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. |
REC325-4331 | 41 - Emergency Management exercises | The Inspector-General of Emergency Management recommends Queensland Fire and Emergency Services conduct annual exercises with every local disaster management group and district disaster management group to confirm the process for developing, approving and issuing of an Emergency Alert, including the use of pre-formatted polygons and messages. Upon completion of the initial statewide exercise, Queensland Fire and Emergency Services will furnish an exercise evaluation report to the Office of the Inspector-General of Emergency Management by 1 November 2023. |
Rec-ID | Code | Recommendation |
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REC324-4311 | 33 - Relief and recovery | Transition initiatives: That, to improve the community’s experience during immediate disaster recovery phase, Government through the SEOCON, NSWRA, DCS/Service NSW and other state agencies as required provide greater support (financial, health [including mental health], temporary accommodation, administrative and other support services) to affected communities by: |
REC324-4316 | 12 - EM agency and authority | Resilience NSW and recovery: That, in order to enhance NSW disaster preparedness, response and recovery, and meet the needs of the people of NSW prior to, during and after a disaster, and provide clarity on agency roles and responsibilities, Resilience NSW be reshaped to ‘Recovery NSW’. The new agency will be more streamlined and agile to drive recovery in the first 100 days post disaster. To achieve this, Resilience NSW’s functions should be reallocated as follows: |
REC324-4318 | 12 - EM agency and authority | Permanent SEOCON: That, to improve NSW’s ability to prepare and respond to floods and other disasters, Government establish a new Deputy Commissioner of NSW Police Force to take on permanently the SEOCON role. This role, in addition to current SEOCON functions, would be responsible for: |
REC324-4297 | 33 - Relief and recovery | Housing , especially social housing: That, to ease housing stress in flood prone areas and ensure new development is resilient and community-centred, Government pursue a multi-pronged, decadal strategy through: |
REC324-4320 | 12 - EM agency and authority | Knowledge resources to support flood management: That, to provide more accurate and complete data for flood threat identification, warning and modelling systems, Government through the proposed new NSW Reconstruction Authority (NSWRA) work with the Australian Government to: |
REC324-4309 | 12 - EM agency and authority | SES and RFS back-office merger: That, to help protect life and property across NSW in storm and flood events, and to improve resourcing and NSW State Emergency Service (SES) frontline capability, Government implement, before the next storm season, a merger of the SES and NSW Rural Fire Services (RFS) back-office and corporate service functions, while maintaining their separate legislative identity, brand, uniform and volunteer membership. This ‘joined-up’ RFS/SES corporate support structure would be under the command of the RFS given its corporate and operational maturity and would be responsible for: |
REC324-4310 | 41 - Emergency Management exercises | Task Force Hawk: That, to ensure disaster readiness, Government establish a high-level Government standing committee, Task Force ‘Hawk’, comprising key Cabinet Ministers, Secretaries and Commissioners that meets, trains and exercises to ensure Government is prepared to respond to any emergency. Task Force ‘Hawk’ should resonate with the community in difficult times to ensure the highest level of confidence in Government’s response. |
Rec-ID | Code | Recommendation |
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REC323-4273 | 33 - Relief and recovery | That the NSW Government overhaul the way in which it conducts its grants process as it frustrated applicants and further traumatised them by repeatedly re-interviewing them and making them prove that they were flooded. |
REC323-4289 | 33 - Relief and recovery | That the NSW Government ensure that all emergency and recovery plans, including state plans, local emergency management plans and functional area plans, are reviewed and updated regularly and provide clarity on the role of non-government partners. |
REC323-4277 | 33 - Relief and recovery | That the NSW Government develop a more proactive, rapid response to manage animal welfare following natural disasters which includes improved collaboration and communication with local veterinarians and animal welfare organisations. |
REC323-4291 | 12 - EM agency and authority | That the NSW Government consider abolishing Resilience NSW if it is unable to ensure: |
REC323-4292 | 12 - EM agency and authority | That the NSW Government consider a restructure of the NSW State Emergency Service with consideration to: realigning the focus of the organisation to harness local knowledge and networks; coordinating more closely with other rescue agencies to bolster its capacity to respond; and increasing salaried staff and resources, and driving volunteer recruitment. |
REC323-4262 | 33 - Relief and recovery | That the NSW Government provide an increased level of targeted support to flood affected communities contending with widespread mould. |
REC323-4269 | 33 - Relief and recovery | That the NSW Government address the mental health needs of local communities following the February-March 2022 floods by: • embedding within state emergency and recovery plans a strategy that provides surge capacity for mental health and social workers by: • prioritising funding for community groups that are currently providing social and mental health support to their local communities • ensuring all flood-impacted communities receive the mental health support they need to fully recover. |
REC323-4271 | 33 - Relief and recovery | That Service NSW establish teams of assessors that can be on the ground to assess and approve grant applications. |
Rec-ID | Code | Recommendation |
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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. |
REC311-2493 | 41 - Emergency Management exercises | To increase shared understanding of risks and enhance capability integration and collaborative planning, both Local Disaster Management Group (LDMG) participate in the exercising of the Paradise Dam Emergency Action Plan. |
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. |
Rec-ID | Code | Recommendation |
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REC002-4007 | 40 - Equipment and consumables | A measure of safety may be found in the use of high explosives combined with wet tamping, or, still better, water cartridges, instead of powder under any of its modifications. Encouragement ought also to be given to the use of patent multiple wedges and applicances of a like nature, for supplanting the use of explosives. Under all circumstances and conditions some provision should be adopted for compelling workmen to thoroughly undercut, shear, or nick, and generally to work the coal as directed by the Manager. |
REC002-4005 | 40 - Equipment and consumables | Where safety-lamps are used the lock should be of such a character as to prevent any workman opening it. If the "Protector" type of lamp be employed the necessity for a lock is the less necessary, as the unscrewing of this type of lamp extinguishes the light. |
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. |
Rec-ID | Code | Recommendation |
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REC238-0806 | 33 - Relief and recovery | Review the adequacy of current arrangements for infrastructure reconstruction following a major flood event in the Hawkesbury-Nepean Valley. |
REC238-0805 | 33 - Relief and recovery | Develop a Hawkesbury-Nepean Flood Recovery Plan, which identifies strategies and arrangement for recovery from severe floods in the Hawkesbury-Nepean Valley. |
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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REC210-0730 | 12 - EM agency and authority | Emergency Management Queensland, in consultation with councils, should develop clear directives about: • the communication and reporting that should take place between the SES and disaster managers, including in relation to task allocation and completion, once disaster management groups have been activated • the communication and reporting that should take place between the SES and disaster managers, including in relation to task allocation and completion, once disaster management groups have been activated • the process for dealing with requests for assistance that exceed an SES unit’s capacity to respond them • the process for seeking extra support for an SES unit that has been overwhelmed by a disaster (whether by way of Emergency Management Queensland or the disaster management arrangements or both) • the role of SES liaison officers in communications with disaster managers about SES disaster operations • the role of incident controllers, and their teams, relative to those SES (or Emergency Management Queensland) personnel charged with the command of SES operations. |
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. |
REC210-0664 | 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. |
REC210-0773 | 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. |
REC210-0729 | 12 - EM agency and authority | Emergency Management Queensland should ensure its staff, SES members and disaster managers are familiar with the directive when it is developed. |
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. |
REC210-0772 | 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. |
REC210-0728 | 12 - EM agency and authority | Emergency Management Queensland, in consultation with councils, should develop a directive that makes clear the authority of an officer of that agency to command a major SES operation. This could be expected to occur when a deployment of additional SES members is made to a region because the response needed is beyond the capacity of its local units. The directive should make clear the powers of the officer and his or her reporting responsibilities to disaster managers in these circumstances. Emergency Management Queensland must also ensure that any officer who assumes such a role has adequate training and skills in the conduct of disaster operations. |
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. |
REC210-0762 | 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. |
REC210-0726 | 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. |
REC210-0736 | 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. |
REC210-0755 | 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. |
REC210-0683 | 13 - Mapping and data quality | All councils should, resources allowing, map the overland flow paths of their urban areas. |
REC210-0725 | 12 - EM agency and authority | The fire service should ensure that station officers are familiar with the procedure for contacting management when requesting the calling in of additional staff; and, in particular, that they have available to them the names and current telephone numbers of the officers to be contacted in the first instance, with alternative contact details in the event that those officers prove unavailable. |
REC210-0731 | 12 - EM agency and authority | Emergency Management Queensland should ensure its staff, SES members and disaster managers are familiar with the directives it develops in relation to these matters. |
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. |
REC210-0665 | 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. |
Rec-ID | Code | Recommendation |
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REC208-0526 | 25 - Inquiry, audit, lessons management and after action review | That OEH’s testing procedures for determining the impact of pollution incidents incorporate additional requirements for the checking and verification of results before those results are released. |
Rec-ID | Code | Recommendation |
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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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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. |
REC121-3768 | 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. |
REC121-3689 | 12 - EM agency and authority | All RMC communications related staff should be selected upon the basis of the ability to convey information clearly, accurately and concisely and to follow strict communications protocols. |
REC121-3708 | 12 - EM agency and authority | RailCorp should employ a Chief Safety Information Officer to manage the collection, collation, and dissemination of safety information within RailCorp. |
REC121-3752 | 12 - EM agency and authority | RailCorp should establish clear safety accountability statements and reporting lines for all management positions. |
REC121-3766 | 12 - EM agency and authority | Staffing arrangements for ITSRR should be reviewed by it to ensure that adequate staff are employed in field positions, actively monitoring the safety of rail operations and compliance with conditions of accreditation. |
REC121-3673 | 41 - Emergency Management exercises | Regular field training exercises should be conducted by RailCorp with the emergency services to ensure that the incident command system and rail displan are able to be fully implemented as quickly as possible and are reviewed and improved. |
REC121-3700 | 12 - EM agency and authority | The RailCorp defects unit should be combined with the passenger fleet maintenance division of RailCorp. |
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. |
REC121-3765 | 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. |
REC121-3658 | 12 - EM agency and authority | All emergency services stations should be provided with access keys to, and maps showing, all gates providing access to RailCorp tracks within their geographic area of responsibility. |
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. |
REC121-3725 | 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. |
REC121-3758 | 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. |
REC121-3693 | 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. |
REC121-3724 | 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. |
REC121-3757 | 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. |
REC121-3691 | 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. |
REC121-3713 | 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. |