timely community messaging Bundaberg LDMG in consultation with Sunwater develop additional Emergency Alerts and associated polygons for a Paradise Dam failure and load these on to the disaster management portal. |
REC311-2492 | 39 - Disaster Risk Management | To increase understanding of hazards and manage risks, dam failure for Paradise Dam be included as a separate risk within the North Burnett Local Disaster Management Plan (LDMP). |
REC311-2498 | 39 - Disaster Risk Management | To enhance shared capacity and collaboratively manage risk, the Chair of the Bundaberg DDMG use the QERMF process to determine if dam failure for Paradise Dam should be reported as a residual risk in this instance due to known changes in the risk profile to: |
REC311-2491 | 10 - Infrastructure | To enable a shared understanding of the risk, changes in the risk profile of referable dams be clearly communicated by entities that own dams to stakeholders and the community likely to be affected. The communication process starts immediately after the change is identified, is tailored to its audience, makes clear the scale of the change, and is documented so that stakeholders and the community can make informed decisions for managing risks. |
REC311-2497 | 39 - Disaster Risk Management | To increase shared understanding of risks, ensure the coordination of plans and manage risks, dam failure for Paradise Dam be included as a separate risk within the Bundaberg District Disaster Management Plan (DDMP). |
REC311-2490 | 39 - Disaster Risk Management | To enable entities to have a shared understanding of forecast information for dam failure events during a flood, including flood wave travel time, speed and height, Emergency Action Plans contain protocols and responsibilities of relevant stakeholders for these aspects. |
REC311-2496 | 10 - Infrastructure | To enhance shared capacity and collaboratively manage risk, the Chair of the Bundaberg LDMG use the Queensland Emergency Risk Management Framework (QERMF) process to determine if dam failure for Paradise Dam should be reported as a residual risk to the Bundaberg DDMG in this instance due to known changes in the risk profile. |
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. |
REC311-2495 | 10 - Infrastructure | To increase understanding of hazards and manage risks, dam failure for Paradise Dam be included as a separate risk within the Bundaberg LDMP. |
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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REC309-2474 | 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. |
REC309-2478 | 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. |
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. |
REC308-2466 | 41 - Emergency Management exercises | Exercising should focus on vertical integration and include all levels of the system. A strategic program of exercises should be developed and implemented. |
REC308-2464 | 16 - Training and behaviour | The provision of system-wide education, guidance and testing to enhance requests for Assistance is strengthened. |
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 |
---|---|---|
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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REC297-1259 | 25 - Inquiry, audit, lessons management and after action review | That DPIPWE examines the Forest Practice Code 2015 for relevance of its concepts to farming and other business activities near rivers, streams and naturally occurring dams and makes recommendations to Government accordingly. |
REC297-1258 | 25 - Inquiry, audit, lessons management and after action review | That DPIPWE examines the WMAwater report along with its own, analyses the differences, consults with the Forest Practices Authority and Environment Protection Authority, and proposes an appropriate course of action to Government. |
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. |
REC297-1272 | 1 - Land-use and building regs | That, to provide greater clarity for building development, design and approval within tolerable risk levels, the Tasmanian Planning Scheme, including a relevant Riverine Flood Hazard Code, is finalised and approved as soon as practicable. |
REC297-1271 | 1 - Land-use and building regs | That the organisations responsible for construction, maintenance and ownership of bridges review their design guidelines and, if necessary, update them to specifically include consideration of debris and flood impacts on bridge design. A review of existing bridges by the responsible organisations could also be undertaken to highlight any potential issues. |
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. |
Rec-ID | Code | Recommendation |
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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. |
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. |
Rec-ID | Code | Recommendation |
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REC295-1278 | 20 - Role of police | That SA Police develop an evacuation plan for the Adelaide Central Business District (CBD) which includes: |
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. |
REC295-1317 | 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. |
REC295-1276 | 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 |
REC295-1297 | 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. |
REC295-1328 | 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. |
REC295-1286 | 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. |
REC295-1313 | 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. |
REC295-1284 | 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. |
REC295-1307 | 20 - Role of police | That, as with earthquake, SA Police be designated the Control Agency under the State Emergency Management Plan for black system events or other major power outages. |
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 |
REC295-1279 | 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. |
REC295-1304 | 20 - Role of police | That SA Police, as the control agency for search and rescue, and State Emergency Service who have the responsibility for providing search and rescue services under the State Emergency Management Plan, develop a swiftwater rescue capability plan that describes key swiftwater risk locations, roles and responsibilities of emergency services, State swiftwater resources and dispatch arrangements. |
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. |
Rec-ID | Code | Recommendation |
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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. |
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. |
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. |
REC281-1201 | 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. |
REC272-1415 | 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 |
---|---|---|
REC267-1153 | 4 - Fire season preparation | Planning for Access to Potentially Isolated Communities |
REC267-1162 | 10 - Infrastructure | Telecommunications and Power Infrastructure |
Rec-ID | Code | Recommendation |
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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. |
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. |
Rec-ID | Code | Recommendation |
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REC250-0796 | 25 - Inquiry, audit, lessons management and after action review | The Department of Premier and Cabinet should lead: x the development of an evaluation framework, based on work undertaken to date by the Department of Human Services, to be used in assessing the impact of relief and recovery programs in the recent floods and in future disaster events x an evaluation of the impact of relief and recovery programs in the recent floods, using this framework. |
REC250-0790 | 25 - Inquiry, audit, lessons management and after action review | The Department of Justice should review the current model for rapid impact assessment to improve the quality of the information collected. |
Rec-ID | Code | Recommendation |
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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. |
REC238-0801 | 1 - Land-use and building regs | Establish a dedicated group or body within an existing agency to provide a more integrated, coordinated and regional approach to land use, infrastructure and evacuation planning and flood modelling in the Hawkesbury-Nepean Valley. |
REC238-0816 | 1 - Land-use and building regs | Ensure appropriate consideration of flood risk in regional and subregional planning |
REC238-0800 | 1 - Land-use and building regs | Improve regional transport infrastructure to address current and projected flood evacuation capacity constraints and timelines. |
REC238-0815 | 1 - Land-use and building regs | Provide improved land use planning tools for managing flood prone land. |
REC238-0814 | 1 - Land-use and building regs | Develop a NSW Planning Policy and Guideline to improve land use planning practices on flood prone land. |
REC238-0808 | 1 - Land-use and building regs | Ensure future road infrastructure planning considers flood evacuation requirements throughout the Hawkesbury-Nepean floodplain. |
Rec-ID | Code | Recommendation |
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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. |
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. |
REC236-2795 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that a short inquiry be conducted by the Senate Standing Committee on Rural and Regional Affairs and Transport into the current status of aviation regulatory reform to assess the direction, progress and resources expended to date to ensure greater visibility of the processes. |
REC236-2793 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that CASA processes in relation to matters highlighted by this investigation be reviewed. This could involve an evaluation benchmarked against a credible peer (such as FAA or CAA) of regulation and audits with respect to: non-RPT passenger carrying operations; approach to audits; and training and standardisation of FOI across regional offices. |
REC236-2792 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that the investigation be re-opened by the ATSB with a focus on organisational, oversight and broader systemic issues. |
REC236-2806 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that the relevant agencies investigate appropriate methods to ensure that information about the incidence of, and variable weather conditions at, Norfolk Island is available to assist flight crews and operators managing risk that may result from unforseen weather events. |
REC236-2788 | 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 |
REC236-2805 | 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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC227-2849 | 20 - Role of police | I recommend that the AFP takes steps to ensure that there are on Christmas Island at all times appropriately trained AFP officers who have completed the National Police Search and Rescue Manager’s Course and that upskilling should be ongoing to establish a cadre of trained search and rescue personnel. |
Rec-ID | Code | Recommendation |
---|---|---|
REC217-1812 | 1 - Land-use and building regs | Streamlined processes to enable access to levees for the purposes of conducting works, including maintenance, must be implemented. Where a levee is managed by a public authority as part of a formal scheme, and is sited on either private land, or on a mixture of public and private land, access to private land for works will be negotiated as part of any scheme agreement. Where a levee is sited on public land, but is not managed by a public authority, local beneficiaries willing to conduct maintenance will be given access to do so, provided: |
REC217-1821 | 1 - Land-use and building regs | Where flood investigations show positive and cost effective outcomes, infrastructure providers, such as VicRoads, will consider enhancing their infrastructure to act as levees. Any development of this nature will require collaboration with, and the approval of, the relevant floodplain authorities. |
REC217-1811 | 1 - Land-use and building regs | Responsible authorities will identify low priority levees for potential removal, and have them removed when funding becomes available. |
REC217-1818 | 1 - Land-use and building regs | The Department of Sustainability and Environment to review ownership of Grampians Wimmera Mallee Water’s Yarriambiack Creek levee, with a view to the appointment of a more suitable public managing authority/authorities. |
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. |
REC217-1810 | 1 - Land-use and building regs | Where a levee has been identified as low priority, and beneficiaries are not willing to contribute to its maintenance, public authorities will inform levee beneficiaries that they will not fund the repair of their levee following a flood event. |
REC217-1817 | 1 - Land-use and building regs | The current technical guidelines for the construction of levee systems will be reviewed. A revised Levee Design, Construction and Maintenance technical guidelines will include guidelines for the construction of both priority public levees, and private levees on private land, such as ring levees, which protect key assets. These guidelines will be made available to all rural councils, who will make landowners constructing new levees on their property aware of the principles and specifications contained in the guidelines and encourage construction based on them. |
REC217-1832 | 1 - Land-use and building regs | The revised Victoria Flood Management Strategy should clearly identify authorities and assign responsibilities for stream blockage and debris removal in waterways posing a high risk to public infrastructure both during and after a flood: |
REC217-1809 | 1 - Land-use and building regs | All priority public levees not currently the subject of approved schemes, will become subject to approved schemes under Division 5, Part 10 of the Water Act 1989. Such schemes will articulate an agreed set of terms, including: |
REC217-1815 | 1 - Land-use and building regs | A regular inspection and maintenance regime will be undertaken for all high priority levees managed by a public authority. All such levees will be inspected by the relevant public authority on an annual basis, and after a flood event. All levees will have a regular maintenance schedule. |
REC217-1831 | 1 - Land-use and building regs | Significant modification of waterways in urban or rural areas will only be considered after the completion of a flood risk management process, undertaken in consultation with members of the community. |
REC217-1808 | 1 - Land-use and building regs | The revised Victoria Flood Management Strategy should provide a strategic framework for the management and ongoing maintenance of Victoria’s levees. The Victoria Flood Management Strategy will provide criteria for a consistent statewide approach to the prioritisation of the state’s levees for future management and investment: |
REC217-1813 | 1 - Land-use and building regs | The Department of Sustainability and Environment will develop guidelines for streamlining the permitting system for conducting works on levees for incorporation in the revised Victoria Flood Management Strategy, in order for maintenance on all levees to occur more quickly. The guidelines will outline circumstances in which exemptions from current approval processes are appropriate. Councils will be permitted to obtain exemptions within their planning schemes for: |
REC217-1826 | 39 - Disaster Risk Management | A revised Victoria Flood Management Strategy should identify and assign roles and responsibilities for the management and ongoing maintenance of Victoria’s waterways, for the purposes of flood protection and flood mitigation: |
REC217-1807 | 1 - Land-use and building regs | A revised Victoria Flood Management Strategy is needed and should clearly articulate the principles, roles and responsibilities for the ownership, management and ongoing maintenance of Victoria’s levees. Neither land tenure nor prior government involvement will dictate ownership of public levees: |
Rec-ID | Code | Recommendation |
---|---|---|
REC210-0626 | 1 - Land-use and building regs | Councils should consider using the limited development (constrained land) zone in their planning schemes for areas that have a very high flood risk. |
REC210-0646 | 1 - Land-use and building regs | The Department of Environment and Resource Management should amend the template assessment report used to assess applications for a material change of use for environmentally relevant activities so that it prompts departmental officers to give specific consideration, as part of the assessment process, to the risk of flooding at the site where the activity is proposed to occur. |
REC210-0675 | 1 - Land-use and building regs | The Queensland Government should consider including in the criteria in the Queensland Plumbing and Wastewater Code a requirement that the risk of leakage from private on-site sewerage systems during floods be minimised. |
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. |
REC210-0633 | 1 - Land-use and building regs | The Queensland Government should include in the model flood planning controls a model planning scheme policy that: • for development proposed on land susceptible to flooding, outlines what additional information an applicant should provide to the assessment manager as part of the development application, or • for development proposed on land where the potential for flooding is unknown, requires an applicant to provide: – as part of the development application, information to enable an assessment of whether the subject land is susceptible to flooding, and – upon a determination the subject land is susceptible to flooding, more detailed information, to allow an assessment of the flood risk. |
REC210-0656 | 1 - Land-use and building regs | The Queensland Government should consider amending the Sustainable Planning Regulation 2009 so that operational work or plumbing or drainage work (including maintenance and repair work) carried out by or on behalf of a public sector entity authorised under a state law to carry out the work is not exempt development under the Sustainable Planning Act 2009 if the development has the potential to reduce floodplain storage. |
REC210-0685 | 1 - Land-use and building regs | In assessing and determining development applications for material change of use in areas susceptible to flood, councils should consider whether the new developments locate essential services infrastructure above basement level, or, alternatively, whether essential services infrastructure located at basement level can be constructed so that it can continue to function during a flood. |
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. |
REC210-0617 | 1 - Land-use and building regs | The Queensland Government should consider implementing a mechanism by which prospective purchasers of property are alerted to the issue of flood risk. To that end, the Queensland Government should consider consulting the Real Estate Institute of Queensland and the Law Society of Queensland as to the appropriateness of amending standard contract conditions so as to include a ‘subject to flood search’ condition, or other means of achieving the same objective. |
REC210-0638 | 1 - Land-use and building regs | The Coordinator-General should amend the guideline for preparing an ‘initial advice statement’ for a significant project under the State Development and Public Works Organisation Act 1971 so that it specifically requires an applicant to consider and provide information about the project’s flood risk. |
REC210-0661 | 1 - Land-use and building regs | There should be a common set of considerations in the decision whether to approve an application to build a levee, including: • the impacts of the proposed levee on the catchment as a whole • the benefits of the proposed levee to the individual or entity applying to build the levee and to any nearby community as a whole • any adverse impacts on other landholders, including the risk of levee failure • the implications of the proposed levee for land planning and emergency management procedures • whether any structural, land planning or emergency management measures can be taken to mitigate the adverse impacts of the proposed levee. |
REC210-0694 | 1 - Land-use and building regs | The Queensland Government should consider whether there should be a legislative requirement that customer dedicated assets be built at or above the applicable defined flood level and if so, the Queensland Government should consider which legislation should contain such a requirement. |
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. |
REC210-0625 | 1 - Land-use and building regs | The Queensland Government should change Temporary State Planning Policy 2/11: Planning for stronger more resilient floodplains to remove the possibility of councils’ using the interim floodplain assessment overlay mapping and Model Code as part of a permanent amendment to their existing planning scheme or as part of a new planning scheme. |
REC210-0645 | 1 - Land-use and building regs | The Department of Environment and Resource Management should amend its information sheet about applications for a material change of use for environmentally relevant activities so that applicants are prompted to include information (if any) about the risk of flooding at the site where the activity is proposed to occur. |
REC210-0674 | 1 - Land-use and building regs | The Queensland Government should consider amending the ‘Limitation’ section of the proposed new part of the Queensland Development Code, Mandatory Part 3.5 ‘Construction of buildings in flood hazard areas’, to allow for the possible application of ‘acceptable solution A1’ to a building located on a lot if: • it is reasonable to expect the part of the lot on which the building work is proposed to be subjected to a maximum velocity of less than 1.5 metres per second, or • the part of the lot on which the building work is proposed is located in an inactive flow or backwater area. |
REC210-0631 | 1 - Land-use and building regs | The Queensland Government should include in the model flood planning controls a model flood overlay code that consolidates assessment criteria relating to flood. |
REC210-0654 | 1 - Land-use and building regs | The Queensland Government should consider drafting assessment criteria to be included in the model flood planning controls 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 applicable defined flood event by measures taken within the subject site (for example, use of compensatory works, detention basins or other engineering mechanisms) • 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. |
REC210-0684 | 1 - Land-use and building regs | Councils should consider amending their planning schemes to include provisions directed to consideration of the flood resilience of basements as a factor in determining the appropriateness of a material change of use. |
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. |
REC210-0616 | 1 - Land-use and building regs | Councils that do not currently do so should consider offering an online database which allows the public to conduct a search on a parcel of land to find development approvals relevant to that parcel of land. |
REC210-0637 | 1 - Land-use and building regs | The Queensland Government should consider amending the Urban Land Development Authority Act 2007, the South Bank Corporation Act 1989, the State Development and Public Works Organisation Act 1971 insofar as it governs state development areas, and other legislation which establishes alternative planning systems that operate independently of the Sustainable Planning Act 2009, to require that: • any planning scheme, interim or otherwise, appropriately reflects any state planning policy with respect to flood • flood risk be considered in the assessment of any development application. |
REC210-0660 | 1 - Land-use and building regs | There should be a consistent process for the determination of applications to build levees. That process should include: • consulting landholders who may be affected by the proposed levee • obtaining or commissioning appropriate hydrological and hydraulic studies to assess the impacts of the proposed levee. |
REC210-0693 | 10 - Infrastructure | Electricity distributors should consider installing connection points for generators to provide electricity supply to non-flooded areas that have had their supply cut during floods. |
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. |
REC210-0624 | 1 - Land-use and building regs | The Queensland Government should ensure that the circumstances in which the Department of Community Safety is to consult the Department of Environment and Resource Management about a planning scheme’s flood modelling and flood mapping are clear. |
REC210-0644 | 1 - Land-use and building regs | The Queensland Government should ensure that the criteria under the Environmental Protection Act 1994 that apply to the assessment of development applications for material change of use for environmentally relevant activities include consideration of the risk of flooding at the site on which the activity is proposed to occur. |
REC210-0673 | 1 - Land-use and building regs | The proposed new part of the Queensland Development Code, Mandatory Part 3.5 ‘Construction of buildings in flood hazard areas’, should be amended so that the performance requirements about utilities and sanitary drains (Performance Requirement P2 and P3) for building on a lot will only be triggered where the council has: • designated part of its area as a natural hazard management area (flood) under section 13 of the Building Regulation 2006, and • either: – declared a height to be the expected flood level under section 13 of the Building Regulation 2006, or – adopted a highest recorded flood level for the lot. |
REC210-0629 | 1 - Land-use and building regs | The Queensland Government should include in the model flood planning controls a requirement that councils have a flood overlay map in their planning schemes. The map should identify the areas of the 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. |
REC210-0652 | 1 - Land-use and building regs | The Queensland Government should review the code for development applications for prescribed tidal work in the Coastal Protection and Management Regulation 2003 to consider whether the design and construction standards should be made more stringent than the existing standards. |
REC210-0682 | 1 - Land-use and building regs | The Department of Environment and Resource Management should review the Queensland Urban Drainage Manual to determine whether it requires updating or improvement, in particular, to reflect the current law and to take into account insights gained from the 2010/2011 floods. |
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. |
REC210-0613 | 1 - Land-use and building regs | Councils should ensure that areas for which there has been no assessment of the likelihood of flooding are indicated on a map and that, as part of the development assessment process for these, there is at least some enquiry into whether a site proposed for development could be subject to flooding. |
REC210-0636 | 1 - Land-use and building regs | The Queensland Government should consider allowing councils to amend a planning scheme to update existing flood mapping information by way of the minor amendment process, provided that adequate public consultation has occurred. |
REC210-0659 | 1 - Land-use and building regs | The Queensland Government should consult with councils to formulate a definition of ‘levee’ to identify what should be regulated. |
REC210-0692 | 10 - Infrastructure | The Queensland Government should consider measures to ensure that requirements are included in the designation of land for community infrastructure under the Sustainable Planning Act 2009 to ensure that critical infrastructure for operating works under the Electricity Act is built to remain operational during and immediately after a flood of a particular magnitude. That magnitude should be determined by an appropriate risk assessment. |
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. |
REC210-0623 | 1 - Land-use and building regs | The Department of Community Safety should put in place administrative arrangements which ensure it can readily ascertain whether its comments are being reflected in council planning schemes. If the Department of Community Safety becomes aware that its comments are not being adequately addressed, it should take steps to follow this up with the Department of Local Government and Planning. |
REC210-0642 | 1 - Land-use and building regs | The Queensland Government should draft assessment criteria to be included in the model flood planning controls that require the impact of flood on commercial property to be minimised. |
REC210-0672 | 1 - Land-use and building regs | The proposed new part of the Queensland Development Code, Mandatory Part 3.5 ‘Construction of buildings in flood hazard areas’, should be amended so that the performance requirement relating to building design and construction (Performance Requirement P1) for building on a lot will only be triggered where the council has: • designated part of its area as a natural hazard management area (flood) under section 13 of the Building Regulation 2006, and • either: – declared a height to be the expected flood level under section 13 of the Building Regulation 2006, or – adopted a highest recorded flood level for the lot, and • either: – declared a velocity to be the expected maximum velocity of flood water for the area in which the lot is located, or – designated the area in which the lot is located an inactive flow or backwater area. |
REC210-0628 | 1 - Land-use and building regs | The Queensland Government should draft model flood planning controls, using a similar format and structure to that in the Queensland Planning Provisions, that councils can adapt for local conditions. The Queensland Government should require these controls to be reflected in new planning schemes. This may be achieved by including the controls in either: • a state planning policy dealing with flood, with an accompanying amendment to the Sustainable Planning Act 2009, or • the Queensland Planning Provisions. The Queensland Government should consult councils to determine which of the two state planning instruments is the more appropriate to include the model flood planning controls. |
REC210-0649 | 1 - Land-use and building regs | The Queensland Government should draft assessment criteria to be included in the model flood planning controls 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. |
REC210-0677 | 1 - Land-use and building regs | Authorities responsible for the management of sewerage infrastructure should conduct a review of their existing infrastructure to identify electrical infrastructure that may be vulnerable to inundation and perform risk and cost/benefit assessments to determine if it should be relocated to a higher level. |
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. |
REC210-0612 | 1 - Land-use and building regs | For non-urban areas or areas where limited development is expected to occur councils should consider, on a risk basis, what level of information about flood risk is required for the area, and undertake the highest ranked of the following options which is appropriate to that need and within the capacities (financial and technical) of the council: a. a map showing ‘zones of risk’ (at least three) derived from information about the likelihood and behaviour of flooding b. a map showing the extent of floods of a range of likelihoods (at least three) c. a flood map based on historic flood levels that have been subjected to a flood frequency analysis to estimate the annual exceedance probability of the selected historical flood d. a historic flood map without flood frequency analysis e. the Queensland Reconstruction Authority Interim Floodplain Assessment Overlay as a way to determine those areas for which further flood studies are required, or f. the Queensland Reconstruction Authority Interim Floodplain Assessment Overlay (preferably refined using local flood information) as a trigger for development assessment. |
REC210-0635 | 1 - Land-use and building regs | The Queensland Government should consider amending the Sustainable Planning Act 2009 to expressly provide either a power to remake or a power to extend a temporary local planning instrument containing interim flood regulation for a further limited period. The power to remake or extend should: a. permit the modification of the temporary local planning instrument to the extent required to ensure its provisions remain relevant, having regard to any requirement that may have been introduced or any information that may have become available while the original temporary local planning instrument was in force b. be contingent on the Minister’s being satisfied that the circumstances listed in section 105 of the Sustainable Planning Act continue to exist and that there are proper grounds for the failure to make a permanent scheme amendment while the original temporary local planning instrument was in force. |
REC210-0658 | 1 - Land-use and building regs | The Queensland Government should consult with councils to determine an effective method for the regulation of the construction of levees in Queensland. In particular, the Queensland Government should consider: • requiring a development permit for the construction of a levee by designating levees as assessable development in the Sustainable Planning Regulation 2009, or • requiring, by way of a state planning policy or mandatory provision in the Queensland Planning Provisions, that councils nominate the construction of a levee as assessable development in their planning schemes. |
REC210-0691 | 1 - Land-use and building regs | 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 critical infrastructure in assessable substation developments is built to remain operational during and immediately after a flood of a particular magnitude. That magnitude should be determined by an appropriate risk assessment. |
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. |
REC210-0622 | 1 - Land-use and building regs | If, as part of a state interest review process, the Department of Local Government and Planning decides that no condition should be imposed requiring a council’s proposed planning scheme to incorporate the effect of the Department of Community Safety’s comments about State Planning Policy 1/03: Mitigating the Adverse Impacts of Flood, Bushfire and Landslide, it should advise the Department of Community Safety of the reasons for its decision. |
REC210-0640 | 1 - Land-use and building regs | The Queensland Government should draft assessment criteria to be included in the model flood planning controls 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. |
REC210-0666 | 1 - Land-use and building regs | The Queensland Government should draft a model planning scheme policy to be included in the model flood planning controls 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. |
REC210-0697 | 1 - Land-use and building regs | Queensland Rail and QR National should continue to investigate opportunities for increasing the flood resilience of their networks, including raising the height of critical equipment. |
REC210-0627 | 1 - Land-use and building regs | The Queensland Government should consider amending the Sustainable Planning Act 2009 to require that consideration be given to the risk of flooding in the preparation or revision of a regional plan. |
REC210-0647 | 1 - Land-use and building regs | The Department of Environment and Resource Management should ensure that, when applications for a material change of use for an environmentally relevant activity are approved by the department, the details of those activities, including their nature and location, are provided to the council within whose area the activity will be conducted. |
REC210-0676 | 1 - Land-use and building regs | Authorities responsible for the construction of sewerage infrastructure should, when embarking on new works, undertake risk and cost/benefit assessments to determine the level at which electrical infrastructure that may be vulnerable to inundation should be placed. |
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. |
REC210-0611 | 1 - Land-use and building regs | For urban areas or areas where development is expected to occur: a. councils with the requisite resources should develop a flood map which shows ‘zones of risk’ (at least three) derived from information about the likelihood and behaviour of flooding b. councils without the requisite resources to produce a flood behaviour map should develop a flood map which shows the extent of floods of a range of likelihoods (at least three). |
REC210-0634 | 1 - Land-use and building regs | If the Queensland Government does not include such a policy in the model flood planning controls, councils should include in their planning schemes a planning scheme policy that: • for development proposed on land susceptible to flooding, outlines what additional information an applicant should provide to the assessment manager as a part of the development application, or • for development proposed on land where potential for flooding is unknown requires an applicant to provide: – as part of the development application, information to enable an assessment of whether the subject land is susceptible to flooding, and – upon a determination the subject land is susceptible to flooding, more detailed information to allow an assessment of the flood risk. |
REC210-0657 | 1 - Land-use and building regs | Levees should be regulated. |
REC210-0690 | 1 - Land-use and building regs | The Queensland Government should draft assessment criteria to be included in the model flood planning controls that require critical infrastructure in assessable substation developments is built to remain operational during and immediately after a flood of a particular magnitude. That magnitude should be determined by an appropriate risk assessment. |
REC210-0758 | 10 - Infrastructure | CS Energy should put in place contingency measures to ensure email and telephone communications at Wivenhoe Power Station are not entirely dependent on a network located off-site. |
REC210-0621 | 1 - Land-use and building regs | The Queensland Government should: a. narrow the definition of ‘development commitment’ in State Planning Policy 1/03: Mitigating the Adverse Impacts of Flood, Bushfire and Landslide to ensure more development applications are assessed for compatibility with flood, and b. investigate whether the compensation provisions of the Sustainable Planning Act 2009 act as a deterrent to the inclusion of flood controls in a planning scheme and consider whether they ought be amended. |
REC210-0639 | 1 - Land-use and building regs | The Queensland Government should consider extending the application of a state planning policy dealing with flood to the types of community infrastructure which are identified in the Sustainable Planning Regulation 2009 and which the community needs to continue functioning, notwithstanding flood. |
REC210-0662 | 1 - Land-use and building regs | The Queensland Government should draft assessment criteria to be included in the model flood planning controls that address: • the prospect of isolation or hindered evacuation • the impact of isolation or hindered evacuation. |
REC210-0695 | 10 - Infrastructure | The Queensland Government should consider implementing mandatory requirements to ensure that all conduits for the purpose of providing electrical supply below the applicable defined flood level are sealed to prevent floodwaters from entering them or flowing into them. |
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. |
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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REC199-0462 | 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. |
REC199-0428 | 25 - Inquiry, audit, lessons management and after action review | the state clarify which agency is responsible for collecting post-flood extent and related data. This should include: • the development of guidelines to ensure consistent standards are applied to post-flood data collection; and • an appropriate process to ensure funding availability for such activities. |
REC199-0453 | 20 - Role of police | Victoria Police revise coordinator arrangements to ensure: • a coordinator presence is maintained at the place where incident control is being exercised • effective control is established and is maintained until the response phase has concluded • key control roles may be performed by personnel from agencies other than the designated control agency • that the timely compilation and distribution of an appropriate Incident Action Plan is recognised as a fundamental component of establishing effective control • those performing the coordinator role at an Incident Control Centre be suitably trained, skilled and experienced in emergency management and where possible possess a degree of local knowledge of the relevant area; and • that the revised coordinator arrangements are reflected within the State Emergency Response Plan |
REC199-0485 | 1 - Land-use and building regs | the state: • adopt a strategy to expedite incorporation of updated flood mapping or modelling into planning schemes • reconsider in what circumstances the ‘1 in 100 year event’ is the appropriate design event • actively support the Australian Building Code Board in its development of a new national standard for residential buildings in flood prone areas. Until such time as any new standard is incorporated into Victorian law, provide advice to householders about appropriate building materials for flood prone areas and ways that houses can be designed or adapted to mitigate flood risk; and • retain the ability of a Catchment Management Authority to require a council to refuse a planning permit or impose particular conditions when the Catchment Management Authority considers the flooding risk to be unacceptable. |
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. |
REC199-0450 | 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. |
REC199-0414 | 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 |
REC199-0448 | 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. |
REC199-0407 | 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. |
REC199-0445 | 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. |
REC199-0463 | 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. |
REC199-0401 | 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. |
REC199-0441 | 4 - Fire season preparation | the state undertake further trials to explore the opportunity for greater use of social media as a credible source of information to and from the public during an emergency |
Rec-ID | Code | Recommendation |
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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 |
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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. |
Rec-ID | Code | Recommendation |
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REC156-3487 | 10 - Infrastructure | Electricity distribution businesses develop and implement alternative arrangements for monitoring fallen powerlines. |
REC156-3500 | 10 - Infrastructure | The Emergency Services Telecommunications Authority, in partnership with Telstra, consider technological solutions to streamline the handover process for Triple Zero calls. |
REC156-3495 | 16 - Training and behaviour | The Department of Primary Industries should work through the appropriate Ministerial Councils to seek alignment of competency standards for line workers across jurisdictions. |
REC156-3494 | 10 - Infrastructure | Energy Safe Victoria finalise the development of the passport system to improve interstate mutual aid arrangements allowing operator access to qualified interstate power restoration personnel. |
Rec-ID | Code | Recommendation |
---|---|---|
REC149-3139 | 39 - Disaster Risk Management | The industry should develop in conjunction with the Regulator a process for addressing the need to maintain the risk profile of a facility moving into extended life operation at the same risk profile as when it was within design life. |
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. |
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. |
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 |
---|---|---|
REC125-3898 | 25 - Inquiry, audit, lessons management and after action review | That agencies develop a detailed improvement plan and commit resources to its implementation. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC121-3664 | 20 - Role of police | The location of the command post for site control at the scene of any rail accident should be identified by NSW Police by a distinctive flashing light. |
REC121-3713 | 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. |
REC121-3675 | 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. |
REC121-3718 | 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. |
REC121-3691 | 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. |
REC121-3751 | 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. |
REC121-3657 | 10 - Infrastructure | All signal telephones must be maintained by RailCorp in proper working order. |
REC121-3710 | 39 - Disaster Risk Management | The ITSRR should have permanent access to the RailCorp intranet. |
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. |
REC121-3673 | 41 - Emergency Management exercises | Regular field training exercises should be conducted by RailCorp with the emergency services to ensure that the incident command system and rail displan are able to be fully implemented as quickly as possible and are reviewed and improved. |
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. |
REC121-3687 | 10 - Infrastructure | There must be compatibility of communications systems throughout the rail network. It is essential that all train drivers, train controllers, signallers, train guards and supervisors of trackside work gangs in New South Wales be able to communicate using the same technology. |
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. |
REC121-3654 | 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. |
REC121-3700 | 39 - Disaster Risk Management | Maintenance plans on all trains should be revised annually. |
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. |
REC121-3672 | 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. |
REC121-3716 | 16 - Training and behaviour | Train driver and guard training should encourage teamwork and discourage authority gradients. |
REC121-3684 | 39 - Disaster Risk Management | The ITSRR should conduct its own risk assessment in relation to the risk of any such high consequence, low probability accident and, if necessary, direct RailCorp to conduct a further risk assessment to reduce the level of residual risk to a level ITSRR regards as acceptable. |
REC121-3744 | 16 - Training and behaviour | All RailCorp operational personnel should be trained in the location and operation of external emergency door release mechanisms. |
REC121-3653 | 10 - Infrastructure | The RMC should be equipped by RailCorp with a transcriber system, or mimic board, or such other system as is necessary to enable identification of the precise location at any time of any train on the RailCorp network. |
REC121-3695 | 10 - Infrastructure | There should be interoperability of communications equipment between all trains operating on the New South Wales rail network. |
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. |
REC121-3670 | 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. |
REC121-3715 | 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. |
REC121-3683 | 39 - Disaster Risk Management | RailCorp should undertake risk assessments of each of its activities as follows: |
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. |
REC121-3651 | 10 - Infrastructure | A dedicated telephone line should be established by RailCorp between the RMC and any Emergency Services Control Centre for use during any emergency. |
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. |
REC121-3756 | 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. |
REC121-3669 | 16 - Training and behaviour | All operational rail staff should be trained by RailCorp in the action check list relevant to each. |
REC121-3714 | 16 - Training and behaviour | RailCorp should use its simulators in an interactive manner. |
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. |
REC121-3719 | 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. |
REC121-3650 | 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. |
REC121-3693 | 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. |
REC121-3753 | 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. |
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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC004-3999 | 10 - Infrastructure | That, in view of the fact that along many of the lines, between the road-bed and the fences, there are numbers of dry inflammable stumps, which, when they catch fire, are very difficult to extinguish, and that the surface of the ground surrounding these stumps is usually chipped by the permanent-way men every summer, thus causing considerable expense without removing the risk of fire, the Railway Department should remove this source of danger, by grabbing them out and burning them as early as may be found practicable. |