Inquiry Search
Rec-ID | Code | Recommendation |
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REC309-2471 | 17 - Assets and technology | As part of the annual Emergency Action Plan review for the Ross River Dam, consideration should be given to the potential impacts of operating the gate outside automatic mode and whether this event has provided any new information and learnings which can be incorporated into the Emergency Action Plan. This should occur prior to the 2019/20 wet season. |
REC309-2470 | 11 - Evacuation and shelters | Evacuation centre plans be revised to better manage vulnerable persons, including the safe storage of medications and providing alternate arrangements for evacuees with additional needs. (e.g. evacuation centre for aged persons). |
REC309-2469 | 12 - EM agency and authority | Entities with disaster management responsibilities need to integrate the eight priorities identified within the Emergency Management Sector Adaptation Plan for Climate Change into their disaster management planning cycle. |
REC309-2476 | 11 - Evacuation and shelters | Energy Queensland and local groups consider establishing formal arrangements that embed measures that assist evacuation plans to increase levels of safety. |
REC309-2474 | 16 - Training and behaviour | The provision of system-wide tools, education, guidance and testing for requests for assistance is strengthened to enhance understanding and outcomes. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
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. |
Rec-ID | Code | Recommendation |
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REC295-1298 | 12 - EM agency and authority | That the State Emergency Service, in consultation with key stakeholders, identify and implement a robust system and procedures for prioritising, allocating and coordinating multiple tasks. |
REC295-1329 | 8 - Communications and warnings | Review and update Part 3, Annex C, of the SEMP ‘Public Information and Warnings’ to: a) clarify the role and responsibilities of the Public Information Functional Support Group and control agencies in relation to public information b) define requirements and processes for liaising with the community, including holding community meetings |
REC295-1335 | 12 - EM agency and authority | Explore alternative emergency management models including the alternative model proposed above to establish a South Australian Emergency Management Office and State Relief and Recovery Office within the South Australian Fire and Emergency Services Commission, to ensure that all the objects and guiding principles of the Emergency Management Act 2004, and State Emergency Management Plan are addressed efficiently and effectively. |
REC295-1282 | 32 - Doctrine, standards, and reform | That the Office for Digital Government, in close partnership with telecommunications companies (e.g. Telstra, Optus, Vodaphone), develop a Control Agency Plan for Information and Communication Technology including mobile communications. The plan should consider: |
REC295-1309 | 32 - Doctrine, standards, and reform | That members of Emergency Management Council ensure they are prepared to undertake their roles and responsibilities during emergency events, including establishing: a) contingencies for communication e.g. satellite phone b) access to relevant documents such as the State Emergency Management Plan, supporting plans, ministerial guidelines, agency plans and contacts in hard copy and/or portable device c) formalised arrangements for briefings (up and down), and d) arrangements for suitable representation e.g. relevant Chief Executive(s) or their deputy, at all Emergency Management Council meetings . |
REC295-1290 | 32 - Doctrine, standards, and reform | Continue development of the Damage Assessment Support Plan to: |
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 |
REC295-1296 | 8 - Communications and warnings | That the SES in collaboration with MFS Communications Centre (Comcen) investigate and implement options to reduce the number of calls coming into the Comcen, (particularly on 132500). Options could include better utilisation of the available options on the Interactive Voice Recording and community education to increase community resilience. |
REC295-1325 | 12 - EM agency and authority | Review and reinstate the State Emergency Management Training Officer and State Emergency Management Planning Officer (capability development) positions to operate with a broad, strategic and leadership focus. |
REC295-1333 | 32 - Doctrine, standards, and reform | Develop a State Relief and Recovery Plan as a distinct part of the State Emergency Management Plan which should include: a) potential locations for suitable facilities for relief and recovery centres which: are in locations safe from hazards such as flooding and bushfire; and, have appropriate access and suitable ablutions. b) formalisation of roles and capabilities of non-government organisations such as Red Cross |
REC295-1281 | 32 - Doctrine, standards, and reform | In order to increase resilience and public safety during emergencies, the State Emergency Management Committee should request the Australia and New Zealand Emergency Management Committee to place on the agenda, and consider establishing a national position, on redundancies for mobile communications (including phone tower back-up power) and the National Broadband Network. |
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. |
REC295-1289 | 32 - Doctrine, standards, and reform | That SA Police, emergency services, health facilities, utility providers and other key service providers, review their Business Continuity Plans giving consideration to factors such as: a) identification of: business critical needs; essential services power requirements; back-up power requirements for all facilities including State, regional and local facilities such as Police, SES, MFS and CFS stations; the need for any arrangements for back-up power to be included in contracts for design and or lease of Government premises b) contingencies for black system events and extended power outages c) regular back-up generator testing regime protocols, including testing under load and for long durations d) contingencies for communications when mobile, landline and/or radios are not operational e.g. satellite phones; and e) alternative State control centre facilities that are pre-identified, equipped and have procedures for moving to the alternative facility. |
REC295-1314 | 32 - Doctrine, standards, and reform | That an Emergency Management Assurance Framework be established as soon as possible to support the emergency management arrangements and the State Emergency Management Plan. Consider establishing an Inspector General Emergency Management department or position. |
REC295-1295 | 32 - Doctrine, standards, and reform | That resources be provided to support the implementation of recommendations in the South Australian Levee Bank Management Issues Paper (DEWNR, 2015) including: a) development of relevant policy; and b) identification of responsibilities in relation to levee management and flood mitigation |
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 |
REC295-1280 | 32 - Doctrine, standards, and reform | That a State Plan be developed for managing the consequences of a black system event or other major power outage. The plan should include: |
REC295-1301 | 32 - Doctrine, standards, and reform | Establish an ‘Interstate Deployment Support Plan’ for incoming interstate resources. The plan should outline responsibilities and arrangements for this function. Consider including this plan into the State emergency management arrangements. |
REC295-1332 | 32 - Doctrine, standards, and reform | Develop a Disaster Waste Management Plan to form part of the State Emergency Management Plan which describe participating agencies and responsibilities for various aspects of waste management during and after emergencies. |
REC295-1287 | 32 - Doctrine, standards, and reform | That the glossary of terms in the State Emergency Management Plan be reviewed to ensure all relevant language is included. All agencies need to ensure the use of clear communication and accurate use of terminology, including in describing the status of critical services e.g. Triple Zero (000), SA Government Radio Network, electrical and water supplies and infrastructure. |
REC295-1313 | 16 - Training and behaviour | That regular training and exercising is conducted for all State Emergency Centre participants including Liaison Officers. |
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. |
REC295-1323 | 32 - Doctrine, standards, and reform | Review and update the role, function, workload and focus of the groups/committees that contribute to incident management and emergency management capabilities including the State Emergency Management Training Committee, Interagency Incident Management Sub-Committee and the Central Exercise Writing Team. |
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. |
REC295-1300 | 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. |
REC295-1331 | 32 - Doctrine, standards, and reform | Task South Australian Fire and Emergency Services Commission with further developing the Emergency Alerts capability across government agencies including to: a) establish and maintain a centralised training program for emergency alert initial and refresher training. b) establish a pool of endorsed Emergency Alert personnel from across government agencies to enable control agencies to assist each other with the emergency alert function during emergencies. c) develop supporting processes to ensure that the capability supports: emergencies involving any hazard; consistent issuing of alerts and warnings; consistent messages; and effective communication and notification of alerts issued to relevant internal and external stakeholders |
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. |
REC295-1311 | 32 - Doctrine, standards, and reform | That the State Emergency Management Plan be reviewed and updated including: a) a better description of the responsibilities of Hazard Leaders Page xx b) establish a mechanism for a hazard leader to identify systemic failures in coordination of their hazard, with a clear process to raise those issues with SEMC and seek a remedy c) establish resilience as a key heading in the plan, with clearly documented strategies and responsibilities; and d) consider the Schar/Mulroney submission and taking a ‘fresh eyes’ approach |
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 |
REC295-1322 | 12 - EM agency and authority | Consider opportunities to identify synergies between the incident management systems used in SA being the, Australasian Interservice Incident Management System (AIIMS) and ICCS Plus. This might include joint training and exercising in roles that are common across both systems. |
REC295-1277 | 32 - Doctrine, standards, and reform | That the Department of Planning, Transport and Infrastructure review their Business Continuity Plan to: |
REC295-1299 | 17 - Assets and technology | That systems for Automatic Vehicle Location and personnel tracking be implemented within the emergency services sector. |
REC295-1330 | 32 - Doctrine, standards, and reform | Update the Public Information Functional Support Group Plan to include: a) standards, outputs, systems and processes required to be used by control agencies and the Public Information Functional Support Group during emergencies b) guidance on the public information cycle through the prevention, preparedness, response and recovery phases which includes the responsibilities and information requirements during different phases, and effective transition between phases c) establishing a public information intelligence cell within the Public Information Functional Service Group; and d) identifying tools or resources to monitor social media |
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. |
REC295-1310 | 32 - Doctrine, standards, and reform | That additional guidance be provided in the State Emergency Management Plan regarding the activation, structure and operation of Zone Emergency Support Teams. This should include: a) the reporting relationship between the Zone Emergency Support Teams, the State Emergency Centre and the State Coordinator b) briefing requirements between the State Coordinator (or their representative) and the Zone Emergency Support Teams when the State Emergency Centre is activated c) responsibilities for provision of local public information; and d) the appointment of public information officers in Zone Emergency Support Teams (where there is no incident management team (established) to provide information to local communities |
REC295-1292 | 32 - Doctrine, standards, and reform | That, giving consideration to the previous recommendation, the Flood |
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. |
Rec-ID | Code | Recommendation |
---|---|---|
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 |
---|---|---|
REC281-1205 | 16 - Training and behaviour | Department of Premier and Cabinet Regional Coordinators: Continue to build the capability of the Department of Premier and Cabinet Regional Coordinator role in recovery operations by providing: · on the ground support for Regional Coordinators during recovery operations by REMOs or OEM Recovery Team · training and developmental opportunities for Regional Coordinators to prepare them for working in the disaster recovery environment. |
REC281-1202 | 13 - Mapping and data quality | Impact Assessment Data Collection: The Office of Emergency Management continues to progress the Impact Assessment Data Collection Project and: · incorporate recovery schema in Rapid Impact Assessments · review procedures for collection of Rapid Impact Assessment Data · review and combine current templates into one, single template for Impact Assessment Reports that is used by all agencies · further develop Impact Assessment Guidelines for agency personnel undertaking impact assessments |
Rec-ID | Code | Recommendation |
---|---|---|
REC272-1417 | 32 - Doctrine, standards, and reform | That the following disaster management doctrine are reviewed and reissued to ensure consistency and improved guidance to local government: |
REC272-1414 | 12 - EM agency and authority | Queensland Fire and Emergency Services coordinate the development of an integrated risk based approach to disaster management planning for Queensland that is consistent with the Standard and applicable at all levels of the arrangements. |
REC272-1421 | 16 - Training and behaviour | In conjunction with the Queensland Fire and Emergency Services review of guidelines, the Public Safety Business Agency should consider reviewing the cyclone shelter management training package to include guidance to the shelter management team on their roles and responsibilities, and powers available under legislation and how these may be exercised. |
REC272-1418 | 12 - EM agency and authority | Queensland Fire and Emergency Services should consider examining regulatory provisions to improve disaster management and business continuity planning for aged care providers. |
Rec-ID | Code | Recommendation |
---|---|---|
REC267-1162 | 10 - Infrastructure | Telecommunications and Power Infrastructure |
REC267-1154 | 36 - Volunteers | Coordination of Volunteer Support |
REC267-1152 | 13 - Mapping and data quality | Impact Assessment Data Sharing Project |
Rec-ID | Code | Recommendation |
---|---|---|
REC177-3283 | 32 - Doctrine, standards, and reform | A separate, identifiable barrier manual should be agreed upon and used by licensees, rig operators, and cementing contractors. These manuals should set out best industry practice in relation to achieving and maintaining well integrity. They should describe barrier types, barrier standards, general principles of well integrity, testing and verification methods and technologies, standard operating procedures (including procedures for the capture and communication of relevant information within and between relevant stakeholder entities). Barrier manuals should address blowout control during drilling, completion, re‐entry, tie‐back of casing strings and so on. Barrier manuals should be the subject of expert external review, and should be regularly updated. |
REC177-3305 | 32 - Doctrine, standards, and reform | Cement integrity should be evaluated wherever practicable by way of cement evaluation tests, rather than relying on pre‐operational calculations of cement and displacement fluid volumes. |
REC177-3322 | 32 - Doctrine, standards, and reform | Batched drilling operations should only be undertaken after careful assessment of the special risks which such operations give rise to; well control must be maintained during the course of batched drilling operations. |
REC177-3338 | 12 - EM agency and authority | Licensees and rig operators should be astute in ensuring that corporate systems and culture encourage rather than discourage raising of well control issues. For instance, do performance bonuses or rewards actually encourage or discourage reporting of issues? Is there a system in place to enable anonymous reporting of well control concerns? What whistleblower protections are in place? |
REC177-3366 | 32 - Doctrine, standards, and reform | The National Plan should be reviewed: |
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. |
REC177-3311 | 32 - Doctrine, standards, and reform | Horizontal or high angle penetration of a reservoir should be avoided wherever practicable until such time as the apparent problems associated with the cementing of a casing shoe in these situations are satisfactorily overcome. If a casing string does penetrate a well horizontally or at a high angle, standard practice should be to install two secondary barriers in addition to the cemented casing shoe. |
REC177-3327 | 32 - Doctrine, standards, and reform | Information relevant to well control must be captured and communicated within and between licensees and rig operators (and relevant third party contractors), in a manner which ensures it comes to the attention of relevant personnel. In particular, protocols should be developed to ensure that changes in shift and hitch do not operate as communication barriers. |
REC177-3343 | 32 - Doctrine, standards, and reform | The OPGGS Act should be amended to allow for a power to suspend a petroleum production licence (in addition to the current power to cancel a licence or suspend its conditions). |
REC177-3377 | 32 - Doctrine, standards, and reform | The Minister consider legislative amendments to the OPGGS Act which make clear that |
REC177-3277 | 32 - Doctrine, standards, and reform | The concept of ‘good oilfield practice’ should be supplemented by the requirement to incorporate into WOMPs non‐exhaustive minimum compliance standards in relation to well control: for example, stipulations as to when BOPs and/or well control systems must be in place and when they can be removed and minimum barrier requirements (a number of other factors that should be stipulated are outlined in other recommendations below). |
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. |
REC177-3316 | 32 - Doctrine, standards, and reform | Wells should be re‐entered with a BOP in place unless a documented risk assessment indicates that well control can be maintained at all times. |
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. |
REC177-3355 | 32 - Doctrine, standards, and reform | The Inquiry also supports Bills and Agostini’s recommendation: ‘…in relation to safety case development and compliance overall, that NOPSA revise its approach to interacting with operators prior to the safety case assessment process and subsequently direct more resources into its advisory functions. We further recommend that NOPSA develop and implement a formal plan for supporting and guiding each operator prior to safety case acceptance, as well as for ongoing compliance with that safety case, recognising the unique experience, capabilities and assessed risk of that operator. Each plan needs to include advice, education and liaison meetings with the operators. The plan needs to be continuously reviewed and reassessed based on the latest information, including the interaction with the operator’. |
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). |
REC177-3304 | 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). |
REC177-3321 | 29 - Operational Health and Safety | Careful consideration must be given to equipment compatibility as part of well construction design. |
REC177-3337 | 12 - EM agency and authority | Supervision/oversight of well control operations (within licensees, rig operators and by regulators) must occur without assuming adherence to good oilfield practice. The opposite assumption should prevail: namely adherence to good oilfield practice may well be compromised by the pursuit of time and cost savings. |
REC177-3364 | 37 - Funding | The funding arrangements that support the National Plan should be reviewed to ensure that the costs associated with both preparedness and response capability are equitably shared between the shipping and offshore petroleum industries. |
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. |
REC177-3309 | 32 - Doctrine, standards, and reform | If performance of barrier installation is outsourced by a licensee, the contractor (for example, the cementing company) should be engaged on terms which clearly require the provision of expert advisory services by the contractor with respect to barrier integrity. |
REC177-3326 | 32 - Doctrine, standards, and reform | Prior to commencement of drilling operations, senior representatives of the licensee and rig operator should exchange certificates to the effect that their respective key personnel and contractors have been informed in writing of agreed well control arrangements. |
REC177-3342 | 32 - Doctrine, standards, and reform | Written (rather than verbal) approval from the DA (or new regulator) should be obtained before the commencement of well activities that lead to a physical change of a wellbore, other than in a true emergency situation (requiring amendment to regulation 17 of the Management of Well Operations Regulations). |
REC177-3373 | 32 - Doctrine, standards, and reform | Arrangements should be developed to minimise duplication between the EPBC Act and the OPGSS Act Environment Regulation. |
REC177-3276 | 32 - Doctrine, standards, and reform | WOMPs should be comprehensive and freestanding, rather than an overarching document cross‐referencing many other documents (although the Inquiry also recommends a freestanding well control manual; this should be a guide to rig and onshore personnel on good oilfield practice). |
REC177-3298 | 32 - Doctrine, standards, and reform | Reliance upon one barrier against a blowout must not take place except with the prior written approval of the relevant regulator and then only in a true emergency situation (see below). |
REC177-3315 | 32 - Doctrine, standards, and reform | PCCCs should be installed in a timely manner (for example, to prevent corrosion in the MLS apparatus). Non‐installation in order to park a BOP is not acceptable. |
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). |
REC177-3354 | 32 - Doctrine, standards, and reform | NOPSA develop a policy of engagement with operators so as to enable experts (including safety experts) to canvas all available options for well control in the event of a blowout. |
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. |
REC177-3303 | 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. |
REC177-3320 | 32 - Doctrine, standards, and reform | Any pro‐formas used by licensees, rig operators and contractors for recording information about installation of barriers should explicitly provide for ‘exception reporting’, that is, the form should include provision for recording any unforseen or untoward events which occur in the course of installation. |
REC177-3336 | 12 - EM agency and authority | Achievement and maintenance of well control should be written into the job responsibilities of key personnel, at every level up to and including CEOs. That is, a functional line of accountability for well control must exist up to, and including, CEOs. |
REC177-3363 | 32 - Doctrine, standards, and reform | DEWHA, in concert with AMSA and with expert input, should develop ‘off the shelf’ monitoring programs that can be speedily implemented following incidents in Commonwealth waters. In this context, the utility of the current Scientific Monitoring program should be peer reviewed to inform future policy. |
REC177-3292 | 32 - Doctrine, standards, and reform | Licensees should be subject to an express obligation to inform regulators of the proposed removal of a barrier, even if they consider that well integrity is not thereby compromised. The information should be provided by way of special report, rather than included in a standard reporting document (such as a DDR). The information provided should include risk assessment details. Removal of a barrier should not take place without prior written approval of the relevant regulator(s). |
REC177-3308 | 32 - Doctrine, standards, and reform | Volumes of cement used in connection with barrier installation should be calculated with the assistance of a pro‐forma which records all relevant baseline data, which should be verified by onshore personnel. |
REC177-3325 | 32 - Doctrine, standards, and reform | Relevant personnel from licensees and rig operators should meet face to face to agree on, and document, well control issues/arrangements prior to commencement of drilling operations. Well control should be regarded as a so‐called SIMOP to signify its critical importance to both licensees and rig operators, and to ensure that they each take responsibility for achievement and maintenance of well control. |
REC177-3341 | 32 - Doctrine, standards, and reform | The definition of ‘good oilfield practice’ in the OPGGS Act is unduly narrow. The current definition is incapable of application except where things ‘are generally accepted as good and safe’. The definition should be amended such that ‘good oilfield practice includes…’. |
REC177-3370 | 32 - Doctrine, standards, and reform | Environment plans and OSCPs should be made publicly available as a condition of approval of proposals under the OPGGS Act, and should clearly set out Scientific Monitoring requirements in the event of an oil spill. |
REC177-3275 | 32 - Doctrine, standards, and reform | Well Operations Management Plan (WOMPs) submitted by licensees to the regulator(s) should continue to be the primary framework document for achieving well integrity. |
REC177-3297 | 32 - Doctrine, standards, and reform | A minimum of two barriers should be in place at all times (including during batched operations) whenever it is reasonably practicable to do so. |
REC177-3314 | 32 - Doctrine, standards, and reform | Secondary barriers (including PCCCs) should only be installed, tested, and removed with a BOP in place unless a documented risk assessment indicates that well control can be maintained at all times. |
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). |
REC177-3353 | 32 - Doctrine, standards, and reform | The regulatory regime should also impose an obligation on an operator to ascertain the availability, and provide details to the regulator, of any potential relief well rigs, prior to the commencement of drilling operations (including prior to each phase of a drilling operation where applicable). |
REC177-3280 | 32 - Doctrine, standards, and reform | Well construction and management plans should include provision for an independent compliance review of well integrity (i) in the event of stipulated triggers; and (ii) at least once in the period between perceived achievement of well integrity and production. The independent compliance review should be undertaken by an expert who is not involved in the day‐to‐day drilling operations. Reviews should be completed in sufficient time to enable results to be implemented in a meaningful manner. |
REC177-3302 | 32 - Doctrine, standards, and reform | Industry, regulators, and training/research institutions should develop standards that address best practices for cementing operations (including liaising, as appropriate, with overseas regulators) with a view to overcoming problems which can effect the integrity of cemented casing shoes, annulus and cement plugs. |
REC177-3319 | 32 - Doctrine, standards, and reform | Drilling programs dealing with barrier installation should incorporate relevant aspects of manufacturer’s instructions. |
REC177-3336 | 12 - EM agency and authority | Achievement and maintenance of well control should be written into the job responsibilities of key personnel, at every level up to and including CEOs. That is, a functional line of accountability for well control must exist up to, and including, CEOs. |
REC177-3362 | 32 - Doctrine, standards, and reform | Procedures for the approval of development projects should ensure that conditions of approval are comprehensive and clearly set out the obligations of their proponents in relation to environmental matters (including expected monitoring and remediation obligations). |
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. |
REC177-3307 | 32 - Doctrine, standards, and reform | Any indication of a compromised cemented shoe which cannot be resolved with a high measure of confidence should result in the installation of additional well control barrier(s). |
REC177-3324 | 32 - Doctrine, standards, and reform | The mere fact that the rig is over the platform should not be regarded by licensees or regulators as sufficient justification for reliance on only one barrier. The default position should be that producible wells are shut‐in when a rig is moved on and off a platform, or when a drilling unit is moved between wells on a platform. |
REC177-3340 | 32 - Doctrine, standards, and reform | To better ensure that ‘risks’ are identified and managed in accordance with sound engineering principles and good oilfield practice, it is recommended that regulation 25(1)(a)(i) and (2)(a)(i) of the Management of Well Operations Regulations, be reworded as follows: ‘A titleholder must not commence / continue a well activity if…a well integrity hazard exists in relation to the well’. |
REC177-3368 | 32 - Doctrine, standards, and reform | The regulatory framework should provide that in respect of all activities in Commonwealth waters: |
REC177-3296 | 32 - Doctrine, standards, and reform | Use of single strings of intermediate casing to penetrate hydrocarbon bearing zones should be carefully risk assessed. Multiple strings of intermediate casing have the advantage of isolating lost circulation zones and sealing off anomalous pressure zones. If intermediate casing is set in a hydrocarbon zone it should be treated as production casing. |
REC177-3313 | 32 - Doctrine, standards, and reform | Barriers should not be installed or removed off‐line. The derrick should be located over a well at the time of removal and installation of any barrier. This will enable more decisive action to be taken in the event a problem arises. |
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. |
REC177-3352 | 32 - Doctrine, standards, and reform | The regulator, rather than the responsible Minister, should be given the power to direct an operator to use a particular rig for the purpose of well control operations, if appropriate in the circumstances, and the power should be used in the future if that rig is the best option available. This would necessarily involve the operator fully compensating for the use of the rig and any other associated costs. The Inquiry suggests that this power could be invoked and given effect as a condition of an operator’s licence. |
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. |
REC177-3301 | 32 - Doctrine, standards, and reform | The industry standard of two barriers should be replaced with the concept of ‘two or more barriers’ as a minimum standard. A minimum standard when operations proceed normally should never be regarded as a sufficient standard in other circumstances. |
REC177-3318 | 32 - Doctrine, standards, and reform | Manufacturers should be consulted about how to address non‐routine operational problems affecting their well control equipment. |
REC177-3335 | 32 - Doctrine, standards, and reform | Licensees, rig operators and relevant third party contractors should develop well control competency standards for key personnel in other entities involved in well control operations. |
REC177-3361 | 32 - Doctrine, standards, and reform | The National Plan should be revised to ensure that it fully comprehends environmental matters and that it recognises the importance of the prompt implementation of Scientific Monitoring to facilitate the assessment of the environmental impacts of an incident. |
REC177-3284 | 32 - Doctrine, standards, and reform | Memoranda of Agreement should be entered into between operators in relation to provision of emergency assistance in the event of blowouts. |
REC177-3306 | 32 - Doctrine, standards, and reform | It should be standard industry practice to re‐test a cemented casing shoe (that is, after WOC) whenever the plugs do not bump or the float valves apparently fail. Standard industry practice should require consideration of other tests in addition to a repeat pressure test. |
REC177-3323 | 32 - Doctrine, standards, and reform | Where multiple wells are drilled, operations and occurrences at one well must be carefully assessed for any implications with respect to well control at other wells. |
REC177-3339 | 32 - Doctrine, standards, and reform | The Inquiry supports the objective (rather than prescriptive) approach to regulation now followed in Australia. However, the pendulum has swung too far away from prescriptive standards. In some areas relating to well integrity there needs to be minimum standards. |
REC177-3367 | 32 - Doctrine, standards, and reform | Procedures and accountabilities should be established to ensure, in the event of a future incident, that: |
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. |
REC177-3312 | 32 - Doctrine, standards, and reform | The BOP and rig should not move from a well until barrier integrity has been verified. |
REC177-3328 | 32 - Doctrine, standards, and reform | All communications between on‐rig and onshore personnel relating to well control should be documented in a timely manner. |
REC177-3350 | 32 - Doctrine, standards, and reform | The recommendations of the Inquiry in relation to suitable ways of achieving well integrity contained in Chapter 3 be included in a guidance manual that is issued for the assistance of industry and regulators. |
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. |
REC177-3300 | 32 - Doctrine, standards, and reform | Licensees and rig operators should install an additional barrier whenever (i) there is any real doubt as to the integrity of any barrier; (ii) whenever the risk of flow from a reservoir increases materially in the course of operations; and (iii) where the consequences of a blowout are grave (for example, for reef systems or shorelines). |
REC177-3317 | 32 - Doctrine, standards, and reform | Any equipment (including PCCCs) used as, or to install, a barrier should be manufactured for that purpose and be generally recognised as fit for purpose. If equipment is designed in‐house by a licensee or rig operator it should not be approved for use unless and until it is subjected to expert external analysis. |
REC177-3334 | 32 - Doctrine, standards, and reform | Licensees, rig operators, and relevant third party contractors should develop well control competency standards for their key personnel. Wherever possible, the competencies of key personnel should be benchmarked against their roles and responsibilities. |
REC177-3359 | 32 - Doctrine, standards, and reform | The National Plan should be reviewed to clarify the arrangements to apply in Commonwealth waters regarding key roles and responsibilities, including in relation to the ESC, in the event of an oil spill. This should also address any necessary training required. |