Inquiry Search
Rec-ID | Code | Recommendation |
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REC325-4321 | 25 - Inquiry, audit, lessons management and after action review | The Inspector-General of Emergency Management recommends this report be returned to the Office of the Inspector-General of Emergency Management to monitor, evaluate, and report on progress and implementation of the recommendations that are accepted in whole or in part by government. |
REC325-4324 | 32 - Doctrine, standards, and reform | The Inspector-General of Emergency Management recommends Queensland Fire and Emergency Services review the tasking protocols used to manage State Emergency Service (SES) tasks undertaken in the response phase of a disaster to enable more complete recording of details for all ‘jobs of opportunity’ (including the personal details of those assisted and/or rescued) to enable better coordination of tasks and reflect outcomes of activities by 1 November 2023. |
REC325-4325 | 32 - Doctrine, standards, and reform | The Inspector-General of Emergency Management recommends Queensland Fire and Emergency Services review and implement State Emergency Service (SES) protocol by 1 November 2023 outlining procedures to be undertaken to ensure persons uplifted from places of immediate danger or risk are transferred to a place of safety. |
REC325-4334 | 32 - Doctrine, standards, and reform | The Inspector-General of Emergency Management recommends Queensland Fire and Emergency Services develop and publish an operationally based quick reference guide that complements the training offered (as per Recommendation 5) by 1 November 2022. The guide will identify key and critical aspects of the Emergency Alert system in relation to the development, composition, request for and authorising of Emergency Alerts and will include a template and an example of ‘good’ messaging using concise, minimal language and Clear Explicit Translatable Language (CETL). |
Rec-ID | Code | Recommendation |
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REC322-4252 | 25 - Inquiry, audit, lessons management and after action review | The Inspector-General Emergency Management recommends Queensland Fire and Emergency Services regularly review and evaluate the effectiveness of the Queensland Bushfire Plan with land managers and stakeholders, including disaster management groups. A review should occur in line with any material change to the Queensland State Disaster Management Plan, the Disaster Management Act 2003, the Prevention Preparedness Response and Recovery Guideline, or after major bushfire events, to ensure appropriate alignment and currency. |
REC322-4238 | 32 - Doctrine, standards, and reform | The Inspector-General Emergency Management recommends the Department of Environment and Science ensure that all Queensland Parks and Wildlife Service regions develop a Disaster Management Operations Plan based on a standardised format. The plans should include provision for annual review to ensure they remain contemporary, interoperable with relevant disaster management plans and aligned to the Department of Environment and Science Emergency Management Plan. |
REC322-4220 | 25 - Inquiry, audit, lessons management and after action review | The Inspector-General Emergency Management recommends Queensland Fire and Emergency Services and the Department of Environment and Science monitor the progress of relevant improvement activities resulting from the K’gari (Fraser Island) Bushfire Review, through their respective lessons management programs. |
REC322-4240 | 25 - Inquiry, audit, lessons management and after action review | The Inspector-General Emergency Management recommends the next review of the Queensland State Disaster Management Plan examines and provides guidance in respect to the application of Queensland’s disaster management arrangements to support hazard specific events such as bushfire. |
REC322-4233 | 32 - Doctrine, standards, and reform | The Inspector-General Emergency Management recommends Queensland Fire and Emergency Services and the Department of Environment and Science review the current description of Level 1, 2, and 3 bushfire incidents and the implied meaning of property in the Queensland Bushfire Plan. This review should identify and agree on clear criteria and decision points for the transfer of control and develop a standard process and templates. |
REC322-4241 | 32 - Doctrine, standards, and reform | The Inspector-General Emergency Management recommends Queensland Fire and Emergency Services consider expanding specialist Remote Area Firefighting Team capability to assist in responding to significant bushfire events which occur in rugged or inaccessible terrain. |
REC322-4234 | 32 - Doctrine, standards, and reform | The Inspector-General Emergency Management recommends the Department of Environment and Science review its suite of operational doctrine to ensure arrangements for situational reporting and requests for assistance are aligned to recognised multi-agency practices used in disaster management. |
REC322-4222 | 4 - Fire season preparation | The Inspector-General Emergency Management recommends the Department of Environment and Science undertake a review of campfire locations on K’gari, including all relevant signage on and off the island, maps and visitor permit information, to promote a consistent message about lighting campfires on K’gari. |
REC322-4246 | 25 - Inquiry, audit, lessons management and after action review | The Inspector-General Emergency Management recommends the Interagency Protocol for Fire Management be reviewed by all relevant entities, including representatives of the Butchulla people, and be updated as a matter of priority. Entities responsible for the protocol should implement a process for regular review and evaluation of its effectiveness. This review process should be conducted after a major bushfire event, or to reflect any material change to applicable legislation and policy. It should also consider pre-arranged approvals and a range of agreed fiscal protocols between the agencies. |
REC322-4236 | 32 - Doctrine, standards, and reform | The Inspector-General Emergency Management recommends the arrangements and requirements for situational reporting when an incident is under the control of the Department of Environment and Science be detailed in the Queensland Bushfire Plan. These arrangements should also be outlined in relevant joint entity agreements and operational doctrine. |
REC322-4218 | 25 - Inquiry, audit, lessons management and after action review | The Inspector-General Emergency Management recommends this report be returned to the IGEM to monitor, evaluate and report on progress and implementation of the recommendations that are accepted in whole or in part by government. |
REC322-4247 | 32 - Doctrine, standards, and reform | The Inspector-General Emergency Management recommends a collaborative review of firelines, tracks and trails on K’gari be undertaken by the Department of Environment and Science, in collaboration with the Locality Specific Area Fire Management Group and the Butchulla people, to ensure an adequate network is agreed by relevant stakeholders, and roles and responsibilities for maintenance are agreed and documented. |
REC322-4237 | 32 - Doctrine, standards, and reform | The Inspector-General Emergency Management recommends the Department of Environment and Science develop and implement a Wildfire Response Plan for Queensland Parks and Wildlife Service Coastal and Islands Region, to be included in the region’s Disaster Management Operations Plan. |
REC322-4219 | 25 - Inquiry, audit, lessons management and after action review | The Inspector-General Emergency Management recommends should a Queensland Government Action Plan be considered, clarity about the intent of the recommendations be sought from the Inspector-General Emergency Management to assist in informing this process. |
Rec-ID | Code | Recommendation |
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REC311-2505 | 25 - Inquiry, audit, lessons management and after action review | This report be returned to the InspectorGeneral Emergency Management to monitor, evaluate and report on progress and implementation of the recommendation(s) that are accepted in whole or in part by government. |
REC311-2504 | 25 - Inquiry, audit, lessons management and after action review | To enable entities in the sector to proactively work to achieve better results for the community, the recommendations and lessons of this review should be evaluated through the lessons management processes of entities involved in dam safety for their value and relevance. |
Rec-ID | Code | Recommendation |
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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. |
REC309-2477 | 21 - Role of Commonwealth Government | The Department of Housing and Public Works should be included within Local Disaster Management Group evacuation centre planning and plans and assist with decision making around the relocation of evacuees from evacuation centres. |
Rec-ID | Code | Recommendation |
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REC308-2455 | 32 - Doctrine, standards, and reform | The Queensland Offers of Assistance Policy, particularly for corporate donations, should be updated and exercised prior to the next season. |
REC308-2453 | 32 - Doctrine, standards, and reform | Business continuity planning should feature permanently in disaster management doctrine. |
REC308-2449 | 25 - Inquiry, audit, lessons management and after action review | Queensland should implement and maintain a system-wide lesson management program. |
Rec-ID | Code | Recommendation |
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REC307-2441 | 32 - Doctrine, standards, and reform | Hazard-specific and disaster management guidelines and plans should explain the circumstances and process for hazard-specific activation of the disaster management arrangements in support of an incident. They should be relevant to local authorities and local and district groups, and used during events. |
REC307-2434 | 32 - Doctrine, standards, and reform | Given an increasing risk of intense fires, the framework of legislation relating to vegetation management, bushfire mitigation and preparation priorities should be re-assessed. The re-assessment should aim to enable more appropriate and flexible means at the local level for the reduction of intense fires. |
REC307-2432 | 32 - Doctrine, standards, and reform | Legislation at state and local level requiring landholders to reduce fire risk on their property should be actively applied |
REC307-2427 | 32 - Doctrine, standards, and reform | Wherever possible, the antecedents that will lead to catastrophic fire weather conditions existing for a particular area should be identified and documented within fire management plan relevant to the area. |
REC307-2443 | 32 - Doctrine, standards, and reform | Planning for response to bushfire risk should identify all stakeholders to be engaged in the response phase and their roles and responsibilities should be clearly documented. |
REC307-2426 | 32 - Doctrine, standards, and reform | Queensland's plans and arrangements for heatwave should be reviewed to provide for an intergrated multi-agency approach to their management. A single agency should lead and oversee this process. |
REC307-2442 | 32 - Doctrine, standards, and reform | Hazard-specific plans and guidelines should be published on external websites for access by relevant stakeholders. |
Rec-ID | Code | Recommendation |
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REC210-0738 | 25 - Inquiry, audit, lessons management and after action review | Seqwater should ensure that any future peer review process: • is co-ordinated by someone independent of those who wrote the report • entails the provision of all relevant information to the peer reviewers • permits sufficient time for the review • documents all contact between those whose actions are under review and the reviewers. |
REC210-0760 | 32 - Doctrine, standards, and reform | CS Energy should amend its business procedure to remove any ambiguity as to the establishment of communications with Seqwater and to acknowledge the formal communications protocol regarding releases. |
REC210-0717 | 32 - Doctrine, standards, and reform | The Queensland Government should consider amending the Environmental Protection Act 1994 to provide a definition of the term ‘emergency’ for the purposes of section 468 of that Act. |
REC210-0737 | 25 - Inquiry, audit, lessons management and after action review | The Department of Environment and Resource Management should ensure that an independent and appropriately qualified person immediately starts the task of reviewing the March flood event report to ensure that the review is completed before the start of the 2012/2013 wet season. |
REC210-0759 | 32 - Doctrine, standards, and reform | CS Energy should review its emergency action plan and business procedures to ensure they are wholly consistent and give appropriate consideration to flooding as a possible emergency event. |
REC210-0714 | 32 - Doctrine, standards, and reform | The Queensland Government should consider amending the Environmental Protection Act 1994 so that it allows for the relaxation of environmental authority conditions, by transitional environmental program or otherwise, as to discharge of water: • pre-emptively, in advance of rainfall or flooding events, or • for all mines in a catchment that is flooding. |
REC210-0773 | 25 - Inquiry, audit, lessons management and after action review | The Department of Environment and Resource Management should prioritise dam safety audits according to risk. The risk assessment should be informed by criteria including: • structure and materials used in construction • age of the dam • time since last inspection • occurrence of a flood event since last audit and the size of that flood event • population at risk if the dam were to fail • experience and capability of dam owner • dam owner compliance history • time since last audit. |
REC210-0736 | 25 - Inquiry, audit, lessons management and after action review | Seqwater should ensure that proper support and oversight mechanisms are put in place around both the substantive and procedural aspects of drafting flood event reports. Seqwater should consider engaging consultants with expertise in the production of reports following significant events to advise on these mechanisms. Measures to be considered should include: • ensuring appropriate systems are in place to ensure the recollections of flood engineers and other parties are recorded immediately after the event, perhaps by engaging an external party to interview the flood engineers and other parties • ensuring that a methodology for writing the report is set out clearly in advance, in writing, and that the final report includes a statement of that methodology • putting in place systems to ensure that members of senior management have sufficient understanding of both the methodology and process by which the report is prepared to allow themselves to be satisfied that these are appropriate. |
REC210-0696 | 21 - Role of Commonwealth Government | Carriers, councils and the Australian Communications and Media Authority should take into account the risk of flooding when considering the placement of telecommunications facilities. |
REC210-0750 | 32 - Doctrine, standards, and reform | The assessment of flood mitigation manuals should be completed by a person with appropriate expertise who has had no involvement in its development, at any stage, and who can be seen to be independent of all individuals who were so involved. |
REC210-0712 | 32 - Doctrine, standards, and reform | The Queensland Government should legislate to clarify the purposes for which a transitional environmental program can be granted. In particular, if the government considers the transitional environmental program the appropriate regulatory mechanism to deal with the discharge of water from mines during flood, section 330 of the Environmental Protection Act 1994 should be clarified to make it clear that it extends to that use. |
REC210-0772 | 25 - Inquiry, audit, lessons management and after action review | Prior to each wet season, the Department of Environment and Resource Management should audit the compliance of each owner of a referable dam with the obligation to have an emergency action plan approved by the Queensland Government. |
REC210-0733 | 32 - Doctrine, standards, and reform | Emergency Management Queensland should pursue the execution of the ‘Local Arrangements’ with councils where a Memorandum of Agreement is in place. The contents of the arrangements should be reviewed and updated regularly |
REC210-0749 | 32 - Doctrine, standards, and reform | The Queensland Government should amend the Water Supply (Safety and Reliability) Act 2008 to designate the Minister as the person who must approve a flood mitigation manual. |
REC210-0770 | 32 - Doctrine, standards, and reform | The Queensland Government should legislate to oblige each owner of a referable dam to have an emergency action plan approved by the appropriate Queensland Government agency. Such plans should be reviewed periodically |
REC210-0726 | 25 - Inquiry, audit, lessons management and after action review | The Queensland Fire and Rescue Service should require that each region records in writing the results of its risk assessment undertaken as part of its annual review of its special operations functional plan. |
REC210-0743 | 25 - Inquiry, audit, lessons management and after action review | Seqwater should, in creating the new Wivenhoe and North Pine flood mitigation manuals, comprehensively consider: • the amount of discretion that is able to be exercised by the flood engineers and the senior flood engineers, and the description of the circumstances in which such discretion may be exercised • the circumstances in which it might be appropriate to release water in advance of an impending flood on the basis of forecasts from the Bureau of Meteorology • if strategies of the form of strategy W2 and W3 in Revision 7 are included in the revised manual, or any strategy defined as a ‘transition strategy’, when and how those strategies should be implemented • if the concept of ‘urban inundation’ is relevant to the operation of the dam, how it should be defined, and if the definition involves diverse concepts, how those concepts can be related back to the strategies, so that flood engineers can reach a clear understanding of their objectives and primary considerations • if the concept of ‘natural peak flow’ is relevant, how it should be defined. |
REC210-0762 | 25 - Inquiry, audit, lessons management and after action review | Seqwater should consider commissioning an investigation into the extent of cracking below the level of the upper gallery of Somerset Dam and the impact of any such cracking on the dam’s stability and, in turn, its operation. |
REC210-0719 | 32 - Doctrine, standards, and reform | The Queensland Government should amend the Environmental Protection Act 1994 so as to permit an emergency direction to be given orally where it is not practicable to provide the direction in writing, with provision for its subsequent confirmation in writing |
Rec-ID | Code | Recommendation |
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REC137-3531 | 32 - Doctrine, standards, and reform | I recommend that CASA consider creating firm guidelines that require consideration of workload, lines of authority, potential conflicts of interest and any other factors that impact upon the ability of “key personnel” to discharge their responsibilities within an aviation organisation when its officers are approving appointments to those positions. |
REC137-3533 | 21 - Role of Commonwealth Government | Accordingly I recommend that the Federal Minister for Transport, consider engaging an external consultant to assess whether high level intervention is warranted. |
Rec-ID | Code | Recommendation |
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REC126-1952 | 25 - Inquiry, audit, lessons management and after action review | That regular periodic reviews be undertaken of changes made to the operational and management arrangements for dealing with wildfires and other emergencies in the ACT, to ensure that those arrangements continue to comply with the Australian Inter-Agency Incident Management System Incident Control System |
REC126-1966 | 32 - Doctrine, standards, and reform | That the Emergency Services Agency investigate and implement arrangements that will provide the capacity to use fire retardant in remote areas |
REC126-1943 | 32 - Doctrine, standards, and reform | That the ACT’s Director of Public Prosecutions Act 1990 be amended by repealing s. 6(d) of the Act |
REC126-2010 | 25 - Inquiry, audit, lessons management and after action review | That the taskforce review the extent to which the recommendations in the McLeod report have been implemented in order to ensure implementation of those not yet implemented |
REC126-1951 | 4 - Fire season preparation | That before each fire season the Emergency Services Agency, in conjunction with the Bush Fire Council – after consultation with the relevant ACT agencies, the Bureau of Meteorology, relevant NSW agencies and the community – conduct a qualitative risk analysis of the conditions and circumstances prevailing and forecast and develop strategies to ensure heightened preparedness during seasons identified as severe |
REC126-1965 | 32 - Doctrine, standards, and reform | That helicopters be used wherever possible to facilitate the rapid deployment of remote area firefighting crews |
REC126-1989 | 32 - Doctrine, standards, and reform | That formal protocols be developed and agreed with NSW authorities, so that a concerted effort that combines the resources of both NSW and the ACT can be brought to bear in the future - without impediment caused by lines on a map that make the ACT an island within the state of NSW |
REC126-1947 | 25 - Inquiry, audit, lessons management and after action review | That the ACT Government commission a review of coroners’ jurisdiction in order to determine whether that jurisdiction ought to be limited or expanded and, if so, to what extend |
REC126-1964 | 32 - Doctrine, standards, and reform | That remote area firefighting resources be deployed to a fire in a remote area as a matter of priority and in preference to the deployment of large tankers |
REC126-1978 | 32 - Doctrine, standards, and reform | That it be a matter of policy and practice that the relevant land management agency is responsible for the initial response to any fire or fires on the land under its care or management – within the overall operational response of the ACT Rural Fire Service |
REC126-1946 | 32 - Doctrine, standards, and reform | That the ACT Government consider amending the Coroners Act 1997 to include what were ss. 56(1)(d) and 56(2)(c) of the 1956 Coroners Act |
REC126-1964 | 32 - Doctrine, standards, and reform | That all firefighting agencies adopt a policy and practice that all fires in remote areas of the ACT be responded to as quickly as possible, with vigorous and sustained efforts made to suppress the fires and not leave them unattended – especially at night – unless there are compelling reasons relating to firefighter safety or lack of resources |
REC126-1977 | 4 - Fire season preparation | That a program be implemented to ensure that existing fire tracks and trails are cleared and accessible at all times and that a network of additional fire trails be established so as to allow direct fire suppression operations without undue delay in the event of a wildfire |
REC126-1945 | 32 - Doctrine, standards, and reform | That s. 47 of the ACT Coroners Act 1997 be expanded to explicitly state that an inquest and the inquiry are not adversarial in nature and are solely inquisitorial, with a view to establishing the truth |
REC126-1962 | 32 - Doctrine, standards, and reform | That version 2 of the Strategic Bushfire Management Plan be completed and introduced without delay |
REC126-1974 | 4 - Fire season preparation | That responsibility for fuel management lie with the land management agency that controls the area and that land managers be given authority to implement prescribed fuel-reduction burns within their area |
REC126-1944 | 32 - Doctrine, standards, and reform | That s. 59 of the ACT Coroners ACT 1997 be amended by deleting the words ‘by instrument’ in s. 59(1) and by deleting the words ‘by his or her instrument of appointment’ in s. 59(2)(b) |
REC126-2011 | 25 - Inquiry, audit, lessons management and after action review | That the taskforce review the recommendations of the seven reviews of the Emergency Services Bureau carried out before the McLeod inquiry and ensure implementation of any of those recommendations that remain relevant but have not been implemented |