Inquiry Search
Rec-ID | Code | Recommendation |
---|---|---|
REC309-2478 | 25 - Inquiry, audit, lessons management and after action review | The progress of recovery for this event be reviewed incrementally over the next 2 to 3 years, with a formal, independent report provided on the effectiveness of the recovery after 3 years. |
REC309-2474 | 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. |
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. |
REC309-2469 | 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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC296-1352 | 10 - Infrastructure | A monthly testing regime needs to be developed that will allow the generator to be tested at full essential load capacity and to ensure that 4 hour monthly testing can be done every month. |
REC296-1357 | 10 - Infrastructure | Monthly test results need to be accurately recorded. |
REC296-1362 | 10 - Infrastructure | Carry out a detailed audit of the current Hospital essential loads to determine the current load requirements of the Hospital. |
REC296-1351 | 10 - Infrastructure | From the above assessment determine the existing generator load requirements and provide a new generator to meet those loads. |
REC296-1356 | 10 - Infrastructure | Accurate records need to be provided as to what is done for each service. |
REC296-1361 | 10 - Infrastructure | Prepare and carry out a testing regime and testing strategy and ensure testing of the generator is done every month for 4 hours over that month and under full Hospital load with test result recorded every 15 minutes. |
REC296-1350 | 10 - Infrastructure | Remove any loads that do not need to be on essential power. |
REC296-1355 | 10 - Infrastructure | Replacement of all original pipes and hoses not yet done. |
REC296-1360 | 10 - Infrastructure | Carry out regular load bank testing on the generator with a load bank large enough to fully load the generator to 110% which will clean out the engine and also identify whether the generator is capable of providing full load for a sustained length of time. |
REC296-1349 | 10 - Infrastructure | Conduct an assessment of the current essential loads and determine if there are loads that should not be on essential power. |
REC296-1354 | 10 - Infrastructure | Monthly and annual maintenance servicing needs to be scheduled for the generator to DPTI or CHSA schedule requirements. |
REC296-1359 | 10 - Infrastructure | Renegotiate the maintenance contract at the end of the current contract and have DPTI through AGFMA take on the maintenance contract. |
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. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC295-1300 | 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. |
REC295-1320 | 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 |
REC295-1288 | 24 - Govt responsibility | That Attorney General’s Department explore options to overcome fatigue and welfare issues of SAGRN staff associated with emergency events of extended duration. |
REC295-1309 | 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 . |
REC295-1325 | 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. |
REC295-1293 | 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 |
REC295-1314 | 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. |
REC295-1332 | 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. |
REC295-1280 | 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: |
REC295-1299 | 17 - Assets and technology | That systems for Automatic Vehicle Location and personnel tracking be implemented within the emergency services sector. |
REC295-1319 | 24 - Govt responsibility | That a single emergency service multi-agency control centre be established with sufficient capacity and capability to deal with all types of emergency incidents in SA. Also consider Police and State Emergency Centre. |
REC295-1287 | 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. |
REC295-1308 | 24 - Govt responsibility | That the Department of the Premier and Cabinet revise the ministerial documents relating to emergency management. |
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 |
REC295-1292 | 32 - Doctrine, standards, and reform | That, giving consideration to the previous recommendation, the Flood |
REC295-1313 | 16 - Training and behaviour | That regular training and exercising is conducted for all State Emergency Centre participants including Liaison Officers. |
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 |
REC295-1279 | 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. |
REC295-1298 | 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. |
REC295-1318 | 24 - Govt responsibility | That the recommendation made following the Pinery bushfire, ‘to review control facilities at State, region and incident level’, be expanded to include all emergency services facilities that will be utilised for major incidents other than bushfire e.g. flood and earthquake and to also be extended into metropolitan areas, and implemented. |
REC295-1286 | 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. |
REC295-1305 | 18 - Access to fire ground | That the annexure to the State Emergency Management Plan, ‘Traffic management during emergencies’, be updated to include: responsibilities and processes for road closures; and, Department of Planning, Transport and Infrastructure requirements in regards to provision of road closure information, notification of changes in road closure status and publishing of that information. |
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. |
REC295-1291 | 24 - Govt responsibility | That the Flood Reform Task Group, as proposed by the Department |
REC295-1312 | 24 - Govt responsibility | That the Department of Education and Child Development be included as a member of State Emergency Management Council and represented in the State Emergency Centre. |
REC295-1330 | 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 |
REC295-1277 | 32 - Doctrine, standards, and reform | That the Department of Planning, Transport and Infrastructure review their Business Continuity Plan to: |
REC295-1297 | 25 - Inquiry, audit, lessons management and after action review | Engage an independent business analyst to review the current call, receipt and dispatch process for emergency services i.e. the Metropolitan Fire Service, Country Fire Service and State Emergency Service, from the initial call for assistance through to response of emergency service resources, including the allocation and coordination of multiple taskings. |
REC295-1317 | 25 - Inquiry, audit, lessons management and after action review | Review representation in the State Emergency Centre including: a) determining if there is a more suitable functional support group e.g. the Procurement Functional Support Group, to replace the Logistics Functional Support Group, and if so, Chief Procurement Officer, DPC, has responsibility for the management of this role within the State Emergency Centre. b) That when the State Crisis Centre is not operating from a physical location, a State Crisis Centre liaison officer is attached to the State Emergency Centre. |
REC295-1284 | 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. |
REC295-1303 | 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. |
REC295-1322 | 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. |
REC295-1290 | 32 - Doctrine, standards, and reform | Continue development of the Damage Assessment Support Plan to: |
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 |
REC295-1328 | 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. |
REC295-1276 | 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 |
REC295-1295 | 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 |
REC295-1316 | 24 - Govt responsibility | That the position of Deputy Director, Office for Digital Government is dedicated to the Office for Digital Government; and that people throughout DPC are identified and trained to perform appropriate roles within the State Crisis Centre |
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: |
REC295-1301 | 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. |
REC295-1321 | 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. |
REC295-1289 | 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. |
REC295-1310 | 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 |
REC295-1327 | 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. |
REC295-1294 | 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. |
REC295-1315 | 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. |
REC295-1333 | 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 |
Rec-ID | Code | Recommendation |
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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. |
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. |
Rec-ID | Code | Recommendation |
---|---|---|
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 |
REC281-1201 | 25 - Inquiry, audit, lessons management and after action review | Preventing Flood Related Fatalities: The NSW Government consider the recommendations from the Preventing Flood Related Fatalities Report when it is released. |
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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC267-1152 | 13 - Mapping and data quality | Impact Assessment Data Sharing Project |
REC267-1151 | 24 - Govt responsibility | Government Communications Coordination |
REC267-1162 | 10 - Infrastructure | Telecommunications and Power Infrastructure |
REC267-1154 | 36 - Volunteers | Coordination of Volunteer Support |
REC267-1153 | 4 - Fire season preparation | Planning for Access to Potentially Isolated Communities |