Inquiry Search
Rec-ID | Code | Recommendation |
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REC285-2520 | 25 - Inquiry, audit, lessons management and after action review | The report recommends that Ambulance Tasmania investigate whether the additional resources in the North and North West regions were effective in reducing average response times. |
REC285-2519 | 12 - EM agency and authority | The report recommends that Ambulance Tasmania develop strategies to improve response times to those of other jurisdictions and undertake cost benefit analysis of those strategies before deciding on implementation. |
REC285-2524 | 25 - Inquiry, audit, lessons management and after action review | The report recommends that Ambulance Tasmania investigate why the level of multiple responses had increased. |
REC285-2522 | 12 - EM agency and authority | The report recommends that Ambulance Tasmania reinforce the requirement to record factors contributing to response time outliers and the remedial action undertaken to address the contributing factors. |
Rec-ID | Code | Recommendation |
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REC272-1418 | 12 - EM agency and authority | Queensland Fire and Emergency Services should consider examining regulatory provisions to improve disaster management and business continuity planning for aged care providers. |
REC272-1415 | 25 - Inquiry, audit, lessons management and after action review | An audit of all local government areas vulnerable to storm tide events is completed and opportunities identified to resolve gaps in evacuation zone planning to ensure consistency with the Queensland Evacuation Guidelines for Disaster Management Groups and neighbouring local government areas. |
REC272-1414 | 12 - EM agency and authority | Queensland Fire and Emergency Services coordinate the development of an integrated risk based approach to disaster management planning for Queensland that is consistent with the Standard and applicable at all levels of the arrangements. |
Rec-ID | Code | Recommendation |
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REC271-1525 | 6 - Insurance and legal liability | The Department of Energy and Water Supply, in conjunction with SunWater, seek clarification of the dam owners’ legal obligation to comply with Emergency Action Plans and, if required, investigate how a more flexible approach may be adopted. |
Rec-ID | Code | Recommendation |
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REC270-1146 | 12 - EM agency and authority | Strengthens its oversight role as lead agency for mitigating Queensland's bushfire risk to acceptable levels by: · coordinating land managers' efforts to assess and mitigate bushfire risk · formalising the role of fire management groups to manage Queensland's fuel loads, including reporting planned and conducted hazard reduction burns and the effectiveness of hazard reduction burns · amending its bushfire mitigation planning to address prevention, preparedness, response and recovery and to manage Queensland's residual bushfire risk · developing and implementing a coordinated strategy to address arson, deterring would-be offenders and rehabilitating convicted offenders · working with local councils to develop and communicate local bushfire plans for communities located in high risk, bushfire-prone areas |
Rec-ID | Code | Recommendation |
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REC268-1424 | 25 - Inquiry, audit, lessons management and after action review | The Queensland Emergency Alert Guidelines is reviewed to reflect current practice and incorporate evidence-based improvements informed by lessons learned and research. |
REC268-1422 | 25 - Inquiry, audit, lessons management and after action review | The Queensland State Disaster Management Plan is reviewed to: |
Rec-ID | Code | Recommendation |
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REC252-2570 | 25 - Inquiry, audit, lessons management and after action review | Western Australia Health should carry out targeted clinical audits in volunteer country sub-centres until longer term solutions are in place |
REC252-2570 | 25 - Inquiry, audit, lessons management and after action review | Western Australia Health should carry out targeted clinical audits in volunteer country sub-centres until longer term solutions are in place |
REC252-2568 | 12 - EM agency and authority | Western Australia Health should develop criteria with St John Ambulance for the allocation of paramedics across the state |
REC252-2567 | 12 - EM agency and authority | Western Australia Health should re-engage with St John Ambulance at a senior level to address strategic and complex issues including long term solutions to ramping |
REC252-2573 | 12 - EM agency and authority | St John Ambulance should build on its regionalisation model and improve engagement with local services in the Kimberley and Pilbara regions |
REC252-2572 | 12 - EM agency and authority | St John Ambulance should explore opportunities for extending the community paramedic model to other areas of identified need |
Rec-ID | Code | Recommendation |
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REC246-0788 | 25 - Inquiry, audit, lessons management and after action review | TFS seek to address the following outstanding items from the recommendations of the Victorian Bushfires Royal Commission. § 45 out of 53 Community Bushfire Response Plans for “at risk” communities have been finalized. The remaining eight should be completed as a priority action. § That TFS progress the development of Community Bushfire Mitigation Plans for the 53 at risk communities, possibly as an action for reactivated Fire Management Area Committees. § TFS, together with other ESOs and local government, should develop a common comprehensive approach to the option of planned evacuation from dangerous or potentially dangerous areas to safer areas and eventual return. § TFS should include factors for consideration for evacuation during a bushfire into their training doctrine for Incident Controllers. § The IAP Template and its application be reinforced as an important operational requirement for IMT’s during the 2013-14 pre-season briefing program. 10 § That TFS review their use of IRMS to ascertain if either its full potential is not being realized through a lack of operator training or it is in fact not providing the required functionality and there is a need to research an improved resource management system which enhances interoperability. § The TFS Publication: Guidelines for Development in Bushfire Prone Areas of Tasmania http://www.fire.tas.gov.au/userfiles/stuartp/file/Publications/BushDeve… s2012.pdf requires an update to reflect the provisions of Planning Directive #5 Bushfire-Prone Areas Code. |
REC246-0783 | 12 - EM agency and authority | TFS review the restriction on interstate personnel filling positions such as Incident Controller and obtain definitive advice on the legal reasons for this. If immunity legislation is unclear then legislative change could be sought to ensure that the immunities enjoyed by Tasmanian incident controllers apply equally to personnel from interstate performing incident controller roles. |
REC246-0782 | 12 - EM agency and authority | That TFS develop a strategy to manage the workloads on career staff to reduce the risk of single point failures through spreading workloads and capability to ensure a level of redundancy and resilience in a number of critical portfolios. This should include deploying volunteer and retained personnel to maximise both its operational and support capacity during major and/or protracted fires and incidents, both in operational centres and in the field in command roles. Other sources of expertise should also be identified in advance of incidents occurring and called upon if necessary. |
REC246-0781 | 12 - EM agency and authority | TFS continue to develop and publish RFOC policy and procedures, ensuring that all partners who perform roles within the RFOC are included in the consultation and training. |
REC246-0789 | 6 - Insurance and legal liability | TFS seek legal opinion on the Bushfire CRC Research Report on legal liability implications of the Prepare, Stay and Defend or Leave Early policy to confirm the advice, consider the implications and implement those that are appropriate. |
Rec-ID | Code | Recommendation |
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REC245-2590 | 12 - EM agency and authority | That: |
Rec-ID | Code | Recommendation |
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REC210-0699 | 6 - Insurance and legal liability | When a policy-holder makes a claim, the insurer should ascertain the policy-holder’s preferred method of contact and ensure that it is used (with other modes of communication if necessary) to keep the policyholder informed about the progress of the claim. However, important decisions regarding the claim – for example, determinations about the outcome of the claim and settlement sums – should always be confirmed in writing. |
REC210-0730 | 12 - EM agency and authority | Emergency Management Queensland, in consultation with councils, should develop clear directives about: • the communication and reporting that should take place between the SES and disaster managers, including in relation to task allocation and completion, once disaster management groups have been activated • the communication and reporting that should take place between the SES and disaster managers, including in relation to task allocation and completion, once disaster management groups have been activated • the process for dealing with requests for assistance that exceed an SES unit’s capacity to respond them • the process for seeking extra support for an SES unit that has been overwhelmed by a disaster (whether by way of Emergency Management Queensland or the disaster management arrangements or both) • the role of SES liaison officers in communications with disaster managers about SES disaster operations • the role of incident controllers, and their teams, relative to those SES (or Emergency Management Queensland) personnel charged with the command of SES operations. |
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. |
REC210-0702 | 6 - Insurance and legal liability | The Insurance Council of Australia should consider an amendment to Part 3 of the code which requires insurers to notify policy-holders of the information on which they relied in assessing claims. |
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. |
REC210-0686 | 6 - Insurance and legal liability | SunWater and the Central Highlands Regional Council should determine the issues of ownership and responsibility for maintenance of the LN1 drain system in Emerald. |
REC210-0729 | 12 - EM agency and authority | Emergency Management Queensland should ensure its staff, SES members and disaster managers are familiar with the directive when it is developed. |
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. |
REC210-0701 | 6 - Insurance and legal liability | Letters notifying policy-holders that their claims have been denied should, at a minimum, state the information upon which the insurer has relied in making the decision. These letters should also advise policy-holders that copies of the information will be made available upon request (in accordance with clause 3.4.3 of the General Insurance Code of Practice) and indicate how policy-holders can make a request. |
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. |
REC210-0728 | 12 - EM agency and authority | Emergency Management Queensland, in consultation with councils, should develop a directive that makes clear the authority of an officer of that agency to command a major SES operation. This could be expected to occur when a deployment of additional SES members is made to a region because the response needed is beyond the capacity of its local units. The directive should make clear the powers of the officer and his or her reporting responsibilities to disaster managers in these circumstances. Emergency Management Queensland must also ensure that any officer who assumes such a role has adequate training and skills in the conduct of disaster operations. |
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. |
REC210-0700 | 6 - Insurance and legal liability | Insurers should review their existing systems and processes and implement any improvements necessary to ensure that accurate and complete records of conversations with policy-holders are made. |
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. |
REC210-0726 | 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. |
REC210-0735 | 6 - Insurance and legal liability | The Crime and Misconduct Commission should investigate whether the conduct of Mr Tibaldi, Mr Ayre and Mr Malone relating to: • preparation of documents surrounding the January 2011 flood event, including the 17 January 2011 brief to the Minister, the 2 March 2011 flood event report, and statements provided to the Commission • oral testimony given to the Commission evidences offence/s against the Criminal Code, and/or official misconduct under the Crime and Misconduct Act 2001 committed by any, or all, of them. |
REC210-0747 | 6 - Insurance and legal liability | Seqwater should ensure a legal review of the Wivenhoe manual and the North Pine manual is completed before the manual is submitted for approval. |
REC210-0725 | 12 - EM agency and authority | The fire service should ensure that station officers are familiar with the procedure for contacting management when requesting the calling in of additional staff; and, in particular, that they have available to them the names and current telephone numbers of the officers to be contacted in the first instance, with alternative contact details in the event that those officers prove unavailable. |
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. |
REC210-0731 | 12 - EM agency and authority | Emergency Management Queensland should ensure its staff, SES members and disaster managers are familiar with the directives it develops in relation to these matters. |
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. |
REC210-0703 | 6 - Insurance and legal liability | The Insurance Council of Australia should amend clause 3.4.3 of the General Insurance Code of Practice so that it requires insurers to inform policy-holders of their right to request a review of an insurer’s decision to refuse to provide access to information on which it relied in assessing claims. |
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. |
Rec-ID | Code | Recommendation |
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REC170-0059 | 15 - Inter-service cooperation | SEMC and EM WA should: ensure all agencies use the same approach to managing incidents. |
REC170-0058 | 15 - Inter-service cooperation | SEMC and EM WA should: ensure that all agencies can access other agencies’ operations centres when needed and that the procedures to do so are documented |
REC170-0062 | 25 - Inquiry, audit, lessons management and after action review | Agencies should: annually assess their capability to respond to emergencies and take measures to address any shortfalls |
Rec-ID | Code | Recommendation |
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REC150-3113 | 12 - EM agency and authority | QFRS provide guidance and support to rural fire brigades in the development of their one year operational plan and three year management plan. |
REC150-3119 | 12 - EM agency and authority | QFRS implement a system to collate and analyse brigade funding information. |
REC150-3112 | 12 - EM agency and authority | Queensland Fire and Rescue Service (QFRS) implement a forward planning process specific to rural fire management as part of the QFRS strategic planning process, which involves regional and area offices and incorporates: |
REC150-3118 | 12 - EM agency and authority | QFRS review the financial accountability and audit requirements of the rural fire brigades to reflect their status as part of QFRS. |
REC150-3124 | 12 - EM agency and authority | QFRS establish a suitable process to reliably capture that information. |
REC150-3117 | 12 - EM agency and authority | QFRS ensure compliance with the brigade accountability requirements for funding received by rural fire brigades as specified in the Rural Fire Brigade Manual |
REC150-3123 | 12 - EM agency and authority | QFRS determine the performance information needed to support effective decision making . |
REC150-3116 | 12 - EM agency and authority | QFRS implement a brigade issues management process to capture, manage and report specific brigade issues. |
REC150-3121 | 12 - EM agency and authority | QFRS utilise performance information on brigade activity as a factor in determining brigade resource and funding needs. |
REC150-3114 | 12 - EM agency and authority | QFRS implement a process to review brigade plans and incorporate specific issues identified into forward planning at the area and regional levels. |
REC150-3120 | 12 - EM agency and authority | QFRS provide assistance to brigades in determining and budgeting for their resource needs. |
Rec-ID | Code | Recommendation |
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REC111-3939 | 25 - Inquiry, audit, lessons management and after action review | It is recommended that the State Disaster Management Group and the Department of Emergency Services review the current disaster district boundary framework and its relevance to the regional boundaries established by other public sector lead entities to ensure that resources within the Disaster Management System are economically, efficiently and effectively allocated across Queensland. |
Rec-ID | Code | Recommendation |
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REC019-4137 | 12 - EM agency and authority | Before the bush fire season starts, the Minister on the recommendation of the Board nominate a person and a deputy person who will be instructed to take charge of fire fighting operations in each district should a dangerous fire occur and render such an appointment advisable. |
REC019-4147 | 12 - EM agency and authority | All local authorities form advisory committees of persons from bush fire brigades and of bush fire control officers to plan co-operation in effort and co-ordination between brigades, to group brigades under brigade group officers and to advise the local authority upon all matters of fire control, including the planning of the district firebreak layout and prosecuting for breaches of the Bush Fires Act. |
REC019-4135 | 12 - EM agency and authority | The Bush Fires Board appoint a Standing Committee of about six of its members, all of whom are likely to be available at any time during the bush fire season to meet and take executive action as necessary. |
REC019-4146 | 6 - Insurance and legal liability | Insurance companies be asked to subsidise the bush fire equipment fund by an amount at least equal to the amount they at present remit on premiums received for fire insurance in approved districts and that the Government contribute an amount to the fund at least equal to that contributed by the Insurance Companies. |
REC019-4159 | 12 - EM agency and authority | The State Emergency Service be used to meet any additional needs but that as far as possible, requests for assistance be directed in the first instance to the Bush Fires Board or at least referred to that Board by the State Emergency Service for advice before action is taken. |
REC019-4134 | 12 - EM agency and authority | All members of the Board be selected for their interest in and experience and knowledge of matters directly associated with bush fire control and not merely as representatives of particular organisations, that the Chairman of the Board be appointed by the Governor instead of being an ex officio appointment of another forester, a member of the timber industry, a police officer and a person with a sound knowledge of weather and its effect upon fire behaviour. |
REC019-4141 | 12 - EM agency and authority | The relative seniority of bush fire control officers be determined with a view to appointing group leaders as chief bush fire control officers. The Shire Clerk should generally be a liaison bush fire control officer rather than a chief fire control officer. |
REC019-4155 | 12 - EM agency and authority | The management of all National Parks in the State be concentrated under one authority to ensure co-ordination in administration and protective measures. |
REC019-4140 | 12 - EM agency and authority | Local authorities select bush fire control officers for their knowledge and experience of bush fires and their qualities of leadership and that as far as practicable, they be captains of bush fire brigades so that the person issuing the permit to burn has the responsibility of extinguishing the fire if it escapes. |
REC019-4154 | 12 - EM agency and authority | A committee be formed and provided with the finance necessary to enable it to supplement the activities of the local bush fire brigades in districts in the far south-west of the State where ratable values are particularly low and the proportion of Crown lands high, and that the Forests Department be authorised to give approval for control burning of Crown lands throughout the State by bushfire brigades within two miles of a State Forest and that outside this distance the Bush Fires Board through its wardens have similar authority. |
REC019-4138 | 12 - EM agency and authority | That care be exercised in recommending the application of emergency bush fire periods so that they will not be applied to districts where their application is unnecessary. |
REC019-4150 | 12 - EM agency and authority | The Forests Department direct more staff to the planning and co-ordination of its bush fire control organisation so that emergency conditions can be met immediately by ample reserves of labour and equipment and that co-ordination between the Department, the local authority, sawmills and other sources of man-power and equipment in and around forestry districts is as complete as possible. This particularly includes co-operative protective burning around the boundaries of forest areas. |