Inquiry Search
Rec-ID | Code | Recommendation |
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REC325-4327 | 17 - Assets and technology | The Inspector-General of Emergency Management recommends all local governments that offer an opt-in system develop strategies to increase the number of subscribers who elect to use this service. As part of the annual disaster management plan assessment process for the period 2023–2025, the Office of the Inspector-General of Emergency Management will request information from the relevant local disaster management groups to highlight and share innovative practices that have led to an increase in subscription levels for opt-in services. |
REC325-4339 | 38 - Agency/Department Reporting | The Inspector-General of Emergency Management recommends that Queensland Fire and Emergency Services review and update the State Disaster Risk Report, including re-evaluating the risk of flooding by all types. Queensland Fire and Emergency Services should publish the updated State Disaster Risk Report by 1 November 2023. |
REC325-4330 | 38 - Agency/Department Reporting | The Inspector-General of Emergency Management recommends Queensland Fire and Emergency Services review the Queensland Emergency Alert Manual – M.1.174 in its entirety by 1 November 2023. The manual should specifically address the authorising environment, legislative obligations and the capability and complexities of the Emergency Alert system. |
REC325-4330 | 38 - Agency/Department Reporting | The Inspector-General of Emergency Management recommends Queensland Fire and Emergency Services review the Queensland Emergency Alert Manual – M.1.174 in its entirety by 1 November 2023. The manual should specifically address the authorising environment, legislative obligations and the capability and complexities of the Emergency Alert system. |
REC325-4324 | 32 - Doctrine, standards, and reform | The Inspector-General of Emergency Management recommends Queensland Fire and Emergency Services review the tasking protocols used to manage State Emergency Service (SES) tasks undertaken in the response phase of a disaster to enable more complete recording of details for all ‘jobs of opportunity’ (including the personal details of those assisted and/or rescued) to enable better coordination of tasks and reflect outcomes of activities by 1 November 2023. |
REC325-4334 | 32 - Doctrine, standards, and reform | The Inspector-General of Emergency Management recommends Queensland Fire and Emergency Services develop and publish an operationally based quick reference guide that complements the training offered (as per Recommendation 5) by 1 November 2022. The guide will identify key and critical aspects of the Emergency Alert system in relation to the development, composition, request for and authorising of Emergency Alerts and will include a template and an example of ‘good’ messaging using concise, minimal language and Clear Explicit Translatable Language (CETL). |
REC325-4325 | 32 - Doctrine, standards, and reform | The Inspector-General of Emergency Management recommends Queensland Fire and Emergency Services review and implement State Emergency Service (SES) protocol by 1 November 2023 outlining procedures to be undertaken to ensure persons uplifted from places of immediate danger or risk are transferred to a place of safety. |
REC325-4335 | 16 - Training and behaviour | The Inspector-General of Emergency Management recommends Queensland Fire and Emergency Services update and deliver training on the workflow reviewed (as per Recommendation 3) of the current Emergency Alert system to all persons responsible at a local, district and state level by 1 November 2022. Training should address system constraints and system complexities in addition to the process of requesting, composing (including Clear Explicit Translatable Language [CETL]), authorising and issuing Emergency Alerts. |
REC325-4326 | 17 - Assets and technology | The Inspector-General of Emergency Management recommends Queensland Fire and Emergency Services lead an inter-agency IT system assessment with Queensland Police Service and local governments to identify disaster management systems currently in use and develop options to enhance connectivity and interoperability between systems. Outputs to be considered include, but are not limited to, consideration of requests for assistance (RFA) and the production of situation reports. |
REC325-4338 | 17 - Assets and technology | The Inspector-General of Emergency Management recommends the Queensland Reconstruction Authority and the Bureau of Meteorology investigate options for the consolidation of ownership, renewed capital and maintenance in the flood warning network in consultation with flood warning infrastructure asset owners. |
Rec-ID | Code | Recommendation |
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REC308-2451 | 17 - Assets and technology | Queensland should examine the feasibility of the installation of storm tide markers in prominent public places and the exploration of new technology to highlight storm tide risk to the community and its visitors. |
REC308-2450 | 17 - Assets and technology | The operation and maintenance of flood gauges should be developed and planned for on a catchment basis. |
REC308-2464 | 16 - Training and behaviour | The provision of system-wide education, guidance and testing to enhance requests for Assistance is strengthened. |
REC308-2455 | 32 - Doctrine, standards, and reform | The Queensland Offers of Assistance Policy, particularly for corporate donations, should be updated and exercised prior to the next season. |
REC308-2453 | 32 - Doctrine, standards, and reform | Business continuity planning should feature permanently in disaster management doctrine. |
Rec-ID | Code | Recommendation |
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REC271-1532 | 32 - Doctrine, standards, and reform | The evacuation sub-plan component of the Local Disaster Managment Plan should be reviewed, including any identified triggers for activation. Ideally, the plan should be tested in a live, multi-agency exercise prior to next summer. |
REC271-1531 | 32 - Doctrine, standards, and reform | Banana Shire Council completes business continuity planning as a matter of priority, including documentation and testing of the plan. |
REC271-1530 | 16 - Training and behaviour | Local Disaster Coordination Centre capability and capacity should be reviewed to ensure adequate staffing arrangements are in place to fill key positions, and that operational protocols are known and practiced across all functions to provide redundancy. Assistance for review and necessary training should be sought from key Local Disaster Management Group member agencies. |
Rec-ID | Code | Recommendation |
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REC258-2537 | 32 - Doctrine, standards, and reform | The Civil Aviation Safety Authority delegates responsibility for the day-to-day operational management of airspace to Airservices Australia, including the designation of air routes, short term designations of temporary Restricted Areas, and temporary changes to the classification of airspace for operational reasons. |
REC258-2554 | 32 - Doctrine, standards, and reform | Recreational Aviation Administration Organisations, in coordination with the Civil Aviation Safety Authority, develop mechanisms to ensure all aircraft to be regulated under CASR Part 149 are registered. |
REC258-2529 | 32 - Doctrine, standards, and reform | The Australian Transport Safety Bureau and the Civil Aviation Safety Authority utilise the provision in their bilateral Memorandum of Understanding to accredit CASA observers to ATSB investigations. |
REC258-2536 | 32 - Doctrine, standards, and reform | The Australian Transport Safety Bureau and the Civil Aviation Safety Authority amend the wording of their existing Memorandum of Understanding to make it more definitive about interaction, coordination, and cooperation. |
REC258-2548 | 17 - Assets and technology | The Civil Aviation Safety Authority shares the risk assessment outputs of Sky Sentinel, its computerised risk assessment system, with the applicable authorisation holder. |
REC258-2527 | 32 - Doctrine, standards, and reform | The Department of Infrastructure and Regional Development plays a stronger policy role in the State Safety Program. |
REC258-2535 | 32 - Doctrine, standards, and reform | Airservices Australia, in conjunction with the Department of Infrastructure and Regional Development and the Civil Aviation Safety Authority, reconsiders the policy on ‘Assessment of Priorities’ that stipulates that air traffic controllers sequence arriving aircraft based on category of operation, rather than on the accepted international practice of ‘first come, first served’. |
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. |
REC258-2534 | 16 - Training and behaviour | The Civil Aviation Safety Authority develops a staff exchange program with industry. |
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: |
REC258-2562 | 32 - Doctrine, standards, and reform | The Civil Aviation Safety Authority amends the current Terms of Reference of the Industry Complaints Commissioner so that: |
REC258-2533 | 32 - Doctrine, standards, and reform | The Civil Aviation Safety Authority: |
REC258-2538 | 32 - Doctrine, standards, and reform | The Department of Infrastructure and Regional Development and Department of Defence (and appropriate agencies) establish an agreed policy position on safety oversight of civil operations into joint user and military airports. |
REC258-2555 | 32 - Doctrine, standards, and reform | The Civil Aviation Safety Authority changes the current two-tier regulatory framework (act and regulations) to a three-tier structure (act, regulations and standards), with: |
REC258-2531 | 32 - Doctrine, standards, and reform | The Civil Aviation Safety Authority’s Board exercises full governance control. The nonexecutive directors should possess a range of appropriate skills and backgrounds in aviation, safety, management, risk, regulation, governance and government. |
Rec-ID | Code | Recommendation |
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REC236-2798 | 32 - Doctrine, standards, and reform | The committee recommends that, where relevant, the ATSB include thorough human factors analysis and discussion in future investigation reports. Where human factors are not considered relevant, the ATSB should include a statement explaining why. |
REC236-2804 | 32 - Doctrine, standards, and reform | The committee recommends that Airservices Australia discuss the safety case for providing a hazard alert service with Fijian and New Zealand ATC (and any other relevant jurisdictions) and encourage them to adopt this practice. |
REC236-2786 | 32 - Doctrine, standards, and reform | The committee recommends that the ATSB be required to document investigative avenues that were explored and then discarded, providing detailed explanations as to why. |
REC236-2796 | 32 - Doctrine, standards, and reform | The committee recommends that the ATSB-CASA Memorandum of Understanding be re-drafted to remove any ambiguity in relation to information that should be shared between the agencies in relation to aviation accident investigations, to require CASA to: |
REC236-2803 | 32 - Doctrine, standards, and reform | The committee recommends that the government consider setting a time limit for agencies to implement or reject recommendations, beyond which ministerial oversight is required where the agencies concerned must report to the minister why the recommendation has not been implemented or that, with ministerial approval, it has been formally rejected. |
REC236-2785 | 32 - Doctrine, standards, and reform | The committee recommends that the ATSB move away from its current approach of forecasting the probability of future events and focus on the analysis of factors which allowed the accident under investigation to occur. This would enable the industry to identify, assess and implement lessons relevant to their own operations. |
REC236-2794 | 32 - Doctrine, standards, and reform | The committee recommends that CASA, in consultation with an Emergency Medical Services industry representative group (eg. Royal Flying Doctor Service, air ambulance operators, rotary wing rescue providers) consider the merit, form and standards of a new category of operations for Emergency Medical Services. The minister should require CASA to approve the industry plan unless there is a clear safety case not to. Scope for industry to assist as part of an audit team should also be investigated where standardisation is an issue. This should be completed within 12 months and the outcome reported publicly. |
REC236-2802 | 32 - Doctrine, standards, and reform | The committee recommends that where the consideration and implementation of an ATSB recommendation may be protracted, the requirement for regular updates (for example 6 monthly) should be included in the TSI Act. |
REC236-2784 | 32 - Doctrine, standards, and reform | The committee recommends that the minister, in issuing a new Statement of Expectations to the ATSB, valid from 1 July 2013, make it clear that safety in aviation operations involving passengers (fare paying or those with no control over the flight they are on, e.g. air ambulance) is to be accorded equal priority irrespective of flight classification. |
REC236-2789 | 32 - Doctrine, standards, and reform | The committee recommends that the Transport Safety Investigation Act 2003 be amended to require that the Chief Commissioner of the ATSB be able to demonstrate extensive aviation safety expertise and experience as a prerequisite for the selection process. |
REC236-2800 | 38 - Agency/Department Reporting | The committee recommends that where a safety action has not been completed before a report being issued that a recommendation should be made. If it has been completed the report should include details of the action, who was involved and how it was resolved. |
REC236-2808 | 38 - Agency/Department Reporting | The committee recommends that in relation to mandatory and confidential reporting, the default position should be that no identifying details should be provided or disclosed. However, if there is a clear risk to safety then the ATSB, CASA and industry representatives should develop a process that contains appropriate checks and balances. |
REC236-2788 | 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 |
REC236-2799 | 38 - Agency/Department Reporting | The committee recommends that the ATSB prepare and release publicly a list of all its identified safety issues and the actions which are being taken or have been taken to address them. The ATSB should indicate its progress in monitoring the actions every 6 months and report every 12 months to Parliament. |
REC236-2807 | 32 - Doctrine, standards, and reform | The committee recommends that the Aeronautical Information Package (AIP) En Route Supplement Australia (ERSA) is updated to reflect the need for caution with regard to Norfolk Island forecasts where the actual conditions can change rapidly and vary from forecasts. |
REC236-2787 | 16 - Training and behaviour | The committee recommends that the training offered by the ATSB across all investigator skills sets be benchmarked against other agencies by an independent body by, for example, inviting the NTSB or commissioning an industry body to conduct such a benchmarking exercise. |
Rec-ID | Code | Recommendation |
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REC235-2809 | 32 - Doctrine, standards, and reform | The Australian National Audit Office recommends that the Department of Regional Australia, Local Government, Arts and Sport improve the arrangements for conducting value for money reviews of Victorian reconstruction projects by pursuing amendments to the operating protocol with Victoria to require that, at regular intervals, the Taskforce is provided with information on all reconstruction projects being delivered within the scope of the National Partnership Agreement. |
Rec-ID | Code | Recommendation |
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REC234-2811 | 32 - Doctrine, standards, and reform | In order to maximise the envisaged benefits from the Inspectorate’s program of value for money reviews, the Australian National Audit Office (ANAO) recommends that the National Disaster Recovery Taskforce improve the application of the sampling approach to make it more representative of the |
REC234-2810 | 38 - Agency/Department Reporting | The Australian National Audit Office (ANAO) recommends that the Australian Government Reconstruction Inspectorate and the National Disaster Recovery Taskforce seek to maximise the benefits from their value for money review activities by obtaining more timely and comprehensive information on project progress and completion from the Queensland Reconstruction Authority, to enable the preliminary value for money assessments to be finalised based on the scope and cost of works that were actually delivered (rather than estimates). |
REC234-2813 | 38 - Agency/Department Reporting | To strengthen its oversight of Queensland reconstruction progress, the Australian National Audit Office (ANAO) recommends that the National Disaster Recovery Taskforce: |
Rec-ID | Code | Recommendation |
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REC210-0775 | 16 - Training and behaviour | The Department of Environment and Resource Management should conduct periodic dam safety information and education sessions with emergency management personnel including those from Emergency Management Queensland, local and district disaster management groups and local councils. Priority should be given to sessions if the Bureau of Meteorology forecasts a wet season with a greater than 50 per cent chance of above median rainfall. |
REC210-0714 | 32 - Doctrine, standards, and reform | The Queensland Government should consider amending the Environmental Protection Act 1994 so that it allows for the relaxation of environmental authority conditions, by transitional environmental program or otherwise, as to discharge of water: • pre-emptively, in advance of rainfall or flooding events, or • for all mines in a catchment that is flooding. |
REC210-0749 | 32 - Doctrine, standards, and reform | The Queensland Government should amend the Water Supply (Safety and Reliability) Act 2008 to designate the Minister as the person who must approve a flood mitigation manual. |
REC210-0770 | 32 - Doctrine, standards, and reform | The Queensland Government should legislate to oblige each owner of a referable dam to have an emergency action plan approved by the appropriate Queensland Government agency. Such plans should be reviewed periodically |
REC210-0712 | 32 - Doctrine, standards, and reform | The Queensland Government should legislate to clarify the purposes for which a transitional environmental program can be granted. In particular, if the government considers the transitional environmental program the appropriate regulatory mechanism to deal with the discharge of water from mines during flood, section 330 of the Environmental Protection Act 1994 should be clarified to make it clear that it extends to that use. |
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. |
REC210-0766 | 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. |
REC210-0733 | 32 - Doctrine, standards, and reform | Emergency Management Queensland should pursue the execution of the ‘Local Arrangements’ with councils where a Memorandum of Agreement is in place. The contents of the arrangements should be reviewed and updated regularly |
REC210-0760 | 32 - Doctrine, standards, and reform | CS Energy should amend its business procedure to remove any ambiguity as to the establishment of communications with Seqwater and to acknowledge the formal communications protocol regarding releases. |
REC210-0719 | 32 - Doctrine, standards, and reform | The Queensland Government should amend the Environmental Protection Act 1994 so as to permit an emergency direction to be given orally where it is not practicable to provide the direction in writing, with provision for its subsequent confirmation in writing |
REC210-0759 | 32 - Doctrine, standards, and reform | CS Energy should review its emergency action plan and business procedures to ensure they are wholly consistent and give appropriate consideration to flooding as a possible emergency event. |
REC210-0717 | 32 - Doctrine, standards, and reform | The Queensland Government should consider amending the Environmental Protection Act 1994 to provide a definition of the term ‘emergency’ for the purposes of section 468 of that Act. |
REC210-0750 | 32 - Doctrine, standards, and reform | The assessment of flood mitigation manuals should be completed by a person with appropriate expertise who has had no involvement in its development, at any stage, and who can be seen to be independent of all individuals who were so involved. |
Rec-ID | Code | Recommendation |
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REC189-2914 | 32 - Doctrine, standards, and reform | The review team recommend that: |
REC189-2909 | 32 - Doctrine, standards, and reform | Equipping the regulator with a wider range of compliance tools under the legislation should continue to be a policy priority. The aim should be to enhance the regulator’s capacity to secure compliance in an appropriately graduated way. The opportunity should be taken to ensure that the regulator and inspectors can, in appropriate cases, bring proceedings that do not require referral to the Commonwealth Director of Public Prosecutions, such as actions for civil penalties or injunctions. |
Rec-ID | Code | Recommendation |
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REC149-3134 | 32 - Doctrine, standards, and reform | Improved and agreed guidelines for Safety Case application and assessment, including suggested structure and content, would alleviate many current problems related to Safety Case processes. |
REC149-3141 | 32 - Doctrine, standards, and reform | NOPSA should complete the next revision of Safety Case guidelines in consultation and agreement with stakeholders and continue its program to achieve consistency with a firmer hand from the CEO and management. |
REC149-3130 | 32 - Doctrine, standards, and reform | The regulations pertaining to vessels of opportunity or their interpretation should be changed to facilitate a risk based approach to regulation. This approach will be consistent with the approach taken in other jurisdictions. |
REC149-3140 | 32 - Doctrine, standards, and reform | The industry should provide advice to NOPSA on where the regulations do not provide sufficient clarity and consider developing broad policy/process guidelines in consultation with the regulator to provide clarity and consistency. Regulators should not take personal views or preferences. |
REC149-3129 | 32 - Doctrine, standards, and reform | The consequences of the disapplication of the Navigation Act 1912 should be analysed, the actual consequences identified and unintended consequences addressed. |
REC149-3138 | 38 - Agency/Department Reporting | The current KPI measures used by the Regulator and industry need to be reassessed and the performance indicators need to be related to the risk profiles of the industry. The industry needs to develop the indicators, which need to be agreed and measured by the industry in discussion with other stakeholders. The KPI's selected should be published in comparison with the worldwide offshore industry and with other industries. NOPSA should continue discussions with Australian Safety and Compensation Council (ASCC) with a view to adopting their goals. |
REC149-3137 | 16 - Training and behaviour | As professional competency is one of the key pillars of any Safety Case, commitment to training for current and future needs remains a fundamental requirement for achieving best practice outcomes in safety. Industry should be encouraged to build on its training commitment now being made to achieve a competent and fully accredited workforce over the next five years. |
REC149-3136 | 16 - Training and behaviour | There is a need for industry in consultation with NOPSA to establish a priority programme of accredited education modules in the Safety Case regime targeting stakeholders in the regime at their respective levels to improve the understanding of the Safety Case and correspondent responsibilities. |
Rec-ID | Code | Recommendation |
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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. |
REC137-3531 | 32 - Doctrine, standards, and reform | I recommend that CASA consider creating firm guidelines that require consideration of workload, lines of authority, potential conflicts of interest and any other factors that impact upon the ability of “key personnel” to discharge their responsibilities within an aviation organisation when its officers are approving appointments to those positions. |
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 |
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REC136-3523 | 38 - Agency/Department Reporting | This Report should be considered for publication so that the insights, data, conclusions and recommendations are available within Queensland and other jurisdictions to assist with disaster management issues in the future. |