Inquiry Search
Rec-ID | Code | Recommendation |
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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 |
REC295-1321 | 16 - Training and behaviour | Through the Emergency Management Workforce Project, identify and provide training and development for SA’s emergency management sector personnel (government agencies, and non-government agencies including volunteers). State Emergency Management Committee should consider supporting recommendations from stage two of the project when the project report is tabled. |
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. |
REC295-1304 | 20 - Role of police | That SA Police, as the control agency for search and rescue, and State Emergency Service who have the responsibility for providing search and rescue services under the State Emergency Management Plan, develop a swiftwater rescue capability plan that describes key swiftwater risk locations, roles and responsibilities of emergency services, State swiftwater resources and dispatch arrangements. |
REC295-1320 | 17 - Assets and technology | Review existing electronic information systems used by emergency services organisations and other government agencies, and: a) establish a single incident information system across the Emergency Services Sector (MFS, CFS and SES), and b) identify opportunities to consolidate incident information systems of other agencies |
REC295-1294 | 13 - Mapping and data quality | That consideration and resources be given to support the implementation of recommendations in the report prepared on behalf of Department of Environment, Water and Natural Resources (Australian Water Environments, 2016), for flood warning classification of stream gauges and other locations. |
REC295-1303 | 16 - Training and behaviour | That the State Emergency Service be provided with resources to enable them to deliver swiftwater awareness training to all first responders including emergency services, SA Police and council crews. |
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. |
REC295-1293 | 13 - Mapping and data quality | That the Flood Reform Task Group identify an appropriate mechanism for stakeholder agencies (including the State Emergency Service, Department of Environment and Natural Resources, Bureau of Meteorology and SA Water, as a minimum) to share data and information and develop plans and strategies for management of water levels in reservoirs and spill management during floods in South Australian water catchments |
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. |
REC295-1302 | 28 - Personal responsibility | That the State Emergency Service together with the Local Government Association and Country Fire Service establish a plan for coordinated provision of sandbags to the public, including options for what is provided, where and when, and the process for effective communication of availability to the public. |
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. |
REC295-1284 | 16 - Training and behaviour | Deliver consistent and regular training in the use of the SA Government Radio Network to all users to maximise the efficiency and effectiveness of the network in times of emergency e.g. reduce the issues associated with network busy signals. |
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. |
REC295-1300 | 17 - Assets and technology | That the State Emergency Service explores options for providing suitable personal protective clothing to personnel from supporting emergency services during major flooding events and sandbagging operations. |
REC295-1313 | 16 - Training and behaviour | That regular training and exercising is conducted for all State Emergency Centre participants including Liaison Officers. |
REC295-1278 | 20 - Role of police | That SA Police develop an evacuation plan for the Adelaide Central Business District (CBD) which includes: |
REC295-1324 | 16 - Training and behaviour | Establish a State incident management and emergency management training capability which provides for: a) consistent training across the State b) personal development and endorsement processes for roles c) identification, recruitment and development of personnel from other government agencies; and d) incident management and State emergency centre functional role training and development across all sectors. e) skills maintenance including upskills, refresher training and exercises f)incident and strategic leadership training g) consistent training for inter-agency liaison officers at all levels |
REC295-1299 | 17 - Assets and technology | That systems for Automatic Vehicle Location and personnel tracking be implemented within the emergency services sector. |
REC295-1307 | 20 - Role of police | That, as with earthquake, SA Police be designated the Control Agency under the State Emergency Management Plan for black system events or other major power outages. |
Rec-ID | Code | Recommendation |
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REC177-3299 | 29 - Operational Health and Safety | Regulatory approval to rely on only one barrier should not be given unless (i) a proper risk assessment is carried out; (ii) exceptional circumstances exist; and (iii) risks involved are reduced to ‘as low as reasonably practicable’. The default position must be that well integrity must be assured. |
REC177-3279 | 29 - Operational Health and Safety | Well construction and management plans, and drilling programs, should include provision for testing and verifying the integrity of all barriers as soon as practicable after installation. |
REC177-3330 | 39 - Disaster Risk Management | Decision‐making about well control issues should be professionalised. Industry participants must recognise that decision‐makers owe independent duties to the public, not just their employer or principal, in relation to well control. Risk management in the context of well control needs to be understood as an ethical/professional duty. Self‐regulation contemplates self‐regulation by the industry, not just by individual licensees and operators. |
REC177-3288 | 29 - Operational Health and Safety | As soon as a risk of barrier failure arises, no other activities should take place in the well other than those directed to removal of the risk. |
REC177-3356 | 39 - Disaster Risk Management | The regulator should pre‐assess and review in a generic sense, and in conjunction with the offshore petroleum industry, available options for well control in the event of a blowout. Being ‘match fit’ in this sense will enable a quicker and more effective response in terms of safety assessment, and will ensure that expectations of both operator and regulator are more readily aligned. |
REC177-3295 | 29 - Operational Health and Safety | Wells drilled into hydrocarbon zones should be treated as live wells, with the potential to blowout unless a documented risk assessment establishes otherwise. |
REC177-3278 | 29 - Operational Health and Safety | Well construction and management plans should include provision(s) for reviewing the integrity of barriers at safety‐critical times or milestones, such as (i) prior to suspension involving departure of the rig from the platform; (ii) prior to re‐entry of a well after suspension; (iii) prior to removal of any barrier. |
REC177-3329 | 17 - Assets and technology | Logistics management of well control equipment should be conducted in such a way as to operate as a check against deficient well control practices, for example, use of serial numbers to track availability, testing, and deployment of well control equipment. |
REC177-3286 | 39 - Disaster Risk Management | Problems which arise in the course of installing barriers must be the subject of consultation between licensees, rig operators, and contractors (if used). A proper risk assessment should then be carried out and remedial steps (including further testing/verification) should be agreed upon, and documented in writing before the performance of remedial work whenever practicable. Joint written certification as to resolution of the problem should take place before resumption of drilling operations. Senior onshore representatives of stakeholder entities should be involved in that certification process. |
REC177-3344 | 25 - Inquiry, audit, lessons management and after action review | There should be a review to determine whether it is appropriate to introduce a rigorous civil penalty regime and/or substantially increase some or all of the penalties that can be imposed for breaches of legislative requirements relating to well integrity and safety. |
REC177-3294 | 29 - Operational Health and Safety | Perceived time and cost savings relating to any matters impacting upon well control should be subjected to rigorous safety assessment. |
REC177-3321 | 29 - Operational Health and Safety | Careful consideration must be given to equipment compatibility as part of well construction design. |
REC177-3285 | 39 - Disaster Risk Management | Pre‐drilling assessments should include a risk assessment of the worst‐case blowout scenario. |
REC177-3333 | 16 - Training and behaviour | Licensees and rig operators (and third party contractors involved in well control operations) should specifically assess, and document, the nature and extent of knowledge/skills of relevant personnel in relation to well control (including familiarity of personnel with agency‐specific requirements and procedures). Training needs and opportunities should be identified. This process should take place on engagement and at appropriate intervals. |
REC177-3293 | 29 - Operational Health and Safety | If a dispute arises between a licensee and a rig operator in relation to a well control issue, and is not resolved between them, the matter must be raised with the relevant regulator before discretionary operations proceed. |
REC144-3387 | 25 - Inquiry, audit, lessons management and after action review | In order that the ACT public can be reassured about the project management and financial planning in relation to the Fairbairn site as a proposed centralised accommodation facility for emergency services, the Auditor-General undertake a review of the project from a financial probity and project management perspective. |
REC177-3304 | 26 - Research | It is recommended that industry, regulators, and training/research institutions liaise with one another with a view to developing better techniques for testing and verifying the integrity of cemented casing shoes as barriers (particularly in atypical situations such as where the casing shoe is located within a reservoir in a horizontal or high angle position at great depth). |
REC177-3282 | 29 - Operational Health and Safety | If a risk assessment or compliance review is triggered by the happening of a predetermined event, specific consideration should be given to whether a ‘hold point’ should be introduced such that work must cease until the problem is resolved (and the subject of appropriate certification). |
REC177-3332 | 16 - Training and behaviour | A specific focus on well control training should be mandatory for key personnel involved in well control operations (including both on‐rig personnel and onshore personnel in supervisory capacities). |
REC177-3291 | 39 - Disaster Risk Management | Removal of a barrier must be the subject of consultation between licensees and rig operators prior to removal. A proper risk assessment should be carried out and agreed upon, and documented in writing before removal. Joint written certification as to the appropriateness of removal should take place before removal. Senior onshore representatives of stakeholder entities should be involved in that certification process. |
REC177-3378 | 25 - Inquiry, audit, lessons management and after action review | In view of the numerous well integrity problems in all of the Montara Oilfield wells, the Minister should commission a detailed audit of all the other offshore wells operated by PTTEPAA to determine whether they too may suffer from well integrity problems. |
REC177-3303 | 29 - Operational Health and Safety | Tracking and analysis of cementing problems/failures should occur to assess industry trends, principal causes, remedial techniques and so on. |
REC177-3281 | 29 - Operational Health and Safety | Wellbore gas bubbling should be regarded as a trigger for independent review of well integrity. Industry and regulators should identify and document other triggers. |
REC177-3331 | 16 - Training and behaviour | Existing well control training programs should be reviewed by the industry, regulators and training providers, with a focus on well control accidents that have occurred (in Australia and overseas). |
REC177-3289 | 39 - Disaster Risk Management | The use/type of barriers (including any change requests relating thereto) must be the subject of consultation between licensees and rig operators prior to installation. A proper risk assessment should be carried out, agreed upon, and documented in writing before installation. Joint written certification as to the appropriateness of the use of particular barriers should take place before installation. Senior onshore representatives of stakeholder entities should be involved in that certification process. |
REC177-3374 | 25 - Inquiry, audit, lessons management and after action review | The Minister should, as the JA for the offshore area of the Territory of Ashmore and Cartier Islands, undertake a review of PTTEPAA’s permit and licence to operate at the Montara Oilfield. |