Inquiry Search
Rec-ID | Code | Recommendation |
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REC325-4323 | 7 - Inter-agency communication | The Inspector-General of Emergency Management recommends Queensland Fire and Emergency Services adopt measures to achieve a common operating picture between deployed Queensland Fire and Emergency Services assets in disaster management operations by 1 November 2023. |
REC325-4326 | 17 - Assets and technology | The Inspector-General of Emergency Management recommends Queensland Fire and Emergency Services lead an inter-agency IT system assessment with Queensland Police Service and local governments to identify disaster management systems currently in use and develop options to enhance connectivity and interoperability between systems. Outputs to be considered include, but are not limited to, consideration of requests for assistance (RFA) and the production of situation reports. |
REC325-4327 | 17 - Assets and technology | The Inspector-General of Emergency Management recommends all local governments that offer an opt-in system develop strategies to increase the number of subscribers who elect to use this service. As part of the annual disaster management plan assessment process for the period 2023–2025, the Office of the Inspector-General of Emergency Management will request information from the relevant local disaster management groups to highlight and share innovative practices that have led to an increase in subscription levels for opt-in services. |
REC325-4338 | 17 - Assets and technology | The Inspector-General of Emergency Management recommends the Queensland Reconstruction Authority and the Bureau of Meteorology investigate options for the consolidation of ownership, renewed capital and maintenance in the flood warning network in consultation with flood warning infrastructure asset owners. |
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. |
Rec-ID | Code | Recommendation |
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REC324-4308 | 26 - Research | Compound mental helath studies: That, to inform Government policies and programs for mental health and disasters, Government commission a longitudinal study on the effect of consecutive disasters on community mental health. |
REC324-4312 | 17 - Assets and technology | Impact to essential services: That, to minimise disruption to essential services, including outages which compromise basic communication coverage, and to ensure access to safe water supply and power during flood events, Government work directly or together with the Australian and other state governments and/or their relevant power and telecommunications regulatory, policy and market bodies to: |
REC324-4319 | 26 - Research | Climate and weather research: That, to enable effective mitigation and adaptation measures in response to changing climate risks, Government establish NSW as a world centre of disaster research and technology development. This should include: |
REC324-4293 | 17 - Assets and technology | Essential services and floodplain infrastructure: That, to minimise disruption to essential services (power, communications, water, sewerage) and to ensure flood infrastructure is fully serviceable before flooding, Government ensure: |
REC324-4303 | 39 - Disaster Risk Management | Risk-based approach to calculating flood planning: That, to take account of greater knowledge of climate change, Government reinforce its adoption of a risk-based approach to calculating the flood planning level for planning purposes and, through the NSWRA, immediately start a process of revising all flood planning level calculations in the state’s high-risk catchments. Flood planning level re-determinations for all high-risk catchments should be completed within 3 years. These revised flood planning levels will need to be factored into all development applications (in-progress and new) in those high-risk catchments. The risk profile of high-risk catchments should be revisited at appropriate time intervals to check that levels are current. A review should take place if there has been a significant trigger event (i.e. changed rainfall, development) or at least every 5 years. As well as reviewing the flood planning level, this 5-yearly review should include reviewing any floodplain lease conditions and adjusting them as necessary in the light of better knowledge of climate change impacts. In working out a tolerable, risk-based flood planning level, consideration should be given to the PMF, 1% AEP, 0.02% AEP, existing development, approved but not yet constructed developments, and existing and approved but not yet constructed evacuation routes. |
REC324-4305 | 39 - Disaster Risk Management | Cost benefit framework:That, to enable a more systematic prioritisation of investment options in risk mitigation before, during and immediately following a natural disaster event, Government adopt and utilise a Disaster Cost Benefit Framework. This Framework will enable Government to estimate the investment required for any given disaster, starting with flood events, and will enable the fast allocation of funding based on detailed and rapid analysis of flood and property modification, mitigation, preparation, response and finance related options including: |
Rec-ID | Code | Recommendation |
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REC323-4258 | 39 - Disaster Risk Management | That the NSW Government significantly increase its investment in flood mitigation and preparation, including its support of local governments to do the same, by: • increasing ongoing, long term funding and access to technical guidance and assistance for local councils • ensuring that land-use planning and development takes a risk-based approach. |
REC323-4263 | 17 - Assets and technology | That the NSW Government prioritise support for the full restoration of sewage treatment facilities on the Richmond River, for the benefit of communities in the Northern Rivers region. |
REC323-4285 | 17 - Assets and technology | That the NSW Government, in consultation with telecommunication providers and satellite communication providers, investigate ways to minimise the complete loss of telecommunication services in natural disasters, including: |
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: |
REC323-4286 | 17 - Assets and technology | That the NSW Government advocate through the National Cabinet for the Bureau of Meteorology to review its rain data infrastructure and flood modelling tools, to ensure forecasting locations, rain and flood gauges and other infrastructure are appropriately placed, maintained and updated. |
REC323-4256 | 17 - Assets and technology | That the NSW Government work with relevant agencies and local landowners to find ways to improve the management of drainage channels including looking for recommendations to reduce red and green tape. |
Rec-ID | Code | Recommendation |
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REC311-2492 | 39 - Disaster Risk Management | To increase understanding of hazards and manage risks, dam failure for Paradise Dam be included as a separate risk within the North Burnett Local Disaster Management Plan (LDMP). |
REC311-2505 | 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. |
REC311-2490 | 39 - Disaster Risk Management | To enable entities to have a shared understanding of forecast information for dam failure events during a flood, including flood wave travel time, speed and height, Emergency Action Plans contain protocols and responsibilities of relevant stakeholders for these aspects. |
REC311-2504 | 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. |
REC311-2499 | 39 - Disaster Risk Management | To ensure enhanced capability integration and enable timely community messaging Bundaberg LDMG in consultation with Sunwater develop additional Emergency Alerts and associated polygons for a Paradise Dam failure and load these on to the disaster management portal. |
REC311-2498 | 39 - Disaster Risk Management | To enhance shared capacity and collaboratively manage risk, the Chair of the Bundaberg DDMG use the QERMF process to determine if dam failure for Paradise Dam should be reported as a residual risk in this instance due to known changes in the risk profile to: |
REC311-2497 | 39 - Disaster Risk Management | To increase shared understanding of risks, ensure the coordination of plans and manage risks, dam failure for Paradise Dam be included as a separate risk within the Bundaberg District Disaster Management Plan (DDMP). |
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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REC002-4006 | 17 - Assets and technology | The Commisison would not insist upon a barometer being provided at each mine. Experience has proved that this is a tardy index to atmospheric conditions. Serious changes in the atmospheric pressure occur and are felt before they are indicated by a barometer. |
Rec-ID | Code | Recommendation |
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REC271-1526 | 13 - Mapping and data quality | In accordance with recommendations of the BMT WBM report, the Banana Shire Council, SunWater, and the Bureau of Meteorology, under the stewardship of the Department of Natural Resources and Mines, jointly identify the requirements for a suitable gauge network for the Callide Valley to allow meaningful and timely flood warnings. The review should identify key stakeholders, examine potential funding sources and include a cost benefit analysis. |
REC271-1522 | 26 - Research | Banana Shire Council investigate means to prioritise the commissioning of a fit-for-purpose flood study for high-risk areas across the Banana Shire to better inform flood risk management, including improved town planning. The outcomes of such a study should be available to the public and inform flood awareness campaigns, flood warnings, and building approvals. |
REC271-1521 | 26 - Research | The Department of Energy and Water Supply and SunWater, undertake the necessary studies to determine whether or not it is feasible to operate Callide Dam as a flood mitigation dam. Such studies should include matters in relation to, but not limited to: |
REC271-1533 | 14 - Incident Mgt Teams | State Disaster Coordination Centre considers requesting a representative from critical infrastructure owners be present as a liaison officer in the State Disaster Coordination Centre during activations for events that may impact on their assets. |
Rec-ID | Code | Recommendation |
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REC238-0804 | 26 - Research | Clarify roles, responsibilities and consider funding options for post-event collection of data and flood intelligence. |
REC238-0802 | 25 - Inquiry, audit, lessons management and after action review | Review the NSW state-wide governance arrangements for flood risk management so that broader issues identified by this Review can be most effectively addressed. |
REC238-0813 | 26 - Research | Develop and maintain a comprehensive flood model and flood modelling framework for the Hawkesbury-Nepean Valley. |
REC238-0807 | 26 - Research | Develop a comprehensive road evacuation network model for floods in the Hawkesbury-Nepean floodplain to inform evacuation capacity assessments and strategic transport and land use planning, and to assist with the real-time operational management of evacuation during floods. |
Rec-ID | Code | Recommendation |
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REC210-0600 | 26 - Research | Brisbane City Council, Ipswich City Council and Somerset Regional Council and the Queensland Government should ensure that, as soon as practicable, a flood study of the Brisbane River catchment is completed in accordance with the process determined by them under recommendation 2.5 and 2.6. The study should: |
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. |
REC210-0745 | 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. |
REC210-0753 | 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. |
REC210-0618 | 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. |
REC210-0722 | 26 - Research | The Queensland Government should seek information about the size, features and condition of abandoned mines, including whether the mine or its surrounding environment were adversely affected by flood, from private landholders who have abandoned mines on their properties. |
REC210-0767 | 26 - Research | The Department of Environment and Resource Management should require Wide Bay Water, in advance of every wet season, to provide details of its expectation as to the operability of the crest gates if a flood occurs, until such time as all gates have been demonstrated to work as designed. |
REC210-0678 | 26 - Research | Queensland Urban Utilities should make the results of its trials on the use of caps for overflow relief gully grates available to other authorities responsible for sewerage infrastructure. Consideration should be given by those authorities as to how the results can be used to improve the flood resilience of their sewerage networks. |
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. |
REC210-0739 | 26 - Research | The Queensland Government should resolve the discrepancy in recorded peak river height for the January 2011 flood of the Brisbane River between the Brisbane City and Port Office gauges. |
REC210-0599 | 26 - Research | The steering committee of the Wivenhoe Dam and Somerset Dam Optimisation Study should consider whether it would be more effective for the floodplain management investigation to be removed from the Wivenhoe Dam and Somerset Dam Optimisation Study. |
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. |
REC210-0744 | 26 - Research | The conditions for the use of a particular strategy in all flood mitigation manuals should reflect objective standards. |
REC210-0609 | 26 - Research | The Queensland Government and Commonwealth Government should ensure the existence and maintenance of a repository of data of the type used in flood studies. The database should include the types of data which the expert panel specified as needed for a comprehensive flood study. Councils, Queensland and Commonwealth Government agencies and dam operators should be able to deposit and obtain access to data. |
REC210-0721 | 26 - Research | The Department of Employment, Economic Development and Innovation should assemble all information currently available to the abandoned mine land program into a single database. The Queensland Government should ensure, using whatever information is available, that the list of abandoned mines is as complete as possible. This should at least include a review of all information held by the Department of Environment and Resource Management and the Department of Employment, Economic Development and Innovation. |
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. |
REC210-0765 | 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. |
REC210-0665 | 13 - Mapping and data quality | Councils should make their flood and overland flow maps and models available to applicants for development approvals, and to consultants engaged by applicants. |
REC210-0705 | 26 - Research | Any mine operator of a site at high risk of flood should obtain the best forecast information available (seasonal and short term) for the region in which the mine is located. |
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. |
REC210-0711 | 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. |
REC210-0743 | 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. |
REC210-0606 | 26 - Research | When commissioning a flood study, the body conducting the study should: • check whether others, such as surrounding councils which are not involved in the study, dam operators, the Department of Environment and Resource Management, and the Bureau of Meteorology, are doing work that may assist the flood study or whether any significant scientific developments are expected in the near future, and decide whether to delay the study • discuss the scope of work with the persons to perform the flood study as well as surrounding councils which are not involved in the study, dam operators, the Department of Environment and Resource Management, and the Bureau of Meteorology |
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. |
REC210-0751 | 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. |
REC210-0764 | 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. |
REC210-0664 | 13 - Mapping and data quality | Councils should, resources allowing, maintain flood maps and overland flow path maps for use in development assessment. For urban areas these maps should be based on hydraulic modelling; the model should be designed to allow it to be easily updated as new information (such as information about further development) becomes available. |
REC210-0704 | 26 - Research | Mine operators should obtain all public seasonal forecasts issued by the Bureau of Meteorology relevant to the regions in which their operations are located. |
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. |
REC210-0710 | 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. |
REC210-0742 | 24 - Govt responsibility | The Queensland Government should ensure that, when it considers options for the operational strategies to |
REC210-0602 | 26 - Research | A recent flood study should be available for use in floodplain management for every urban area in Queensland. Where no recent study exists, one should be initiated. |
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. |
REC210-0748 | 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. |
REC210-0762 | 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. |
REC210-0620 | 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. |
REC210-0736 | 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. |
REC210-0709 | 26 - Research | The Queensland Government should determine, as far as possible, the impact of mine discharges during the 2010/2011 wet season on freshwater and marine water quality and fauna and flora. |
REC210-0741 | 26 - Research | The steering committee of the North Pine Dam Optimisation Study should consider whether it would be beneficial for the floodplain management investigation to be removed from the North Pine Dam Optimisation Study. |
REC210-0601 | 26 - Research | Ipswich City Council should determine whether the results, models and maps produced by the Brisbane River flood study are sufficient for its floodplain management. If they are not, Ipswich City Council should ensure appropriate work is done by way of data collection and creation and hydrologic and hydraulic modelling for use in its floodplain management. |
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. |
REC210-0746 | 13 - Mapping and data quality | Seqwater should consider engaging a technical writer to develop completely new manuals after the operational strategies for Wivenhoe, Somerset and North Pine dams are set by the Queensland Government. |
REC210-0755 | 13 - Mapping and data quality | CS Energy should supplement physical monitoring of Splityard Creek Dam with visual monitoring by installing surveillance cameras or similar devices. |
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. |
REC210-0726 | 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. |
REC210-0683 | 13 - Mapping and data quality | All councils should, resources allowing, map the overland flow paths of their urban areas. |
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. |
REC210-0740 | 26 - Research | The steering committees of the Wivenhoe Dam and Somerset Dam Optimisation Study and the North Pine Dam Optimisation Study should consider removing the water supply security investigation from each study. |
Rec-ID | Code | Recommendation |
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REC208-0526 | 25 - Inquiry, audit, lessons management and after action review | That OEH’s testing procedures for determining the impact of pollution incidents incorporate additional requirements for the checking and verification of results before those results are released. |
REC208-0525 | 7 - Inter-agency communication | That the Office of Environment and Heritage amend its operating procedures for the Environment Line to ensure that there are clear obligations to pass on information relevant to other agencies, to those agencies in a timely manner. |
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 |
---|---|---|
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. |
REC121-3666 | 14 - Incident Mgt Teams | The rail commander should have complete authority to direct and control any rail employees attending the site of a rail accident, in accordance with directions given or arrangements put in place by the site controller, until the rescue phase of the emergency response to the rail accident has been completed. |
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. |
REC121-3693 | 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. |
REC121-3720 | 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. |
REC121-3665 | 14 - Incident Mgt Teams | The role of the rail commander should be to provide support and assistance to the site controller and emergency services personnel until the rescue phase of the emergency response to any rail accident is completed. |
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. |
REC121-3691 | 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. |
REC121-3768 | 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. |
REC121-3713 | 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. |
REC121-3663 | 14 - Incident Mgt Teams | The incident command system should clearly identify the roles of the rail commander, site controller, police commander and commanders of the other emergency services, and the way in which each is to work together during the recovery phase of any rail accident. |
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. |
REC121-3684 | 39 - Disaster Risk Management | The ITSRR should conduct its own risk assessment in relation to the risk of any such high consequence, low probability accident and, if necessary, direct RailCorp to conduct a further risk assessment to reduce the level of residual risk to a level ITSRR regards as acceptable. |
REC121-3767 | 24 - Govt responsibility | All accredited rail organisations should be required to re-apply every three years to ITSRR for accreditation. |
REC121-3710 | 39 - Disaster Risk Management | The ITSRR should have permanent access to the RailCorp intranet. |
REC121-3656 | 17 - Assets and technology | Satellite telephones should be provided by RailCorp to all rail commanders at any emergency. |
REC121-3725 | 13 - Mapping and data quality | The data and information management system should be compatible with any data and information management system established by the ATSB for the designated interstate rail network, provided that the establishment of a compatible system does not reduce the amount or quality of the information obtained by ITSRR below the optimum levels which it needs to conduct trend analysis, and otherwise properly manage the safety of rail operations in New South Wales. |
REC121-3683 | 39 - Disaster Risk Management | RailCorp should undertake risk assessments of each of its activities as follows: |
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. |
REC121-3700 | 39 - Disaster Risk Management | Maintenance plans on all trains should be revised annually. |
REC121-3652 | 14 - Incident Mgt Teams | A designated staff member at the RMC should act as the rail emergency management co-ordinator. He or she should be the sole point of contact at the RMC with other rail personnel involved in the rail accident and emergency services personnel during the rescue phase of the emergency response. |
REC121-3724 | 13 - Mapping and data quality | The ITSRR should establish a data and information management system, containing all data and information that it requires, to continually monitor the safety of the New South Wales rail system. |
REC121-3676 | 14 - Incident Mgt Teams | A direct line of communication should be established between the RMC and Emergency Services Operations Control Centre by a “tie line” or otherwise, so as to ensure that in the case of a serious rail accident there is an open line of communication between the officer in charge of the management of the incident at the RMC and the various emergency response services. |
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. |
REC121-3694 | 25 - Inquiry, audit, lessons management and after action review | The ITSRR should conduct random audits of accredited rail organisations for compliance with communications protocols. |