Inquiry Search
Rec-ID | Code | Recommendation |
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REC309-2479 | 34 - Local knowledge | Local groups should plan for and establish clear arrangements to effectively manage offers of assistance including the management of goods, services and volunteers. |
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. |
REC309-2475 | 15 - Inter-service cooperation | Greater emphasis be placed on pre-planned and pre-determined arrangements between the Australian Defence Force and State and local agencies. |
REC309-2471 | 17 - Assets and technology | As part of the annual Emergency Action Plan review for the Ross River Dam, consideration should be given to the potential impacts of operating the gate outside automatic mode and whether this event has provided any new information and learnings which can be incorporated into the Emergency Action Plan. This should occur prior to the 2019/20 wet season. |
REC309-2467 | 9 - Community education | Further work be undertaken to develop effective public flood risk messaging and community education materials that are easy to understand and tested with the community to ensure flood risk is understood. |
Rec-ID | Code | Recommendation |
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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. |
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. |
Rec-ID | Code | Recommendation |
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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. |
REC295-1306 | 9 - Community education | Develop practical policy outcomes to support resilience (e.g. the 72- hour model) and promote this broadly to community through media, awareness campaigns, policies etc. Research should be undertaken to gain insight into the types of messaging and activities that have the most impact on sustained behaviour change within the community before committing to a particular model. |
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. |
REC295-1305 | 18 - Access to fire ground | That the annexure to the State Emergency Management Plan, ‘Traffic management during emergencies’, be updated to include: responsibilities and processes for road closures; and, Department of Planning, Transport and Infrastructure requirements in regards to provision of road closure information, notification of changes in road closure status and publishing of that information. |
REC295-1326 | 14 - Incident Mgt Teams | Establish a State-wide resourcing capability to support incident management teams, regional coordination centres, zone emergency centres, relief centres, recovery centres and State control centres. some of the features of such a capability should include: a) multi-agency, cross-government, State-wide pool of incident management and emergency management personnel building on the State incident management team concept currently facilitated by the Country Fire Service, and expanded to include all hazards, multiagency teams with a roster that provides year-round coverage b) a system that enables staff and volunteers from any agency to identify their availability for upcoming shifts c) a rostering system that enables one or more incident management teams, staging areas, regional coordination centres, State control centres and relief centres to develop, maintain and distribute rosters and structure charts in a more coordinated manner d) identifying areas of expertise for key incident and emergency management functions (e.g. public information, alerts and warning, media liaison, logistics and resource management) that would benefit from a coordinated and resource pooling approach and take steps to implement (consider the Mapping Functional Support Group model as a potential service delivery model). |
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 |
REC295-1300 | 17 - Assets and technology | That the State Emergency Service explores options for providing suitable personal protective clothing to personnel from supporting emergency services during major flooding events and sandbagging operations. |
REC295-1320 | 17 - Assets and technology | Review existing electronic information systems used by emergency services organisations and other government agencies, and: a) establish a single incident information system across the Emergency Services Sector (MFS, CFS and SES), and b) identify opportunities to consolidate incident information systems of other agencies |
REC295-1299 | 17 - Assets and technology | That systems for Automatic Vehicle Location and personnel tracking be implemented within the emergency services sector. |
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. |
REC295-1297 | 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. |
Rec-ID | Code | Recommendation |
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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. |
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. |
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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REC267-1159 | 9 - Community education | Improving Community Preparedness and Resilience |
REC267-1154 | 36 - Volunteers | Coordination of Volunteer Support |
REC267-1153 | 4 - Fire season preparation | Planning for Access to Potentially Isolated Communities |
REC267-1150 | 9 - Community education | Media Engagement Consideration should be given on future recovery operations to adopting a more structured approach to media engagement, with regular media briefings undertaken at a frequency dependent upon the phase of the recovery activities and the level of media interest. These briefings could be conducted at different locations around the region, if appropriate, and would provide the opportunity for communication of key messages and provide journalists with the opportunity to ask questions regarding the recovery. This could be complemented by media coverage of community engagement visits. For all recovery operations, |
REC267-1149 | 15 - Inter-service cooperation | PES External Surge Program The success of the PES External Surge Program and the willingness of participants to deploy at short notice to support the recovery effort is commendable, as is the readiness of their supervisors to release them from their duties to enable deployment. The Program, supported by an appropriate training program, is one that should be sustained as part of the whole of Government recovery readiness effort. |
REC267-1162 | 10 - Infrastructure | Telecommunications and Power Infrastructure |
Rec-ID | Code | Recommendation |
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REC233-1590 | 25 - Inquiry, audit, lessons management and after action review | Department of Broadband, Communications and the Digital Economy seek regular updates from Telstra on the implementation of the recommendations of its inquiry into the Warrnambool exchange fire. |
Rec-ID | Code | Recommendation |
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REC215-1871 | 14 - Incident Mgt Teams | Fire services can improve outcomes by developing a checklist for use by incident controllers |
REC215-1879 | 25 - Inquiry, audit, lessons management and after action review | Regulators can help to achieve improved outcomes by auditing compliance with the BPEM guidelines on a regular basis |
REC215-1877 | 39 - Disaster Risk Management | Regulators can help to achieve improved outcomes by considering the issues identified by this review |
REC215-1876 | 39 - Disaster Risk Management | Fire services can improve outcomes by initiating discussions with landfill operators about fire management planning and emphasising the critical importance of water supplies and early intervention |
REC215-1875 | 1 - Land-use and building regs | Fire services can improve outcomes by seeking input to decisions about siting, design and fire water systems as part of the planning and licensing processes |
REC215-1874 | 15 - Inter-service cooperation | Fire services can improve outcomes by working with EPA as the regulator and licensing authority to achieve improved compliance with the required outcomes specified in the BPEM guidelines |
Rec-ID | Code | Recommendation |
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REC204-1919 | 1 - Land-use and building regs | Tourism WA must give specific regard as to whether land use approvals need to be sought, particularly from Department of Regional Development and Lands, when conducting due diligence for event sponsorship proposals that require sign off by both departments. |
REC204-1918 | 1 - Land-use and building regs | Department of Regional Development and Lands and Department of Environment and Conservation should consider how their respective land use approval processes can incorporate the input of Local Emergency Management Committees (LEMCs) as part of risk assessments for high risk events and adventure sport activities. |
REC204-1916 | 25 - Inquiry, audit, lessons management and after action review | Local Emergency Management Committee (LEMC) processes should be reviewed to ensure that: |
REC204-1914 | 15 - Inter-service cooperation | FESA, WA Police and St John Ambulance establish a uniform protocol for handling multiple agency emergency responses that does not involve callers having to make multiple calls to 000. |
REC204-1913 | 25 - Inquiry, audit, lessons management and after action review | The Department of the Attorney General consider conducting a review of the Civil Liability Act 2002 (WA) in light of the 2011 Kimberley Ultramarathon. Such a review should consider issues such as the effectiveness given to competitor waivers under the Act and the potential difficulties of establishing proceedings and enforcing a judgement against foreign‐based providers of recreational activities. |
REC204-1908 | 39 - Disaster Risk Management | As part of the current revision of its contract template for sponsorship agreements, Tourism WA should ensure that: |
Rec-ID | Code | Recommendation |
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REC198-2905 | 14 - Incident Mgt Teams | The Fire Services Commissioner ensures that there is a single standard for the tabards worn by the IMT on the fireground and in control centres to ensure consistency and aid interoperability. |
REC198-2903 | 15 - Inter-service cooperation | The CFA works with MFB to ensure that the MFB control unit is available for responding to large fires and multi-agency incidents in fringe CFA areas |
REC198-2902 | 14 - Incident Mgt Teams | The Fire Services Commissioner clarifies the role of regional controller for major fires and incidents other than bushfire. |
Rec-ID | Code | Recommendation |
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REC197-1740 | 36 - Volunteers | The CFA, in consultation with the VFBV and volunteers, develop and introduce an arrangement whereby a volunteer can transfer from one brigade to another and still remain a member of the CFA, without the need to resign. |
REC197-1739 | 36 - Volunteers | The CFA, in consultation with the VFBV and volunteers, develop a systemic exit strategy, which ensures that relevant information is captured consistently across all brigades. |
REC197-1770 | 36 - Volunteers | The CFA, in consultation with the VFBV and volunteers, review the arrangements for the reimbursement of volunteer expenses. This review could be done in conjunction with the review of possible reimbursement of employers of CFA volunteers as recommended in Recommendation 5. |
REC197-1735 | 36 - Volunteers | A. The CFA continue to explore and develop initiatives with modern information and communication technologies to maximise the benefits that they may bring to volunteer involvement in the CFA. |
REC197-1745 | 36 - Volunteers | The CFA revisit with the UFU the arrangements relating to Community Education Firefighters/Fire Officers and the use of volunteers in this role. |
REC197-1734 | 36 - Volunteers | A. Consideration be given to the VFBV being funded directly by Government rather than by the CFA. |
REC197-1742 | 36 - Volunteers | The CFA, in consultation with the VFBV and volunteers, develop initiatives and strategies that will maximise the involvement of young people as volunteers and their retention as volunteers. |
REC197-1733 | 25 - Inquiry, audit, lessons management and after action review | That a review of the Country Fire Authority Act 1958 and the Country Fire Authority Regulations 2004 be undertaken. |
REC197-1741 | 9 - Community education | A. The CFA further develop community education programs to specifically engage culturally and linguistically diverse (CALD) communities to address the importance of ethnic diversity. |
Rec-ID | Code | Recommendation |
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REC166-3007 | 15 - Inter-service cooperation | That Tasmania Fire Service implement Recommendation 5 above; and that Aurora continue to co-operate with that Service. |
REC166-3004 | 17 - Assets and technology | That the Tasmania Fire Service consider improvements in radio units installed in breathing apparatus: |
REC166-3009 | 25 - Inquiry, audit, lessons management and after action review | That the Tasmania Fire Service conduct an audit of all shopping centres to ensure that there exists within those centres adequate fire protection and evacuation systems. |
REC166-3008 | 1 - Land-use and building regs | That any building fitted with heat-activated closing devices or fire and smoke doors be assessed to establish if it constitutes a fire hazard under section 165 of the Building Act 2000 and that, where appropriate, such doors be replaced with smoke activated doors. |
Rec-ID | Code | Recommendation |
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REC061-3413 | 15 - Inter-service cooperation | The Committee recommends to the Minister for Police and Emergency Services that a joint communications and dispatch facility be established under the Minister's control to implement the following minimum services to the Victoria Police and the emergency services: |
REC061-3258 | 25 - Inquiry, audit, lessons management and after action review | The Committee recommends that the Metropolitan Fire Brigades Board be reviewed five years from the tabling of this report in Parliament. |
REC061-3257 | 9 - Community education | The Committee recommends that the FireVision concept used by the Metropolitan Fire Brigades Board be extended through the Directorate of School Education's Interactive Television Program to all emergency services and in particular to rural fire and emergency services. |
REC061-3248 | 15 - Inter-service cooperation | The Committee recommends to the Minister for Police and Emergency Services that a joint communications and dispatch facility be established under the Minister's control to implement the following minimum services to the Victoria Police and the emergency services: |
REC061-3423 | 25 - Inquiry, audit, lessons management and after action review | The Committee recommends that the Metropolitan Fire Brigades Board be reviewed five years from the tabling of this report in Parliament. |
REC061-3422 | 9 - Community education | The Committee recommends that the FireVision concept used by the Metropolitan Fire Brigades Board be extended through the Directorate of School Education's Interactive Television Program to all emergency services and in particular to rural fire and emergency services. |