Inquiry Search
Rec-ID | Code | Recommendation |
---|---|---|
REC325-4337 | 8 - Communications and warnings | The Inspector-General of Emergency Management recommends Queensland Fire and Emergency Services lead an urgent multi-agency (including but not limited to the Queensland Police Service and Brisbane City Council) review of the workflow, of the current Emergency Alert system, including requesting, composing, authorising and issuing of Emergency Alerts by 1 November 2022. |
REC325-4323 | 7 - Inter-agency communication | The Inspector-General of Emergency Management recommends Queensland Fire and Emergency Services adopt measures to achieve a common operating picture between deployed Queensland Fire and Emergency Services assets in disaster management operations by 1 November 2023. |
REC325-4329 | 8 - Communications and warnings | The Inspector-General of Emergency Management recommends Queensland Fire and Emergency Services implement the Australian Warning System for all nationally agreed hazards by 1 November 2023. Implementation should include guidance and training to all local governments and agencies operationally involved in disaster management, with emphasis on those agencies with hazard specific responsibility. |
REC325-4332 | 8 - Communications and warnings | The Inspector-General of Emergency Management recommends that all local governments that do not have pre-formatted messages and polygons engage with Queensland Fire and Emergency Services and determine whether their local disaster management group capability could be improved through the development of pre-formatted polygons and messages. |
REC325-4332 | 8 - Communications and warnings | The Inspector-General of Emergency Management recommends that all local governments that currently use pre-formatted messages within the Emergency Alert system review and, where necessary, redraft messages using the principles of Clear Explicit Translatable Language (CETL). |
REC325-4336 | 8 - Communications and warnings | The Inspector-General of Emergency Management recommends Queensland Fire and Emergency Services, in consultation with the Queensland Police Service, incorporate into the workflow of the current Emergency Alert system a process that ensures the inclusion of an ‘urgent approval and distribution without delay’ process for Emergency Alert messages by 1 November 2022. |
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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC322-4243 | 14 - Incident Mgt Teams | The Inspector-General Emergency Management recommends the Department of Environment and Science identify opportunities to increase Queensland Parks and Wildlife Service’s capability in incident management and multi-agency fire response, through exercising plans and procedures in collaboration with other stakeholders, including disaster and fire management groups at all levels. |
REC322-4230 | 34 - Local knowledge | The Inspector-General Emergency Management recommends Queensland Fire and Emergency Services engages with land managers and other stakeholders on K’gari to source data to inform Predictive Services products. |
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. |
REC322-4245 | 14 - Incident Mgt Teams | The Inspector-General Emergency Management recommends the Department of Environment and Science establish pre-determined financial delegations and authority for Queensland Parks and Wildlife Service Incident Controllers. |
REC322-4231 | 8 - Communications and warnings | The Inspector-General Emergency Management recommends Queensland Fire and Emergency Services examines the use of predictive service capability to inform prevention and preparedness in addition to response activities. |
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. |
REC322-4246 | 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. |
REC322-4232 | 11 - Evacuation and shelters | The Inspector-General Emergency Management recommends the Maryborough District Disaster Management Group works with the Fraser Coast Local Disaster Management Group to plan for the evacuation of K’gari due to bushfire. Once developed, the plan should be exercised and regularly reviewed. |
REC322-4225 | 8 - Communications and warnings | The Inspector-General Emergency Management recommends the Maryborough District Disaster Management Group works with the Fraser Coast Local Disaster Management Group to prepare and exercise a communications sub-plan with all responsible agencies, to clarify the roles, responsibilities and communication channels used for restricting access to K’gari. |
REC322-4250 | 34 - Local knowledge | The Inspector-General Emergency Management recommends the Locality Specific Fire Management Group for K’gari meet at least twice per year, in person or virtually. |
REC322-4235 | 14 - Incident Mgt Teams | The Inspector-General Emergency Management recommends the Department of Environment and Science review the resourcing model to ensure surge capacity is available to support incident management functions during response operations. This includes processes to request assistance from other departments and entities with responsibilities for fire and incident management. |
REC322-4227 | 34 - Local knowledge | The Inspector-General Emergency Management recommends the membership of the K’gari Locality Specific Fire Management Group be expanded to include representatives of the Butchulla people, community associations from each township and tourism and business operators with interests on the island. |
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. |
REC322-4240 | 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. |
REC322-4228 | 8 - Communications and warnings | The Inspector-General Emergency Management recommends a public information resource be developed by Queensland Fire and Emergency Services to inform the community and stakeholders about aerial assets utilised in bushfire response. |
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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC317-4098 | 8 - Communications and warnings | The Australian Government should facilitate state and territory governments working together to develop minimum national standards of information to be included in bushfire warnings apps. |
REC317-4074 | 25 - Inquiry, audit, lessons management and after action review | The Australian Government should review the content of the Defence Assistance to the Civil Community manual to ensure consistency of language and application with a revised COMDISPLAN. |
REC317-4090 | 11 - Evacuation and shelters | State and territory governments should, as a priority, adopt nationally consistent terminology and functions for the different sheltering facilities, including evacuation centres, Neighbourhood Safer Places, places of last resort and natural disaster shelters. |
REC317-4096 | 8 - Communications and warnings | State and territory governments should urgently deliver and implement thevall-hazard Australian Warning System. |
REC317-4066 | 2 - Emergency powers | The Australian Government should make provision, in legislation, for a declaration of a state of national emergency. The declaration should include the following components: |
REC317-4089 | 11 - Evacuation and shelters | State and territory governments should ensure that those responsible for evacuation planning periodically review those plans, and update them where appropriate, including in relation to: |
REC317-4094 | 8 - Communications and warnings | State and territory governments should expedite the development and implementation of the Australian Fire Danger Rating System. It should ensure that there is national consistency in the visual display of the AFDRS and action to be taken in response to each rating. |
REC317-4088 | 11 - Evacuation and shelters | State and territory governments should ensure that those responsible for evacuation planning periodically review those plans, and update them where appropriate, including in relation to: |
REC317-4093 | 11 - Evacuation and shelters | State and territory governments should ensure those responsible for evacuation planning periodically review those plans, and update where appropriate, to provide for coordination between states and territories in cross border areas and to provide cross-border access to evacuation centres. |
REC317-4102 | 25 - Inquiry, audit, lessons management and after action review | Australian, state and territory governments should review Australian Medical Assistance Team capabilities and procedures and develop necessary training, exercising and other arrangements to build capacity for domestic deployments. |
REC317-4081 | 18 - Access to fire ground | State and territory governments should provide information to the public on the closure and opening of roads. Information should be provided in real-time, or in advance based on predictions, where possible. |
REC317-4092 | 11 - Evacuation and shelters | State and territory governments should ensure those responsible for evacuation planning periodically review these plans, and update them where appropriate, to account for the existence and standard of any evacuation centres and safer places (however described) in the community, including: |
REC317-4099 | 8 - Communications and warnings | Australian, state and territory governments should continue to explore the feasibility of a national, all-hazard emergency warning app. |
REC317-4080 | 18 - Access to fire ground | State and territory governments should include road closure and opening information on all roads within their borders on public apps. |
REC317-4091 | 11 - Evacuation and shelters | State and territory governments should provide further community education on the function and limitations of different sheltering facilities, including evacuation centres, Neighbourhood Safer Places, places of last resort and natural disaster shelters. This education should be nationally consistent. |
Rec-ID | Code | Recommendation |
---|---|---|
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 |
---|---|---|
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. |
REC309-2476 | 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. |
REC309-2475 | 15 - Inter-service cooperation | Greater emphasis be placed on pre-planned and pre-determined arrangements between the Australian Defence Force and State and local agencies. |
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). |
REC309-2479 | 34 - Local knowledge | Local groups should plan for and establish clear arrangements to effectively manage offers of assistance including the management of goods, services and volunteers. |
Rec-ID | Code | Recommendation |
---|---|---|
REC308-2460 | 11 - Evacuation and shelters | The Queensland Chief Health Officer should work with the Office of the Inspector-General Emergency Management to raise, with the Commonwealth, the need for all aged care providers to plan and exercise for evacuation to a similar safe establishment. |
REC308-2459 | 14 - Incident Mgt Teams | Significant effort should be invested to provide disaster decision-makers at every level with a shared understanding of risks, the situation, and capability, so that they can agree on the best decisions for the communities they serve. |
REC308-2457 | 8 - Communications and warnings | Efforts are made to improve the timeliness, accuracy and targeting of Emergency Alert messaging by: |
REC308-2449 | 25 - Inquiry, audit, lessons management and after action review | Queensland should implement and maintain a system-wide lesson management program. |
REC308-2462 | 11 - Evacuation and shelters | Relevant authorities should work with the tourism sector to clarify future arrangements for evacuation. In particular they should look closely at differentiating voluntary and directed evacuations in their messaging, |
Rec-ID | Code | Recommendation |
---|---|---|
REC307-2440 | 8 - Communications and warnings | Communications protocols about hazard-specific events should be developed to clarify responsibilities and the principles for the release of information and warnings. They should be included in all related hazard-specific plans and published on relevant websites, and used during events. |
REC307-2438 | 8 - Communications and warnings | The national messages for catastrophic fire danger ratings should be integrated with all existing and new community bushfire safety information. |
REC307-2446 | 14 - Incident Mgt Teams | Coordinated arrangements for liaison officer deployment should be considered and documented by disaster management groups across the full spectrum of risk identified for their area of responsibility, and not rely on a singular inflexible approach. |
Rec-ID | Code | Recommendation |
---|---|---|
REC290-1213 | 34 - Local knowledge | Structures to incorporate local knowledge and situational awareness into the fire response |
REC290-1210 | 15 - Inter-service cooperation | Co‐designed arrangements that support a unified response to fire |
REC290-1209 | 15 - Inter-service cooperation | Coordinated and targeted mitigation of fire risk |
REC290-1218 | 7 - Inter-agency communication | Cross-agency resource management system |
REC290-1214 | 14 - Incident Mgt Teams | Flexible pre‐formed multi‐ agency IMTs |
Rec-ID | Code | Recommendation |
---|---|---|
REC277-1166 | 7 - Inter-agency communication | Develop an integrated inter-agency resource management system: Large and complex fire incidents require resources from multiple agencies. Developing an integrated inter-agency resource management system will have three main benefits: identifying potential resources will be more straightforward • the status and location of resource deployments can be tracked • planning of deployments can take into account all relevant information |
REC277-1164 | 14 - Incident Mgt Teams | Establish multi-agency preformed IMTs: An effective IMT for large and complex fire incidents requires the capacity and expertise of multiple agencies. Establishing multi-agency preformed IMTs will have three main benefits: adequate IMT resources can be deployed with ease • strong working relationships will be built between IMT members • common approaches to incident management and fire response can be embedded. |
Rec-ID | Code | Recommendation |
---|---|---|
REC265-1122 | 18 - Access to fire ground | DFES, in consultation with bushfire volunteers should develop a procedure for the controlled entry and exit of volunteers to the fire ground |
REC265-1105 | 15 - Inter-service cooperation | The Executive Teams of both DFES and DPaW should meet quarterly to review and agree joint improvements relating to issues of interoperability, complementarity and the alignment of firefighting doctrine. The establishment of a unified command in joint State Operations Centre, Regional Operations Centre and Incident Management Teams should be pursued as an overarching goal. |
REC265-1121 | 18 - Access to fire ground | A Restricted Access Permit system for the entry/ re-entry of residents, based on the one developed for the Parkerville Stoneville Mt Helena Bushfire should be finalised. |
REC265-1102 | 25 - Inquiry, audit, lessons management and after action review | SEMC Secretariat Community Emergency Management Officers should work with the Shire to document the Shire of Mundaring’s learnings from the Parkerville Stoneville Mt Helena fire with a view to sharing this with other local authorities particularly those facing similar situations in order to extend the range of tools available to assist local governments to understand their roles and responsibilities in future emergencies. |
REC265-1118 | 8 - Communications and warnings | Consideration should be given to an automatic ‘Advice’ notice being issued as soon as a fire is reported in a pre- determined high risk area such as the Darling Scarp on days when adverse fire weather conditions are forecast. |
REC265-1111 | 15 - Inter-service cooperation | All agencies engaged in bushfire response should develop expeditious procedures for the mobilisation of resources in support of other agencies. See discussion in Section 7.1. |
REC265-1109 | 14 - Incident Mgt Teams | Future appointments to the role of Incident Controller should be limited to one for the entire duration of the incident, with nominated Deputy Incident Controllers to assist or ‘take charge’ in the Incident Controller’s absence. This measure will provide for a single point of responsibility and control for the incident and assist with any subsequent review or enquiry. If it is not possible to implement this proposal for liability reasons, the number of Incident Controllers should nevertheless be reduced to the minimum. |
REC265-1106 | 15 - Inter-service cooperation | In addition to regular meetings of the DFES/DPaW Interagency Bushfire Management Committee, the two organisations should use joint exercises to identify agreed firefighting approaches for common or likely scenarios. |
Rec-ID | Code | Recommendation |
---|---|---|
REC254-1587 | 14 - Incident Mgt Teams | WA adopts a culture of joint IMTs in future. At Regional and State levels, DFES and DEC maintain standing contributions. |
REC254-1586 | 15 - Inter-service cooperation | Future coordination/support/control of integrated emergency management across all agencies in Albany needs to be merged and located in a single joint facility. This issue needs to be reviewed statewide. |
REC254-1585 | 14 - Incident Mgt Teams | DFES and Local Government Bushfire Brigades ensure that only those with the required AIIMS competence have the authority to manage Level 1 incidents, noting they may not be Fire Control Officers. |
Rec-ID | Code | Recommendation |
---|---|---|
REC233-1604 | 8 - Communications and warnings | Governments and other stakeholders consider reviewing their existing emergency management arrangements to ensure public communications are clear and the public is kept informed of the incident response. |
REC233-1603 | 8 - Communications and warnings | Department of Broadband, Communications and the Digital Economy (DBCDE) to work with the Triple Zero Awareness Work Group through Australian Communications and Media Authority's (ACMA) Emergency Service Advisory Committee to review Triple Zero awareness messages with regard to telecommunications outages. |
REC233-1592 | 8 - Communications and warnings | Department of Broadband, Communications and the Digital Economy will work with the Communications Sector Group within the Trusted Information Sharing Network to develop best practice guidance for owners of critical communications infrastructure regarding public messaging during a prolonged telecommunications outage covering: |
REC233-1590 | 25 - Inquiry, audit, lessons management and after action review | Department of Broadband, Communications and the Digital Economy seek regular updates from Telstra on the implementation of the recommendations of its inquiry into the Warrnambool exchange fire. |
Rec-ID | Code | Recommendation |
---|---|---|
REC227-2849 | 20 - Role of police | I recommend that the AFP takes steps to ensure that there are on Christmas Island at all times appropriately trained AFP officers who have completed the National Police Search and Rescue Manager’s Course and that upskilling should be ongoing to establish a cadre of trained search and rescue personnel. |
REC227-2847 | 15 - Inter-service cooperation | I recommend that Border Protection Command implement a surveillance strategy, possibly with the assistance of other Commonwealth authorities and organisations on the island such as the AFP, which heightens its coverage at times when the weather and sea conditions are rough. |
Rec-ID | Code | Recommendation |
---|---|---|
REC226-0565 | 14 - Incident Mgt Teams | Contingency planning is a critical function in the early stages of an escalating incident, and should provide the foundation of an IAP. |
REC226-0590 | 8 - Communications and warnings | Expand the exploitation of social media, including graphical content for state alerts and warnings. Consider increasing the graphical content of web-based warnings. |
REC226-0552 | 7 - Inter-agency communication | Communications planning for geographic regions with recognised black spots and specific communications challenges should be prepared in advance of an emergency in order to support the IMT Communications Planning Officer |
REC226-0573 | 14 - Incident Mgt Teams | Strategic direction seeks to identify and resource those areas of tactical action that offer the greatest advantage. |
REC226-0558 | 14 - Incident Mgt Teams | Predetermined locations for Level 3 IMTs should be reviewed and adequately resourced with necessary communications and IT capacity. |
REC226-0584 | 14 - Incident Mgt Teams | Reporting and control should be through the incident chain of command and not through agency chains of command |
REC226-0564 | 14 - Incident Mgt Teams | The expected scenario, with a view to the worst-case scenario should provide the basis for an IAP. |
REC226-0589 | 8 - Communications and warnings | The process for initiating and releasing State Alert messages requires review. |
REC226-0551 | 14 - Incident Mgt Teams | As presently implemented, the AIIMS planning role is under-developed and provides insufficient support to the Incident Controller. |
REC226-0572 | 14 - Incident Mgt Teams | Contingency planning before the fire may have supported the IMT in recognising and seizing strategic opportunities earlier. |
REC226-0557 | 14 - Incident Mgt Teams | An intensive exercise/training program should be developed and maintained across agencies to identify and establish a pool of current Incident Controllers who are capable of managing a Level 3 incident. |
REC226-0578 | 15 - Inter-service cooperation | There would be benefit in progressively aligning the geographic boundaries of each of the agencies and seeking to co-locate their headquarters within those boundaries. |
REC226-0563 | 14 - Incident Mgt Teams | Procedures to relocate IMTs need to be established in doctrine and exercised to ensure continuity of control. |
REC226-0588 | 8 - Communications and warnings | Timely alerts and updates to the community are essential. |
REC226-0550 | 14 - Incident Mgt Teams | Greater investment in training on specific functions within the AIIMS structure will improve the support provided to the Incident Controller. |
REC226-0570 | 14 - Incident Mgt Teams | Logistics and resource officers in IMTs need to collaborate and establish full awareness and control over the available resources. |
REC226-0556 | 14 - Incident Mgt Teams | Within the AIIMS IMT doctrine the roles of the Incident Controller and Deputy Incident Controllers should be defined and well-practiced. |
REC226-0577 | 7 - Inter-agency communication | A system of vehicle tracking should be fitted to all fire appliances and linked to the common operating picture. Good communications planning is essential for good command and control. |
REC226-0562 | 14 - Incident Mgt Teams | Opportunities be sought to utilise local government representatives in other areas of the IMT particularly in public information or other community related functions. |
REC226-0587 | 14 - Incident Mgt Teams | To be effective, multi-agency IMTs will need to be exercised regularly and supported by sound and comprehensive doctrine. |
REC226-0548 | 15 - Inter-service cooperation | Inter-agency cooperation to manage fire precincts in a tenure-blind fashion is necessary for effective fire suppression. |
REC226-0567 | 14 - Incident Mgt Teams | IMTs need to establish early and effective liaison with Local Governments. |
REC226-0592 | 11 - Evacuation and shelters | Decisions on evacuations need to be made early enough for people to be fully informed, prepared and to move to a place of greater safety. Failure to conduct good planning can create situations where loss of life can occur |
REC226-0555 | 14 - Incident Mgt Teams | The state should identify the number of fully trained, experienced and accredited Level 3 Incident Controllers required to be available at any time and establish a process for identification of suitable personnel, ongoing training and accreditation. |
REC226-0575 | 14 - Incident Mgt Teams | In multi-agency responses the culture, training and equipment characteristics of each of the agencies should be considered in their employment. |
REC226-0561 | 34 - Local knowledge | Suitably experienced local representatives should be engaged to provide advice to the IMT in all Level 2 and Level 3 incidents at the earliest opportunity. |
REC226-0586 | 14 - Incident Mgt Teams | At Level 3, the available fire management expertise should be applied overwhelmingly to the fire management aspects of emergency management, possibly in incident control, and certainly in situations planning and operations roles. |
REC226-0566 | 14 - Incident Mgt Teams | Incident Controllers should be supported by a planning function that combines experienced weather forecasters, fire behaviour experts and local knowledge. |
REC226-0591 | 8 - Communications and warnings | Radio bulletins need to be up to date and time stamped. Where social media is used the messages need to be up to date and accurate. Websites need to be up to date and accurate. |
REC226-0554 | 14 - Incident Mgt Teams | For incidents of this complexity, effective control in the critical phase (first 24-36 hours of the fire) requires an appropriately resourced IMT. |
REC226-0574 | 14 - Incident Mgt Teams | Clear direction to divisional and sector commanders and a common communications platform enables maximum return to be gained from the application of tactical resources and this rests on good incident action planning, and good command and control. |
REC226-0560 | 15 - Inter-service cooperation | There would be value in progressively aligning the geographical boundaries of emergency management agencies and co-locating where possible within regions and districts. |
REC226-0585 | 14 - Incident Mgt Teams | DEC’s fire management expertise should be augmented by multi-agency IMTs that incorporate the expertise of other agencies and in fast developing situations the appropriate decisions will need to be made early. |
Rec-ID | Code | Recommendation |
---|---|---|
REC225-0538 | 14 - Incident Mgt Teams | WA adopts a culture of joint IMTs in future. At Regional and State levels, DFES and DEC maintain standing contributions. |
REC225-0537 | 7 - Inter-agency communication | Future coordination/support/control of integrated emergency management across all agencies in Albany needs to be merged and located in a single joint facility. This issue needs to be reviewed statewide. |
REC225-0535 | 2 - Emergency powers | DFES or DEC (depending on land tenure) is mandated to take over control of emergency incidents from Local Government once they have been declared Level 2 incidents. WESTPLAN BUSHFIRE and legislation to be amended accordingly. |
REC225-0540 | 25 - Inquiry, audit, lessons management and after action review | : In due course, acts of bravery are considered and recommendations for awards are submitted, including commendations for the delivery of First Aid. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC210-0761 | 2 - Emergency powers | The Queensland Government should consider whether to empower Seqwater, through the flood operations centre, to direct CS Energy to stop or delay releases from Splityard Creek Dam where a flood event is declared under the Manual of Operational Procedures for Flood Mitigation at Wivenhoe Dam and Somerset Dam. |
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. |
REC210-0757 | 15 - Inter-service cooperation | The protocol should make provision for the use of telephone and/or radio where communication by email is not possible. Where necessary, CS Energy and Seqwater should make additional radio equipment available to relevant personnel. |
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. |
REC210-0756 | 15 - Inter-service cooperation | CS Energy and Seqwater should agree upon and adhere to a formal communication protocol that requires CS Energy personnel to advise Seqwater, through the Flood Operations Centre, of water movements between Splityard Creek Dam and Wivenhoe Dam or Pryde Creek once a flood event is declared under the Manual of Operational Procedures for Flood Mitigation at Wivenhoe Dam and Somerset Dam. The protocol should ensure that a direct line of communication is established between CS Energy personnel physically located at the power station and the Flood Operations Centre. |
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. |
REC210-0727 | 2 - Emergency powers | The Disaster Management Act 2003 should be amended to give the chief executive of the department administering the Act (or his or her delegate) the authority to appoint an officer of Emergency Management Queensland to direct SES operations in extraordinary circumstances |
REC210-0754 | 2 - Emergency powers | As part of the longer term review of the Manual of Operational Procedures for Flood Mitigation at Wivenhoe Dam and Somerset Dam the Queensland Government should consider whether the dam operators should be able to extend the drawdown of the lake beyond seven days in order to reduce downstream bank slumping |
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. |
REC210-0726 | 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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC203-0291 | 18 - Access to fire ground | Local knowledge should be accessed to inform the placement and operation of VCPs. |
REC203-0299 | 15 - Inter-service cooperation | The state should converge on a single communications platform for all emergency management and support agencies. |
REC203-0304 | 8 - Communications and warnings | Further community education may be needed on how to interpret messages. |
REC203-0290 | 18 - Access to fire ground | VCPs are one of the instruments by which the Incident Controller manages the emergency. VCPs without communications cannot be fully effective in their role. Determine and implement an appropriate communications platform for emergency management |
REC203-0298 | 15 - Inter-service cooperation | The state should progressively align on a shared platform, such as WebEO C , to establish a Common Operating Picture (COP). |
REC203-0303 | 8 - Communications and warnings | A high level review of alerts, warnings and messaging is needed to match community expectations with what is practical and achievable. |
REC203-0289 | 18 - Access to fire ground | There needs to be a better appreciation of the role of Vehicle Control Points (VCPs) and how they are managed in bushfire emergencies by all key agencies and the community |
REC203-0294 | 14 - Incident Mgt Teams | Opportunities should be sought to embed other local government representatives in other areas of the IMT particularly in public information. |
REC203-0302 | 8 - Communications and warnings | Web sites need to be kept updated. |
REC203-0307 | 11 - Evacuation and shelters | When people are being moved away from their homes it’s important that they move to a place of greater safety and that their movement is relatively assured. |
REC203-0288 | 15 - Inter-service cooperation | The State Duty Officer from DEC and the State Duty Director, FES A need to confer whenever a Level 2 or 3 incident is declared to satisfy themselves that they have appropriate incident management structures and resources across the state are at an appropriate level of preparedness. |
REC203-0293 | 34 - Local knowledge | Suitably experienced personnel with local knowledge should be connected to the Operations and Planning section in all Level 3 incidents in the vicinity of substantial settlements. |
REC203-0301 | 15 - Inter-service cooperation | Early in an incident, close and effective liaison needs to be established with local government agencies. |
REC203-0306 | 8 - Communications and warnings | Local emergency management committees and planning should identify modes of community contact |
REC203-0287 | 15 - Inter-service cooperation | On a regional basis there would be value in closer working relationship between DEC crews and VBFBs to build mutual trust and confidence. This could be done by opportunity engagement of VBFBs in DEC fire management or through exercises. |
REC203-0292 | 18 - Access to fire ground | There is a need for community education on how road-blocks and VCPs operate in the event of an emergency. |
REC203-0300 | 14 - Incident Mgt Teams | Reporting and control should be through the incident chain of command, and not through agency chain of command. |
REC203-0305 | 8 - Communications and warnings | The agencies need to develop techniques to ensure accuracy of information across all media. |
Rec-ID | Code | Recommendation |
---|---|---|
REC172-0006 | 14 - Incident Mgt Teams | Prior to the bushfire season, potential IMG members, many of whom are members of the Local Emergency Management Committee (LEMC) should be made aware of, and possibly exercise, their role as an IMG member. |
REC172-0033 | 8 - Communications and warnings | Public meetings are to be encouraged for all Level 3 incidents that affect, or have the potential to affect communities. |
REC172-0011 | 18 - Access to fire ground | At Level 3 incidents the position of ‘Traffic Operations Officer’ –be established and filled by a WAPOL officer. A role description for this position is required and should be included in the “Guidelines for the Operations of Road Closures During Bushfires 2008”. This officer is to be supported by a suitably qualified officer from MRWA that is capable of developing Traffic Management Plans that address risk and are cognisant of considerations associated with road type, appropriate speed limitations, signage requirements, traffic volumes, detours for local traffic and heavy haulage etc. This role should report to the IC and have strong links to the Operations Section, Planning Section (particularly the Situation Unit) and the Information Unit. |
REC172-0038 | 34 - Local knowledge | The ISU should be provided with a person with local knowledge at Level 3 incidents. |
REC172-0016 | 18 - Access to fire ground | Full briefings of traffic management personnel should be provided prior to dispatch to work areas – why road closed, what their authority level is, level of current risk etc |
REC172-0005 | 14 - Incident Mgt Teams | Potential IMG membership should be identified in local hazard management plans. The information needs to be kept current. The contact details for each member should be recorded. These plans and contact details need to be available to any IMT mobilised to deal with an incident within the jurisdiction. This means access to this information via internet and storage and maintenance at a centralised facility managed by FESA. |
REC172-0032 | 8 - Communications and warnings | A review of community messages, their construction and component parts, the process to activate them and the technology required to deliver the messages by digital and non-digital media should be undertaken. The desired outcome is to define standard messages, procedures, tools and technologies that can be utilised by all HMA’s in Western Australia. |
REC172-0010 | 14 - Incident Mgt Teams | The responsibilities and obligations for an OAM and OAMG (when established) needs to clarified and codified in Westplan Bushfire with regard to • Provision of information to participating organisations about the progress and potential of an incident; • Dealing with information disseminated to the public; and • Sourcing, coordinating and prioritising resources required by incidents within the Operations Area. There is lack of clarity in current arrangements concerning the role of the agency undertaking control operations e.g. DEC or a local govt and the transfer of these responsibilities to an OAMG when established. |
REC172-0037 | 8 - Communications and warnings | ABC Radio should be a participant in IMG and/or OAMG. LEMC and DEMC should plan for this involvement in Local and District Emergency Management Plans. |
REC172-0015 | 8 - Communications and warnings | Provision of timely, accurate and regular information to the community via electronic media (radio and internet) is a recognised function of the Information Unit in liaison with the Traffic Operations Officer. The aim of this arrangement is to facilitate appropriate behaviour in the travelling public and local community concerning access limitations and disruptions to the fire ground and surrounding areas. |
REC172-0043 | 7 - Inter-agency communication | There needs to be a system that allows laptop computers brought to an incident to be configured at the start of the season and allow them to be easily activated to the correct configuration when they arrive at the incident. |
REC172-0004 | 14 - Incident Mgt Teams | A formal IMG meeting should be convened as early as possible at initiating incidents with potential. At the very least early advice to potential IMG members should be made that a meeting is likely to be convened. The initial IMG should include all IMG representatives to ensure comprehensive briefing, agency specific situational awareness and issue identification. |
REC172-0009 | 14 - Incident Mgt Teams | When an OAMG is established, a formal declaration of its establishment needs to be transmitted to all organisation/agencies involved. The declaration should clearly establish the reporting arrangements for Incident Controllers to the OAM as described in Westplan Bushfire. |
REC172-0036 | 8 - Communications and warnings | Wherever possible the ISU should be co-located with Operations and Logistics Sections to ensure effective communications and the ICC in which they operate should be located in the affected community. |
REC172-0014 | 18 - Access to fire ground | The Interagency Guidelines for Road closure needs to be reviewed to incorporate a mechanism to identify bone-fide local landholders to facilitate their movement in and out of cordoned areas in sympathy with the Stay and Defend requirements. |
REC172-0042 | 7 - Inter-agency communication | Portable, reliable mobile repeaters are required to provide radio communications into areas not covered by existing repeater networks. These repeaters need the capacity to be linked. |
REC172-0008 | 14 - Incident Mgt Teams | Potential OAMG membership should be identified in DEMC protocols and local hazard management plans. The information needs to be kept current. The contact details for each member should be recorded. These plans and contact details need to be available to any IMT mobilised to deal with an incident within the jurisdiction. This means access to this information via internet and storage and maintenance at a centralised facility managed by FESA.] |
REC172-0035 | 14 - Incident Mgt Teams | At Level 3 incidents the Information Services Unit should be adequately resourced with information technology and at least 6 persons, all of whom are very experienced and capable in dealing with the information demands of a Level 3 incident. |
REC172-0013 | 18 - Access to fire ground | In preparing traffic management plans consideration should be given to which VCP’s are critical and need to be resourced with uniformed Police Officers and which VCP’s can be manned with civilian contractors. |
REC172-0040 | 8 - Communications and warnings | The information templates used by the ISU in developing public information boards need to be standardised and posted on the DEC Fire Management Services webpage to allow access and use by the ISU. A standard across government would add significantly to their acceptance and use by the public as a reliable source of information. |
REC172-0022 | 15 - Inter-service cooperation | The declaration of a potential Level 3 incident should be notified to FESA who can facilitate an early warning to CFCO’s in the Shire and surrounding LGA’s. |
REC172-0007 | 14 - Incident Mgt Teams | A formal OAMG meeting should be convened as early as possible for incidents with the potential to be Level 3 incidents. At the very least early advice to potential OAMG members should be made on days that exhibit extreme fire weather and other high ignition risk factors that a meeting is likely to be convened. The initial OAMG should include all OAMG representatives identified by LEMAC and DEMAC for each area to ensure comprehensive briefing, agency specific situational awareness and issue identification. |
REC172-0034 | 8 - Communications and warnings | A centralised emergency services website should be established that the public can access for reliable and up to date information on any incident. The website must be capable of reliably servicing a very high traffic load and be easily updated by HMA’s. |
REC172-0012 | 18 - Access to fire ground | Main Roads Western Australia, Police and LGA’s be encouraged via State emergency arrangements to establish a distributed cache of “hard” road barriers for deployment to major incidents |
REC172-0039 | 18 - Access to fire ground | Dedicated information packages should be made available to personnel operating Vehicle Control Points at the shift briefing. |
REC172-0017 | 18 - Access to fire ground | Information packs to be provided to road traffic personnel to assist with enquiries by public or provision to members of public and landholders who are defending homes/stock etc |
Rec-ID | Code | Recommendation |
---|---|---|
REC171-0067 | 14 - Incident Mgt Teams | That to the extent it has not already done so, DEC take action to ensure that in future cases relevant weather forecast information, particularly information as to significant wind changes, is promptly transmitted through the Incident Management Team and made available to persons with field operation responsibility. |
REC171-0066 | 8 - Communications and warnings | That arrangements be put in place for signage to be retained at Norseman and available at short notice to enable motorists to be warned of potential problems existing on the Great Eastern Highway west of Coolgardie. |
Rec-ID | Code | Recommendation |
---|---|---|
REC166-3006 | 20 - Role of police | That the recommendations contained in the Police Operational Debrief Report of 22 October 2007 to 7 November 2007, submitted to the Coroner, be further considered by the Tasmania Police for adoption where considered appropriate by Tasmania Police. |
REC166-3009 | 25 - Inquiry, audit, lessons management and after action review | That the Tasmania Fire Service conduct an audit of all shopping centres to ensure that there exists within those centres adequate fire protection and evacuation systems. |
REC166-3007 | 15 - Inter-service cooperation | That Tasmania Fire Service implement Recommendation 5 above; and that Aurora continue to co-operate with that Service. |
Rec-ID | Code | Recommendation |
---|---|---|
REC148-3175 | 25 - Inquiry, audit, lessons management and after action review | That the officer responsible for the importation of horses arrange for Biosecurity Australia to review, at least once every two years, the operating procedures to ensure that they adequately identify and manage the risk of entry and spread of equine influenza associated with the importation of horses into Australia. The outcome of each such review should be the subject of a written report and recommendations to the person responsible for the importation of horses and the Executive Director of AQIS. A determination should then be made as to whether any, and if so what, changes should be made to the operating procedures. |
REC148-3170 | 25 - Inquiry, audit, lessons management and after action review | That the officer responsible for the importation of horses arrange for Biosecurity Australia to conduct within six months, an inspection and review of the process of horse importation from the time horses arrive in Australia until the completion of their post-arrival quarantine in order to: |
REC148-3167 | 25 - Inquiry, audit, lessons management and after action review | That the facilities at Eastern Creek and Spotswood Quarantine Stations be reviewed by AQIS in consultation with experts in biosecurity and interested parties including state and territory governments, import agents, veterinarians, farriers, operators of private quarantine stations, and representatives of horse owners, horse racing organisations and equestrian organisations. There should in any event be constructed without delay, an adequate supply of hygienic, modern showering facilities and places of entry and exit to the stations and the horse sections of them that can be supervised and monitored continually. There should also be provided at those stations as soon as is practicable suitable means of electronic surveillance, including closed-circuit television; a secure place to store chemicals, drugs, instruments and equipment for use by people attending the quarantined horses, and a set of horse stalls and yards separate from the main stalls and yards to enable isolation of horses suffering from contagious or infectious diseases. These reviews should also consider the desirability of separate areas in quarantine stations to hold horses forming part of a single quarantine intake but that have been imported from different regions or have undergone pre-export quarantine in different places. The reviews should be carried out without delay, and the two quarantine stations should be upgraded in accordance with the recommendations of the reviews. |
REC148-3154 | 25 - Inquiry, audit, lessons management and after action review | That the officer responsible for the importation of horses arrange for Biosecurity Australia or another qualified body to inspect and review the activities and events that occur from the time horses enter pre-export quarantine until the time they arrive at an airport in Australia, in order to identify any biosecurity risks and recommend any necessary changes to import conditions or other requirements. This inspection and review shall be performed without delay for each country or region from which horses are imported to Australia, and it should take account of my other recommendations and comments in this report. |
REC148-3182 | 25 - Inquiry, audit, lessons management and after action review | That Biosecurity Australia review that formal import risk analysis at least once every two years to take into account any relevant developments in scientific knowledge—specifically testing methods, vaccines, vaccination procedures and other matters that affect biosecurity. Reports on the reviews should be provided to the officer responsible for the importation of horses and should contain recommendations for any necessary changes to policies for importation. |
Rec-ID | Code | Recommendation |
---|---|---|
REC019-4157 | 18 - Access to fire ground | Local authorities and if necessary the Minister take active steps to enforce the removal of fire hazards from the vicinity of buildings in rural areas and that special attention be given to the removal of dead trees on the edges of pasture land and on firebreaks in timbered country. |
REC019-4136 | 34 - Local knowledge | The Bush Fires Board appoint a Regional Committee of Board members co-opt local members for each climatic region of the State to study the bush fire control problems of the region and advise the Board so that inter alia adequate attention may be given by the Board to co-ordinating the beginning and termination of the prohibited burning times in adjoining districts and to any advisable variations of these duties according to seasonal conditions each year. |