Inquiry Search
Rec-ID | Code | Recommendation |
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REC309-2478 | 25 - Inquiry, audit, lessons management and after action review | The progress of recovery for this event be reviewed incrementally over the next 2 to 3 years, with a formal, independent report provided on the effectiveness of the recovery after 3 years. |
REC309-2472 | 38 - Agency/Department Reporting | A single point of truth be established for accurately capturing and reporting on disaster management group activation levels for any given timeframe. |
Rec-ID | Code | Recommendation |
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REC308-2454 | 10 - Infrastructure | Local disaster management groups should focus on the business continuity of local critical infrastructure and its integration with other plans. |
REC308-2449 | 25 - Inquiry, audit, lessons management and after action review | Queensland should implement and maintain a system-wide lesson management program. |
Rec-ID | Code | Recommendation |
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REC002-4012 | 38 - Agency/Department Reporting | Complete sets of daily-report books should be provided, and kept in the mine or office, to be overlooked by the Inspector during his periodical visits. |
Rec-ID | Code | Recommendation |
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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. |
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. |
Rec-ID | Code | Recommendation |
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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. |
REC295-1279 | 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. |
REC295-1317 | 25 - Inquiry, audit, lessons management and after action review | Review representation in the State Emergency Centre including: a) determining if there is a more suitable functional support group e.g. the Procurement Functional Support Group, to replace the Logistics Functional Support Group, and if so, Chief Procurement Officer, DPC, has responsibility for the management of this role within the State Emergency Centre. b) That when the State Crisis Centre is not operating from a physical location, a State Crisis Centre liaison officer is attached to the State Emergency Centre. |
REC295-1315 | 25 - Inquiry, audit, lessons management and after action review | That a review of the role and effectiveness of the State Emergency Management Committee (SEMC) including: the legislative functions; membership including the chair; roles and responsibilities; and, SEMC Advisory Groups be undertaken. |
REC295-1297 | 25 - Inquiry, audit, lessons management and after action review | Engage an independent business analyst to review the current call, receipt and dispatch process for emergency services i.e. the Metropolitan Fire Service, Country Fire Service and State Emergency Service, from the initial call for assistance through to response of emergency service resources, including the allocation and coordination of multiple taskings. |
REC295-1276 | 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 |
REC295-1328 | 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. |
Rec-ID | Code | Recommendation |
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REC292-2369 | 26 - Research | I recommend that the New South Wales Police Force evaluate whether the use of noise-attenuation devices should be mandated when explosive distraction devices are used. |
REC292-2370 | 25 - Inquiry, audit, lessons management and after action review | I recommend that the New South Wales Police Force undertake a formal assessment of alternatives to the TOU’s current soft-point ammunition to determine whether a more appropriate form of ammunition is reasonably available. |
Rec-ID | Code | Recommendation |
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REC284-1369 | 10 - Infrastructure | Review all generator locations for arrangements for temporary generator installation, including design of modifications as required for electrical connections and spatial requirements at installation locations, to be documented in an emergency procedure. |
REC284-1374 | 10 - Infrastructure | Provide walls around critical electrical infrastructure within the main plant area to provide security and protection from catastrophic water system failures. |
REC284-1368 | 10 - Infrastructure | Improvements to installation to be implemented as follows: - Lighting within the generator enclosure and immediately adjacent to be emergency battery-backed type. - Improvements to the spatial layout within the main generator enclosure should be investigated, including allowance for the control panel door to open 180o (only 90o currently); moving the fuel pumps to a more accessible location, and ensuring clear access to the day tank for manual filling if required. - Improvements to communications facilities between critical areas, including fixed phone line connections between the main control room, main generator control panel in the P (energy) Building, and the generator enclosure, and allowing link to offsite specialist advice. - Where generator maintenance requires operations outdoors (not applicable to main generator, but applicable to others), a shelter over the relevant area should be provided to allow safe work during wet or hot weather. - Written emergency procedures to be prepared covering credible failure scenarios with step by step checklists and recommended actions. |
REC284-1373 | 10 - Infrastructure | Review generator installations details as noted in report and implement physical improvements where possible. |
REC284-1367 | 10 - Infrastructure | Add to generator test procedure a checklist at the end of testing which includes checking that all systems are back to normal positions and includes a requirement to leave the day tank full where there is a bulk tank/day tank arrangement. |
REC284-1372 | 10 - Infrastructure | As part of the electrical master plan update recommended above, a complete and consistent set of single line diagrams describing the electrical distribution network be prepared. Relevant diagrams to be laminated and displayed in the main substations. Labelling to all main electrical equipment be reviewed and updated in accordance with the final documents. |
REC284-1366 | 10 - Infrastructure | A detailed review of the fuel control and BMS systems (for all generators) be carried out and actions taken to: 1) Ensure that the fuel alarm system is operational and properly calibrated, and ensure that the alarms are connected to the BMS. 2) Ensure that the BMS transmits these alarms effectively to the maintenance staff. 3) If this review demonstrates risk of fuel control systems not adequately reporting alarms, consider an independent day tank level switch to be installed in each generator fuel tank, directly connected to the BMS. 4) Consider the feasibility of adding a “fuel system not in auto” or “fuel system fault/fail safe watchdog” or “pre-alarm identifying that the generator is about to shut down without intervention” feature to current systems – subject to details of each individual generator system. |
REC284-1371 | 10 - Infrastructure | Generator dual redundant starter systems should be considered. |
REC284-1365 | 10 - Infrastructure | The electrical master plan for the site should be updated to include planning for the scheduled replacement or refurbishment of those parts of the infrastructure that have not been renewed in the last 10 years. This planning to consider other upgrades or plans for the FMC overall. |
REC284-1370 | 10 - Infrastructure | Review control system for the main generator normal/essential changeover system and ensure that it has effective backup/manual or redundant operations, and suitable testing facilities. The Essential board that supplies the main generator power to Blocks A, B, C (except theatres), D, E (except certain critical engineering plant) (MD-1-4P-10E), is a potential single point of failure of a significant portion of the emergency power system and as part of the Master Plan update should be considered as a priority. |
Rec-ID | Code | Recommendation |
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REC281-1201 | 25 - Inquiry, audit, lessons management and after action review | Preventing Flood Related Fatalities: The NSW Government consider the recommendations from the Preventing Flood Related Fatalities Report when it is released. |
Rec-ID | Code | Recommendation |
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REC272-1415 | 25 - Inquiry, audit, lessons management and after action review | An audit of all local government areas vulnerable to storm tide events is completed and opportunities identified to resolve gaps in evacuation zone planning to ensure consistency with the Queensland Evacuation Guidelines for Disaster Management Groups and neighbouring local government areas. |
Rec-ID | Code | Recommendation |
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REC267-1162 | 10 - Infrastructure | Telecommunications and Power Infrastructure |
REC267-1153 | 4 - Fire season preparation | Planning for Access to Potentially Isolated Communities |
Rec-ID | Code | Recommendation |
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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. |
REC258-2552 | 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. |
REC258-2551 | 25 - Inquiry, audit, lessons management and after action review | The Civil Aviation Safety Authority assures consistency of audits across all regions, and delivers audit reports within an agreed timeframe. |
REC258-2549 | 25 - Inquiry, audit, lessons management and after action review | The Civil Aviation Safety Authority provides full disclosure of audit findings at audit exit briefings in accordance with international best practice. |
REC258-2528 | 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. |
Rec-ID | Code | Recommendation |
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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. |
REC236-2808 | 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. |
REC236-2805 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that the relevant agencies review whether any equipment or other changes can be made to improve the weather forecasting at Norfolk Island. The review would include whether the Unicom operator should be an approved meteorological observer. |
REC236-2800 | 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. |
REC236-2801 | 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. |
REC236-2799 | 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. |
REC236-2795 | 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. |
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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REC169-2989 | 38 - Agency/Department Reporting | The Department of Premier and Cabinet should lead the development of a performance management framework for measuring, monitoring and reporting on the implementation of Part 6 of the Act and the CIP framework. The framework should include key indicators, targets and reporting arrangements for assessing the extent to which departments, agencies and industry have fulfilled their obligations, as well as measures for monitoring achievement of joint objectives. |
REC169-2998 | 38 - Agency/Department Reporting | Reports on the training exercises should be retained in an appropriately secured central repository so that consolidated results of the exercises can be drawn together effectively. |
REC169-2997 | 38 - Agency/Department Reporting | The Department of Premier and Cabinet and Victoria Police, in consultation with departments, should standardise reporting on training exercises conducted under Part 6 of the Act and the CIP framework to promote greater consistency and to enable better identification of lessons learned and continuous improvement. |
Rec-ID | Code | Recommendation |
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REC158-3429 | 38 - Agency/Department Reporting | That the nominated marine safety authority is required to ensure that incident notification and data recording requirements for Victorian commercial ports are consistent and adhered to. |
REC158-3428 | 38 - Agency/Department Reporting | That the nominated marine safety authority, in consultation with the Emergency Services Commissioner and senior emergency services personnel, is responsible for monitoring the implementation and auditing against appropriate performance standards, risk management guidelines and good practice guidelines. |
REC158-3452 | 25 - Inquiry, audit, lessons management and after action review | That the nominated marine safety authority undertakes a further assessment to determine the recommendations from this Review that may also be applicable to State waters outside commercial port waters. |
Rec-ID | Code | Recommendation |
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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. |
REC156-3494 | 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. |
REC156-3487 | 10 - Infrastructure | Electricity distribution businesses develop and implement alternative arrangements for monitoring fallen powerlines. |
REC156-3506 | 26 - Research | The Office of the Emergency Services Commissioner facilitate further research into technologies that will reduce the need for the public to speak to an operator during an emergency as a component of the proposed emergency warning and alert system and Victorian Emergency Information Line. |
Rec-ID | Code | Recommendation |
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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. |
REC149-3145 | 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 |
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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. |
Rec-ID | Code | Recommendation |
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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. |
REC121-3776 | 38 - Agency/Department Reporting | The Minister for Transport Services should retain, independently of ITSRR, safety auditors to provide a report to the Minister confirming or qualifying the contents of each such ITSRR quarterly report. |
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. |
REC121-3694 | 25 - Inquiry, audit, lessons management and after action review | The ITSRR should conduct random audits of accredited rail organisations for compliance with communications protocols. |
REC121-3712 | 38 - Agency/Department Reporting | RailCorp and ITSRR should co-operate with national programs for the collection, collation, trend analysis and dissemination of safety critical information. |
REC121-3758 | 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. |
REC121-3775 | 38 - Agency/Department Reporting | The Minister for Transport Services must table in Parliament, each such quarterly report by 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. |
REC121-3693 | 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. |
REC121-3697 | 38 - Agency/Department Reporting | All train drivers’ defects reports should be entered by RailCorp into a computerised record and tracked to finalisation. |
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. |
REC121-3774 | 38 - Agency/Department Reporting | The ITSRR must provide a quarterly report to the Minister for Transport Services on the progress made by RailCorp in implementing these recommendations, including: |
REC121-3691 | 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. |
REC121-3695 | 10 - Infrastructure | There should be interoperability of communications equipment between all trains operating on the New South Wales rail network. |
REC121-3753 | 25 - Inquiry, audit, lessons management and after action review | The RailCorp Board should establish independent external safety auditing processes to regularly audit and report to the Board on the implementation of an integrated safety management system by RailCorp and on safety performance generally. |
REC121-3729 | 38 - Agency/Department Reporting | All reports of the Chief Investigator of OTSI should be delivered, upon completion and without being reviewed, to ITSRR and the Minister for Transport Services. |
REC121-3687 | 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. |
REC121-3726 | 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. |
REC121-3723 | 38 - Agency/Department Reporting | All ATSB accident investigation reports should be made public. |
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. |
REC121-3657 | 10 - Infrastructure | All signal telephones must be maintained by RailCorp in proper working order. |
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. |
REC121-3722 | 38 - Agency/Department Reporting | The ATSB should deliver any report of any such rail accident which it investigates to the Board of any rail organisation involved in the accident, ITSRR and the Minister for Transport Services. |
Rec-ID | Code | Recommendation |
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REC117-3641 | 38 - Agency/Department Reporting | The ANAO recommends that, to ensure the outcomes of evaluations are effectively used to enhance the national counter-terrorism arrangements, the Attorney-General’s Department and the Department of the Prime Minister and Cabinet take appropriate measures to ensure: |
REC117-3633 | 38 - Agency/Department Reporting | The ANAO recommends that, to provide better information to contribute to strategic assessments, decisions and reporting, the Attorney-General’s Department, with input and guidance from the Department of the Prime Minister and Cabinet: |
Rec-ID | Code | Recommendation |
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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. |