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. |
REC325-4322 | 24 - Govt responsibility | The Inspector-General of Emergency Management recommends the Dam Safety Regulator review the Emergency Action Plan for Referable Dam Guideline with particular regard to the distinction between the process required by a flood event as compared to a dam failure event by 1 November 2023. The Emergency Action Plan for Referable Dam Guideline review will be informed by a discussion, facilitated by the Dam Safety Regulator, between dam owner Seqwater, the Brisbane City Council Flood Information Centre, the Brisbane Local Disaster Management Group and the Brisbane District Disaster Management Group. The purpose of the facilitation is to achieve inter-agency understanding of warning and notification responsibilities. The reviewed Emergency Action Plan for Referable Dam Guideline should be published, promoted and shared via a stakeholder engagement exercise with Queensland’s referable dam owners, disaster management stakeholders including local disaster management groups and district disaster management group. |
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. |
REC325-4339 | 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. |
Rec-ID | Code | Recommendation |
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REC319-4199 | 24 - Govt responsibility | Relief and recovery capability: The Inspector-General for Emergency Management recommends that Emergency Management Victoria and the entity referred to in Recommendation 13, or otherwise responsible government department – in collaboration with the relevant relief and recovery organisations: |
Rec-ID | Code | Recommendation |
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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. |
REC311-2504 | 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. |
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. |
REC311-2495 | 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. |
REC311-2491 | 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. |
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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REC306-2425 | 24 - Govt responsibility | We recommend that the Department of Natural Resources and Mines and the four councils work together to effectively and economically regulate levee banks. |
REC306-2422 | 24 - Govt responsibility | We recommend that, in the absence of stand-alone catchment management authorities, the Department of Infrastructure, Local Government and Planning fulfil its obligation under the State Disaster Management Plan to drive the enhancement of flood resilience in the four catchments by: |
Rec-ID | Code | Recommendation |
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REC002-4001 | 35 - Business and Industry in relation to industry | The Commission consider that in all mines where gas exists the course of the air should be directed to sweep along the working-faces; in mines worked by Pillar and Stall, bratticing must be resorted to to carry the gas from the face as it issues, and so prevent any accumulation of explosive gases or of gases inimical to life. In cases where gas exists it would be better that no bords should be broken off the back or return heading or supplied with air fouled by dangerous gases. The panel system of working by confining and localising districts, or some modification thereof, might be pursued with advantage. |
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. |
REC002-4010 | 35 - Business and Industry in relation to industry | The Commission do not approve of removing any responsibility from the management by increasing the power or number of the Inspectors. The visits of these officials should, so far as possible, be visits of surprise. |
REC002-4008 | 35 - Business and Industry in relation to industry | Where dust exists in quantity, and under conditions favourable for ignition, it should be periodically and sufficiently dampened by water |
REC002-4004 | 35 - Business and Industry in relation to industry | Where safety-lamps are used, and the obligation is laid upon the men to cleanse the same, all examinations, tests, and repairs to these should be done by the owners. |
REC002-4003 | 35 - Business and Industry in relation to industry | Where gas exists, and no provisions are made for its constant removal, no shots should be fired, and, where permitted in a gassy mine, shots should be fired only by a man specially appointed, and at such hours when the miners are not within the mine. All shots should be tamped by stone well damped, and only copper or wooden tools should be employed. As far as possible the use of explosives should be discouraged, and skilful mining encouraged. Danger-boards should be placed further from the faces whence gas issues (say), where practicable, 50 yards. |
Rec-ID | Code | Recommendation |
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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. |
REC297-1258 | 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. |
REC297-1270 | 24 - Govt responsibility | That, in the event of a major emergency such as the June floods, a government department (DPAC or State Growth) be appointed to coordinate infrastructure repair, to the extent that funding allows, for the whole state. Individual entities will still have the right and responsibility to repair and maintain their own assets, but some central oversight and coordination is, in our view, likely to be beneficial. |
REC297-1257 | 35 - Business and Industry in relation to industry | That in the event that Hydro Tasmania decides to start cloud seeding again, water managers, represented by DPIPWE, work with Hydro Tasmania to ensure appropriate, best practice application of the guidelines issued by the Agricultural and Resource Management Council of Australia and New Zealand. |
REC297-1269 | 35 - Business and Industry in relation to industry | That Government engages with non-government organisations that may provide services during emergency events to clarify the terms and conditions for support through a written arrangement (MOU or similar). |
REC297-1255 | 24 - Govt responsibility | That Government establishes a central flood policy unit responsible for coordinating flood policy across all government agencies, including Government Businesses, and ensures that such a unit has a whole-of-government and community focus. |
REC297-1268 | 24 - Govt responsibility | That DPAC becomes the Management Authority for recovery in Tasmania. |
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. |
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. |
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. |
REC295-1288 | 24 - Govt responsibility | That Attorney General’s Department explore options to overcome fatigue and welfare issues of SAGRN staff associated with emergency events of extended duration. |
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. |
REC295-1327 | 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. |
REC295-1286 | 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. |
REC295-1312 | 24 - Govt responsibility | That the Department of Education and Child Development be included as a member of State Emergency Management Council and represented in the State Emergency Centre. |
REC295-1319 | 24 - Govt responsibility | That a single emergency service multi-agency control centre be established with sufficient capacity and capability to deal with all types of emergency incidents in SA. Also consider Police and State Emergency Centre. |
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. |
REC295-1308 | 24 - Govt responsibility | That the Department of the Premier and Cabinet revise the ministerial documents relating to emergency management. |
REC295-1318 | 24 - Govt responsibility | That the recommendation made following the Pinery bushfire, ‘to review control facilities at State, region and incident level’, be expanded to include all emergency services facilities that will be utilised for major incidents other than bushfire e.g. flood and earthquake and to also be extended into metropolitan areas, and implemented. |
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. |
REC295-1317 | 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. |
REC295-1274 | 35 - Business and Industry in relation to industry | That relevant agencies, such as the Department of State Development, SA Police and emergency services, collaborate to establish an education campaign to encourage businesses in South Australia to develop Business Continuity Plans which, among other potential hazards such as flood and fire, also take into account the potential impact of an extended power outage. |
REC295-1291 | 24 - Govt responsibility | That the Flood Reform Task Group, as proposed by the Department |
REC295-1316 | 24 - Govt responsibility | That the position of Deputy Director, Office for Digital Government is dedicated to the Office for Digital Government; and that people throughout DPC are identified and trained to perform appropriate roles within the State Crisis Centre |
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. |
REC272-1420 | 24 - Govt responsibility | The Department of Housing and Public Works should consider preparing an annual communique to asset owners of, and local governments with access to public cyclone shelters, outlining the maintenance and certification process and pre-season status. |
REC272-1418 | 24 - Govt responsibility | A state-wide engagement strategy is coordinated to ensure community messaging is consistent across all levels of Queensland’s disaster management arrangements. |
REC272-1416 | 24 - Govt responsibility | A state-wide strategy, including a common definition, is developed for identifying and engaging vulnerable people in emergencies. |
Rec-ID | Code | Recommendation |
---|---|---|
REC267-1157 | 35 - Business and Industry in relation to industry | Improvements to the Targeting of Government Support to Build Primary Industry Resilience |
REC267-1153 | 4 - Fire season preparation | Planning for Access to Potentially Isolated Communities |
REC267-1151 | 24 - Govt responsibility | Government Communications Coordination |
REC267-1162 | 10 - Infrastructure | Telecommunications and Power Infrastructure |
Rec-ID | Code | Recommendation |
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REC258-2526 | 24 - Govt responsibility | The Australian Government develops the State Safety Program into a strategic plan for Australia’s aviation safety system, under the leadership of the Aviation Policy Group, and uses it as the foundation for rationalising and improving coordination mechanisms. |
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. |
REC258-2539 | 35 - Business and Industry in relation to industry | The Civil Aviation Safety Authority changes its regulatory philosophy and, together with industry, builds an effective collaborative relationship on a foundation of mutual understanding and respect. |
REC258-2561 | 24 - Govt responsibility | The Australian Government amends regulations so that background checks and the requirement to hold an Aviation Security Identification Card are only required for unescorted access to Security Restricted Areas, not for general airside access. This approach would align with international practice. |
REC258-2530 | 24 - Govt responsibility | The Australian Government appoints an additional Australian Transport Safety Bureau Commissioner with aviation operational and safety management experience. |
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. |
REC258-2528 | 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. |
REC258-2552 | 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. |
Rec-ID | Code | Recommendation |
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REC250-0794 | 24 - Govt responsibility | Rural Finance Corporation (Department of Treasury and Finance) and Regional Development Victoria should coordinate any future disaster relief and recovery programs for businesses. |
REC250-0793 | 24 - Govt responsibility | The Department of Premier and Cabinet should develop clear guidelines for departments in designing community disaster relief and recovery programs. |
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. |
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. |
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. |
Rec-ID | Code | Recommendation |
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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. |
REC236-2793 | 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. |
REC236-2805 | 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. |
REC236-2792 | 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. |
REC236-2801 | 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. |
REC236-2800 | 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. |
REC236-2799 | 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. |
REC236-2808 | 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. |
REC236-2795 | 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. |
Rec-ID | Code | Recommendation |
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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: |
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). |
Rec-ID | Code | Recommendation |
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REC217-1824 | 24 - Govt responsibility | The Victorian Government to implement the recommendations of the Victorian Floods Review in relation to the development and implementation of appropriate flood mitigation and protection strategies for essential services. |
REC217-1843 | 24 - Govt responsibility | The state government implement the Victorian Floods Review recommendation 10 in relation to the datums used to describe river and stream heights. |
REC217-1823 | 24 - Govt responsibility | The Victorian Government should work with the New South Wales Government and the Murray Darling Basin Authority to establish an appropriate floodplain management committee and to develop a floodplain management strategy for the Murray River. The strategy will define priority regions for the development of floodplain management plans, address ways of improving the management of all levees on the Murray River, and seek agreement in relation to improved approvals processes, levee heights and maintenance regimes. |
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. |
REC217-1822 | 24 - Govt responsibility | The state government will work with Grampians Wimmera Mallee Water and stakeholders to determine ongoing ownership and associated responsibilities for redundant channel infrastructure in the Wimmera and the Mallee. |
REC217-1839 | 24 - Govt responsibility | The state government accept recommendations 25 to 28, inclusive, of the Victorian Floods Review. |
REC217-1835 | 24 - Govt responsibility | Within the jurisdiction of Melbourne Water, it shares with local councils the responsibility to manage local drainage systems as outlined under the Water Act 1989 and the Local Government Act 1989 respectively: |
REC217-1827 | 24 - Govt responsibility | The role of flood risk management planning rests with CMAs and Melbourne Water (under the Water Act 1989), and is a shared responsibility with local government. Shared responsibilities for flood risk management planning and implementation will be consistently reflected in government policy. |
REC217-1846 | 24 - Govt responsibility | The state government should implement the recommendations of the Victorian Floods Review in relation to the creation of resilience committees and resilience plans, with responsible authorities. |
Rec-ID | Code | Recommendation |
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REC210-0619 | 24 - Govt responsibility | In the event that the review does not adequately account for Queensland conditions, the Queensland Government should produce a document that provides appropriate guidelines for floodplain management in the Queensland context. |
REC210-0706 | 24 - Govt responsibility | The Department of Environment and Resource Management should prepare a list of relevant considerations to be taken into account in performing a risk assessment to decide which sites to inspect. Bureau of Meteorology forecasts should be one consideration. |
REC210-0745 | 24 - Govt responsibility | The Queensland Government should ensure that all flood mitigation manuals include the requirement that those operating the dam during flood events hold current registrations as professional engineers. |
REC210-0713 | 24 - Govt responsibility | The Queensland Government should refine the criteria which must be considered in assessment of applications for relaxation of environmental authority conditions, by transitional environmental program or otherwise, in response to flood. |
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. |
REC210-0726 | 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. |
REC210-0771 | 24 - Govt responsibility | The Queensland Government should, in consultation with the Department of Environment and Resource Management and Emergency Management Queensland, determine which agency is appropriate to review and approve emergency action plans for referable dams. |
REC210-0618 | 24 - Govt responsibility | The Queensland Government should endeavour to ensure that Queensland conditions are appropriately considered in the National Flood Risk Advisory Group’s review of best practice principles. |
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. |
REC210-0695 | 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. |
REC210-0711 | 24 - Govt responsibility | Unless the Department of Environment and Resource Management has decided not to permit discharges, it should assist each mine operator in its application for an environmental authority to ensure, as far as possible, that each authority includes provisions for discharges during times of heavy rainfall and flood. |
REC210-0753 | 24 - Govt responsibility | The Department of Environment and Resource Management should prepare formal work procedures for the review of flood event reports created under emergency action plans and flood mitigation manuals. These should include procedures for: • making enquiries with the owners of referable dams that have catchments that have been subject to heavy rainfall (or where there is other reason to believe the emergency action plan has been triggered) as to whether the emergency action plans have been triggered • reminding owners of referable dams that have had emergency action plans triggered of their obligation to submit a flood event report • upon receipt of a flood event report, reviewing it, identifying any dam safety or other issues or areas where insufficient detail has been provided, raising those matters with the dam owner or other affected party and identifying appropriate remedial steps 28 Queensland Floods Commission of Inquiry | Final Report Complete list of Final Report recommendations • raising any issues identified in the report that are beyond the expertise of the Department of Environment and Resource Management, or are likely to be of particular interest to another body, with the appropriate body • keeping a record of the process and results of the review of the flood event report • fixing an appropriate timeline for the completion of each of the above steps: the time required may depend on specific circumstances, but must allow for any potential safety issues to be identified and remedied efficiently. |
REC210-0720 | 24 - Govt responsibility | The Queensland Government should determine which of its agencies should take responsibility for the management of all existing and new abandoned mine sites in Queensland. |
REC210-0765 | 24 - Govt responsibility | As part of the longer term review of the Manual of Operational Procedures for Flood Mitigation at Wivenhoe Dam and Somerset Dam, the Queensland Government should consider the impact of possible upgrades of bridges downstream of Wivenhoe Dam on different operating strategies for the dam. |
REC210-0742 | 24 - Govt responsibility | The Queensland Government should ensure that, when it considers options for the operational strategies to |
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. |
REC210-0710 | 24 - Govt responsibility | The Department of Environment and Resource Management should assist mine operators in their applications for amended environmental authorities to ensure, as far as possible, that each environmental authority contains a tailored version of Table 4 of the model conditions. The Department of Environment and Resource Management should provide to mining companies its monitoring data and its suggested values for Table 4 on the basis of an assessment of the catchment which takes into account the cumulative effect of different operators’ releases. |
REC210-0752 | 24 - Govt responsibility | Prior to approving a flood mitigation manual, the Queensland Government should be satisfied that its terms are expressed in a manner that allows a determination of compliance with it to be made by reference to objective standards. |
REC210-0718 | 24 - Govt responsibility | The Queensland Government should make public the procedural guide used by Department of Environment and Resource Management officers to decide whether to grant an emergency direction. |
REC210-0764 | 24 - Govt responsibility | The Department of Transport and Main Roads, in conjunction with Brisbane City Council and Somerset Regional Council, should investigate options for the upgrade of Brisbane River crossings between Wivenhoe Dam and Colleges Crossing and undertake a cost-benefit analysis of these to determine the outcome which best serves the public interest. |
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. |
REC210-0774 | 24 - Govt responsibility | The Department of Environment and Resource Management and Emergency Management Queensland should ensure that each has copies of current emergency action plans for all dams in Queensland. |
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. |
REC210-0708 | 35 - Business and Industry in relation to industry | The Queensland Government should work collaboratively with the Commonwealth Government and mine operators to ensure co-ordinated and effective monitoring of salts, metals and other contaminants in marine environments that may be affected by mine discharges. |
REC210-0751 | 24 - Govt responsibility | The Queensland Government should continue to assess and review the adequacy of work procedures DS 5.1 and 5.3, having regard to the need for flood mitigation manuals to reflect the will of the executive. |
REC210-0716 | 24 - Govt responsibility | The Queensland Government should make public the procedural guide used by Department of Environment and Resource Management officers to decide whether to grant a transitional environmental program. |
REC210-0763 | 35 - Business and Industry in relation to industry | Seqwater should ensure that the Somerset Dam gallery is not susceptible to flooding during overtopping events. |
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. |
REC210-0773 | 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. |
REC210-0620 | 24 - Govt responsibility | The Queensland Government should determine whether existing guidelines are sufficient for councils to understand best practice in the performance of flood studies and the production of flood maps. If a lack of current guidelines is identified, the government should create and circulate guidance material for councils. |
REC210-0707 | 24 - Govt responsibility | The Department of Environment and Resource Management should conduct risk assessments in time for site inspections, and the implementation of solutions to problems identified at inspections, to take place before 1 November of each year. |
REC210-0748 | 24 - Govt responsibility | The Queensland Government should consider whether North Pine Dam should be operated as a flood mitigation dam when it considers possible operating strategies and full supply levels as part of the longer term review of the Manual of Operational Procedures for Flood Mitigation at North Pine Dam. |
REC210-0715 | 24 - Govt responsibility | The Queensland Government should prepare a procedural guide for officers deciding whether to grant a relaxation of environmental authority conditions, by transitional environmental program or otherwise, with guidance as to: • the meaning of each criterion • examples of the types of things that may be relevant to each criterion • the priority, if any, to be afforded to different criteria. |
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. |
REC210-0736 | 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. |
REC210-0772 | 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. |
Rec-ID | Code | Recommendation |
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REC208-0527 | 35 - Business and Industry in relation to industry | That the Office of Environment and Heritage require Orica to engage and fund appropriate independent experts to oversee any modifications to the plant in the next major maintenance overhaul of the plant in 2016 and in any upgrades to the plant prior to that date. |
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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REC199-0424 | 35 - Business and Industry in relation to industry | the state require dam owners and operators to review storage operating manuals to incorporate lessons from the 2010–11 floods and make this information publicly available. The manuals should include a clear policy on dam surcharging and pre-release. |
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 |
REC199-0466 | 24 - Govt responsibility | the Departments of Health and Human Services finalise the definition of ‘vulnerable person’ and the list of facility types where vulnerable people are located and ensure that the definition and associated policy(ies) are applicable across ‘all hazards’. |
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. |
REC199-0428 | 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. |
REC199-0465 | 24 - Govt responsibility | the state undertake major reform of Victoria’s emergency management arrangements to bring about an effective ‘all hazards, all agencies’ approach, incorporating: • clarity of command and control in all emergencies • common operating platforms, including communications and information technology • interoperability between all agencies • regular joint training and exercising by all agencies • the development and implementation of performance standards for each emergency management agency • the development and maintenance of effective planning arrangements at all levels of emergency management • a meaningful monitoring and audit regime for designated standards and planning requirements; and • an effective accountability mechanism to support the maintenance of legislative and other agency obligations. |
REC199-0406 | 24 - Govt responsibility | the state expand the Regional Water Monitoring Partnerships model to include all flood warning gauges. |
REC199-0427 | 35 - Business and Industry in relation to industry | the state require dam owners and operators provide regular situational reports to the relevant control agency where dam issues may impact incident management. |
REC199-0455 | 24 - Govt responsibility | the state conduct an ‘all hazards’ needs analysis to determine requirements for level 3 Incident Control Centres with a focus on ‘all hazards’ and multi-agency capability. Following this analysis, the state take steps to ensure the availability of sufficient and functional level 3 Incident Control Centres across the state with an ‘all hazards’ and multi-agency capability |
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. |
REC199-0426 | 35 - Business and Industry in relation to industry | the state require that dam owners and operators inform people situated downstream of water storages if the owners/operators become aware of an immediate threat arising from the dam to the safety of those people. The owner/operators should provide this information as soon as the owner/operators become aware of the threat. |
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. |
REC199-0400 | 24 - Govt responsibility | The state take the necessary measures to clarify roles, responsibilities and cost-sharing arrangements for flood warning systems, including tasking state and regional bodies to be responsible for the flood warning system. This will require engaging with the commonwealth to amend the 2001 arrangements, updating the 1998 floodplain management strategy accordingly and continuing to support commonwealth initiatives designed to improve flood mapping standards and associated issues. |
REC199-0425 | 35 - Business and Industry in relation to industry | the state require that dam owners and operators inform the control agency and the Bureau of Meteorology about the management and operation of dams and weirs consistent with the flood warning requirements of the relevant river systems, including providing telemetry at sites as necessary. This may require the state proactively liaising with other states to ensure equivalent obligations are placed on interstate dam operators where the dam may impact Victorian communities. |
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. |
REC199-0481 | 24 - Govt responsibility | the state (consistent with recommendation 46) develop a model for determining the capability and capacity of departments and agencies with roles and responsibilities in large scale or protracted emergencies. The issues of capability and capacity should be addressed at all levels of emergency management planning. |
Rec-ID | Code | Recommendation |
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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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REC158-3454 | 24 - Govt responsibility | That the Department of Transport ensures that key stakeholders are engaged during the implementation of the approved Review recommendations. |
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. |
REC158-3448 | 24 - Govt responsibility | That the Director of Marine Safety works with the Australian Maritime Safety Authority to ensure that State and port emergency arrangements interface appropriately with the National Maritime Emergency Response Arrangements. |
REC158-3433 | 24 - Govt responsibility | That Harbour Masters are employed by a government body and remain geographically located at the port. |
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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC149-3132 | 35 - Business and Industry in relation to industry | Coverage of the regime should be increased to cover the complete hydrocarbons production system from wells through to custody transfer point or reasonable physical/technical system boundary. If NOPSA is also to be responsible for Carbon Capture and Storage it needs to be resourced to ensure that this does not detract from NOPSA's current responsibilities. |
REC149-3131 | 35 - Business and Industry in relation to industry | The exploration/production operator making all major decisions related to petroleum activities (i.e. selection of rig, well design and selection of service companies) should be made responsible for demonstrating to the regulator that drilling operations can be conducted safely. Where the drilling contractor owns the rig and conducts the day-to-day management of safety on the rig, this duty can be described in a rig specific Safety Case that is owned by the drilling contractor. This rig specific Safety Case does not have to be submitted for every well/well operation. |
REC149-3146 | 35 - Business and Industry in relation to industry | NOPSA should consider establishing a small forum for consultation consisting of representatives of relevant stakeholders. The representatives should have standing, with authority to participate in decision making and take on commitment on behalf of their stakeholder group. |
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. |
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. |
REC149-3133 | 35 - Business and Industry in relation to industry | Because some issues related to emergency response are beyond any single operator and usually occur outside the title area, there is a need for the representatives of the offshore industry to work together with other governments, interested and involved parties to develop the strategies to be utilised and the emergency planning model that will satisfy the requirements of all parties. |
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. |
REC125-3893 | 35 - Business and Industry in relation to industry | That Melbourne Water ensures that stakeholders (and especially local councils) are fully consulted before and during the development of drainage strategies and plans. These plans should consider councils’ drainage systems. |
REC125-3892 | 35 - Business and Industry in relation to industry | That Melbourne Water ensures stakeholder expectations are fully considered when setting flood risk reduction targets. |
Rec-ID | Code | Recommendation |
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REC121-3723 | 38 - Agency/Department Reporting | All ATSB accident investigation reports should be made public. |
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. |
REC121-3758 | 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. |
REC121-3697 | 38 - Agency/Department Reporting | All train drivers’ defects reports should be entered by RailCorp into a computerised record and tracked to finalisation. |
REC121-3775 | 38 - Agency/Department Reporting | The Minister for Transport Services must table in Parliament, each such quarterly report 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. |
REC121-3678 | 35 - Business and Industry in relation to industry | All railway owners and operators should have a quality assurance program for the design and construction of rolling stock and regular review of construction to ensure that the rolling stock satisfies the original functional performance specifications. |
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. |
REC121-3695 | 10 - Infrastructure | There should be interoperability of communications equipment between all trains operating on the New South Wales rail network. |
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: |
REC121-3721 | 24 - Govt responsibility | The ITSRR should ensure that OTSI, as a division of ITSRR, co-operates and assists the ATSB in the conduct of any independent investigation by the ATSB of any rail accident or incident in New South Wales. |
REC121-3657 | 10 - Infrastructure | All signal telephones must be maintained by RailCorp in proper working order. |
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. |
REC121-3694 | 25 - Inquiry, audit, lessons management and after action review | The ITSRR should conduct random audits of accredited rail organisations for compliance with communications protocols. |
REC121-3768 | 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. |
REC121-3720 | 24 - Govt responsibility | The New South Wales Government should make the necessary arrangements with the Australian Government, including any necessary legislation, for the Australian Transport Safety Bureau (ATSB) to have the power to investigate all rail accidents occurring on the New South Wales rail network the investigation of which may advance the knowledge of the causes of rail accidents in Australia. |
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. |
REC121-3729 | 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. |
REC121-3693 | 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. |
REC121-3767 | 24 - Govt responsibility | All accredited rail organisations should be required to re-apply every three years to ITSRR for accreditation. |
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. |
REC121-3651 | 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. |
REC121-3726 | 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. |
REC121-3691 | 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. |
REC121-3765 | 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. |
REC121-3712 | 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. |
REC121-3776 | 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. |
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. |