Inquiry Search
Rec-ID | Code | Recommendation |
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REC258-2551 | 25 - Inquiry, audit, lessons management and after action review | The Civil Aviation Safety Authority assures consistency of audits across all regions, and delivers audit reports within an agreed timeframe. |
REC258-2528 | 25 - Inquiry, audit, lessons management and after action review | The Australian Transport Safety Bureau investigates as many fatal accidents in the sport and recreational aviation sector as its resources will allow. |
REC258-2558 | 12 - EM agency and authority | The Civil Aviation Safety Authority applies a project management approach to the completion of all Civil Aviation Safety Regulation Parts not yet in force, with drafting to be completed within one year and consultation completed one year later, with: |
REC258-2545 | 12 - EM agency and authority | The Australian Transport Safety Bureau transfers its safety education function to the Civil Aviation Safety Authority. |
REC258-2550 | 6 - Insurance and legal liability | The Civil Aviation Safety Authority introduces grading of Non-Compliance Notices on a scale of seriousness. |
REC258-2557 | 6 - Insurance and legal liability | The Civil Aviation Safety Authority reassesses the penalties in the Civil Aviation Safety Regulations. |
REC258-2544 | 6 - Insurance and legal liability | The Australian Transport Safety Bureau transfers information from Mandatory Occurrence Reports to the Civil Aviation Safety Authority, without redaction or de-identification. |
REC258-2549 | 25 - Inquiry, audit, lessons management and after action review | The Civil Aviation Safety Authority provides full disclosure of audit findings at audit exit briefings in accordance with international best practice. |
REC258-2556 | 25 - Inquiry, audit, lessons management and after action review | The Civil Aviation Safety Authority structures all regulations not yet made with the three-tier approach, and subsequently reviews all other Civil Aviation Safety Regulation Parts (in consultation with industry) to determine if they should be remade using the three-tier structure. |
REC258-2543 | 6 - Insurance and legal liability | The Civil Aviation Safety Authority reintroduces a ‘use of discretion’ procedure that gives operators or individuals the opportunity to discuss and, if necessary, remedy a perceived breach prior to CASA taking any formal action. This procedure is to be followed in all cases, except where CASA identifies a Serious and Imminent Risk to Air Safety. |
REC258-2548 | 17 - Assets and technology | The Civil Aviation Safety Authority shares the risk assessment outputs of Sky Sentinel, its computerised risk assessment system, with the applicable authorisation holder. |
REC258-2553 | 12 - EM agency and authority | The Civil Aviation Safety Authority establishes a safety oversight risk management hierarchy based on a categorisation of operations. Rule making and surveillance priorities should be proportionate to the safety risk. |
REC258-2540 | 6 - Insurance and legal liability | The Civil Aviation Safety Authority continues to provide appropriate indemnity to all industry personnel with delegations of authority. |
REC258-2547 | 12 - EM agency and authority | The Civil Aviation Safety Authority establishes small offices at specific industry centres to improve monitoring, service quality, communications and collaborative relationships. |
REC258-2552 | 25 - Inquiry, audit, lessons management and after action review | The Civil Aviation Safety Authority implements a system of using third-party commercial audits as a supplementary tool to its surveillance system. |
REC258-2532 | 12 - EM agency and authority | The next Director of Aviation Safety has leadership and management experience and capabilities in cultural change of large organisations. Aviation or other safety industry experience is highly desirable. |
REC258-2546 | 12 - EM agency and authority | The Civil Aviation Safety Authority changes its organisational structure to a client-oriented output model. |
Rec-ID | Code | Recommendation |
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REC257-1539 | 25 - Inquiry, audit, lessons management and after action review | Defence Security Authority conduct an investigation into the whereabouts of items of anaccounted explosive ordnance issued to Defence Explosive Ordnance Training School Exercise Marrangaroo. |
REC257-1548 | 25 - Inquiry, audit, lessons management and after action review | The Regional Director-Defence Support-Northern NSW, make contact with Deputy Commissioner ~~~~~ Director of Operational Services Rural Fire Service, to arrange a headquarters driven bipartite review of the events of 16 October 2013 with a review to mitigation of future fire events generally, and with specific reference to: |
REC257-1546 | 25 - Inquiry, audit, lessons management and after action review | Defence undertake a review of its ability to respond to a fire within Marrangaroo Training Area, whether bushfire or structural. The underlying assumption should be that the only response available to fight a fire within Marrangaroo Training Area will be provided by Defence. Further, such response must occur while a fire is in its initial stages. A review must either acknowledge the risk of fire occurring in th future, or upgrade Defence's firefighting capability at Marrangaroo Training Area. |
REC257-1544 | 17 - Assets and technology | Defence should not procure any firefighting vehicle for Marrangaroo Training Area without first consulting relevant personnel within the Rural Fire Service on an appropriate type of vehicle, and obtaining training for the personnel proposed to use it. Alternatively, Defence should explore contracted firefighitng support during periods of live-fire on Marrangaroo Training Area. |
REC257-1542 | 17 - Assets and technology | Firefighitng capability at Marrangaroo Training Area be upgraded so that Australian Defence Force members are not placed in situations of unacceptable risk. Specifically, those participating in range practices must have access to a firefighting vehicle close by and easily deployed, and capable of throwing a large quantity of water an appreciable distance into areas adjacent to the ranges, should a fire occur. |
REC257-1541 | 17 - Assets and technology | A Stryker unit, or an upgraded firefighting unit, be present at the range sentry point, remain manned and ready to deploy during range activites, with its driver in direct radio contact with the Range Safety Officer. Upon the range being declared clear by the Safety Officer inspecting the range after a demolition serial, the firefighting unit must proceed forward to the range wile the periphery of the range continues to be inspected by the Safety Officer, and remain on the range until the Safety officer declares that the area is clear of fire or that it is otherwise appropriate for the fireghting unit to leave the range area. |
Rec-ID | Code | Recommendation |
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REC256-1573 | 25 - Inquiry, audit, lessons management and after action review | The Australian Government should schedule an independent and public review of the progress of reforms to natural disaster funding arrangements five years after implementation has commenced. This review should examine the operation and efficacy of the arrangements, including the: |
REC256-1572 | 6 - Insurance and legal liability | Insurers should provide additional standardised information to households regarding their insurance policies, the natural hazards they face and indicative costs of rebuilding after a natural disaster. This work should be led by the Insurance Council of Australia developing guidelines, within one year, to ensure consistency in the provision and presentation of this information across insurers. |
REC256-1570 | 1 - Land-use and building regs | All governments should put in place best-practice institutional and governance arrangements for the provision of public infrastructure, including road infrastructure. These should include: |
REC256-1564 | 6 - Insurance and legal liability | State and territory governments, local governments and insurers should explore opportunities for collaboration and partnerships. Partnerships, for example, could be formed through the Insurance Council of Australia and state-based local government associations (or regional organisations of councils). Consideration could be given to the Trusted Information Sharing Network model. Partnerships could involve: |
Rec-ID | Code | Recommendation |
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REC207-2882 | 39 - Disaster Risk Management | Review disaster recovery and business continuity plans. |
REC207-2881 | 17 - Assets and technology | Extend ICT governance arrangements to all applications and subject in-house development to rigorous approval processes. |
Rec-ID | Code | Recommendation |
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REC205-1900 | 1 - Land-use and building regs | As a priority, state and territory governments should ensure that land-use planning systems are sufficiently flexible to enable a risk management approach to incorporating climate change risks into planning decisions at the state, territory, regional and local government levels. Consideration should be given to: |
REC205-1906 | 6 - Insurance and legal liability | Governments should not subsidise household or business property insurance, whether directly or by underwriting risks. |
REC205-1905 | 6 - Insurance and legal liability | The Australian Government should only proceed with reforms that require all household insurers to offer flood cover if it can be demonstrated that the benefits to the wider community would exceed the costs. |
REC205-1903 | 25 - Inquiry, audit, lessons management and after action review | The Australian Government should commission an independent public review of disaster prevention and recovery arrangements. This should be broader than the review currently being conducted by the Attorney-General’s Department. The review should cover the Natural Disaster Relief and Recovery Arrangements, as well as the funding mechanisms for disaster mitigation, including the National Partnership Agreement on Natural Disaster Resilience. This review should: |
REC205-1902 | 25 - Inquiry, audit, lessons management and after action review | The Council of Australian Governments should commission an independent public inquiry to develop an appropriate response to managing the risks of climate change to existing settlements. The inquiry should: |
REC205-1901 | 1 - Land-use and building regs | The Council of Australian Governments’ Building Ministers’ Forum should provide formal direction to the Australian Building Codes Board to: |
Rec-ID | Code | Recommendation |
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REC177-3310 | 6 - Insurance and legal liability | Consideration should be given to ways to ensure that contractors who are involved in barrier installation (such as cementing companies) have a direct interest in the performance of works to a proper standard. In particular, consideration should be given to (i) preventing contractors from avoiding the economic consequences of negligent installation of barriers; and/or (ii) imposing specific legislative standards of workmanship on contractors with respect to well control (similar to those which presently apply to licensees). |
REC177-3337 | 12 - EM agency and authority | Supervision/oversight of well control operations (within licensees, rig operators and by regulators) must occur without assuming adherence to good oilfield practice. The opposite assumption should prevail: namely adherence to good oilfield practice may well be compromised by the pursuit of time and cost savings. |
REC177-3369 | 6 - Insurance and legal liability | The obligation of companies involved in an incident to meet the full costs of monitoring and remediation should be made a condition of approval of proposals under the EPBC Act and OPGGS Act. Suitable arrangements (insurance or otherwise) need to be in place to ensure that companies have this capacity. |
REC177-3291 | 39 - Disaster Risk Management | Removal of a barrier must be the subject of consultation between licensees and rig operators prior to removal. A proper risk assessment should be carried out and agreed upon, and documented in writing before removal. Joint written certification as to the appropriateness of removal should take place before removal. Senior onshore representatives of stakeholder entities should be involved in that certification process. |
REC177-3336 | 12 - EM agency and authority | Achievement and maintenance of well control should be written into the job responsibilities of key personnel, at every level up to and including CEOs. That is, a functional line of accountability for well control must exist up to, and including, CEOs. |
REC177-3365 | 6 - Insurance and legal liability | The National Plan should specify that the cost of responding to an oil spill, or other damage to the offshore marine environment, will be totally met by the owner/operator. This would be consistent with the Inquiry’s recommendation for legislative changes to the regulatory framework concerning owner/operators meeting the cost of monitoring and remediation of environmental damage. |
REC177-3289 | 39 - Disaster Risk Management | The use/type of barriers (including any change requests relating thereto) must be the subject of consultation between licensees and rig operators prior to installation. A proper risk assessment should be carried out, agreed upon, and documented in writing before installation. Joint written certification as to the appropriateness of the use of particular barriers should take place before installation. Senior onshore representatives of stakeholder entities should be involved in that certification process. |
REC177-3336 | 12 - EM agency and authority | Achievement and maintenance of well control should be written into the job responsibilities of key personnel, at every level up to and including CEOs. That is, a functional line of accountability for well control must exist up to, and including, CEOs. |
REC177-3356 | 39 - Disaster Risk Management | The regulator should pre‐assess and review in a generic sense, and in conjunction with the offshore petroleum industry, available options for well control in the event of a blowout. Being ‘match fit’ in this sense will enable a quicker and more effective response in terms of safety assessment, and will ensure that expectations of both operator and regulator are more readily aligned. |
REC177-3286 | 39 - Disaster Risk Management | Problems which arise in the course of installing barriers must be the subject of consultation between licensees, rig operators, and contractors (if used). A proper risk assessment should then be carried out and remedial steps (including further testing/verification) should be agreed upon, and documented in writing before the performance of remedial work whenever practicable. Joint written certification as to resolution of the problem should take place before resumption of drilling operations. Senior onshore representatives of stakeholder entities should be involved in that certification process. |
REC144-3387 | 25 - Inquiry, audit, lessons management and after action review | In order that the ACT public can be reassured about the project management and financial planning in relation to the Fairbairn site as a proposed centralised accommodation facility for emergency services, the Auditor-General undertake a review of the project from a financial probity and project management perspective. |
REC177-3330 | 39 - Disaster Risk Management | Decision‐making about well control issues should be professionalised. Industry participants must recognise that decision‐makers owe independent duties to the public, not just their employer or principal, in relation to well control. Risk management in the context of well control needs to be understood as an ethical/professional duty. Self‐regulation contemplates self‐regulation by the industry, not just by individual licensees and operators. |
REC177-3344 | 25 - Inquiry, audit, lessons management and after action review | There should be a review to determine whether it is appropriate to introduce a rigorous civil penalty regime and/or substantially increase some or all of the penalties that can be imposed for breaches of legislative requirements relating to well integrity and safety. |
REC177-3285 | 39 - Disaster Risk Management | Pre‐drilling assessments should include a risk assessment of the worst‐case blowout scenario. |
REC177-3378 | 25 - Inquiry, audit, lessons management and after action review | In view of the numerous well integrity problems in all of the Montara Oilfield wells, the Minister should commission a detailed audit of all the other offshore wells operated by PTTEPAA to determine whether they too may suffer from well integrity problems. |
REC177-3329 | 17 - Assets and technology | Logistics management of well control equipment should be conducted in such a way as to operate as a check against deficient well control practices, for example, use of serial numbers to track availability, testing, and deployment of well control equipment. |
REC177-3338 | 12 - EM agency and authority | Licensees and rig operators should be astute in ensuring that corporate systems and culture encourage rather than discourage raising of well control issues. For instance, do performance bonuses or rewards actually encourage or discourage reporting of issues? Is there a system in place to enable anonymous reporting of well control concerns? What whistleblower protections are in place? |
REC177-3374 | 25 - Inquiry, audit, lessons management and after action review | The Minister should, as the JA for the offshore area of the Territory of Ashmore and Cartier Islands, undertake a review of PTTEPAA’s permit and licence to operate at the Montara Oilfield. |
Rec-ID | Code | Recommendation |
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REC161-3034 | 12 - EM agency and authority | That National Offshore Petroleum Safety Authority critically review its regulatory manning levels based on its current workload and the recommendations for additional areas of focus and increased auditing presented in this Report. To meet these requirements, we estimate that National Offshore Petroleum Safety Authority requires up to 50 inspectors in total plus associated support staff to bring overall staffing from about 55 to 75. RET should help facilitate the necessary ongoing levy funding in consultation with industry. |
REC161-3030 | 25 - Inquiry, audit, lessons management and after action review | That National Offshore Petroleum Safety Authority review the risk assessment of pipelines. National Offshore Petroleum Safety Authority should focus, in particular, on the efficacy of anti-corrosion systems, and recognise potential interference effects and MAE escalation risks associated with adjacent pipelines and unlicenced pipes even if they fall outside its direct regulatory responsibilities. |
Rec-ID | Code | Recommendation |
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REC149-3139 | 39 - Disaster Risk Management | The industry should develop in conjunction with the Regulator a process for addressing the need to maintain the risk profile of a facility moving into extended life operation at the same risk profile as when it was within design life. |
REC149-3145 | 25 - Inquiry, audit, lessons management and after action review | NOPSA should consider an audit regime that targets Greenfields operations at commencement of operations. |
Rec-ID | Code | Recommendation |
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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 |
REC126-2002 | 1 - Land-use and building regs | That consideration be given when building to the positioning of outbuildings around residential structures such that their potential impact on the main structure is reduced |
REC126-1963 | 12 - EM agency and authority | That priority be given to ensuring that the ACT has an adequate resource of remote area firefighting teams consisting of personnel with high levels of fitness and training in remote fire suppression |
REC126-1975 | 5 - Hazard reduction burns | That prescribed burning operations be conducted according to agreed standard burning prescriptions |
REC126-2000 | 1 - Land-use and building regs | That the ACT Government consider taking measures to implement the provisions of Australian Standard 3959, Construction of Buildings in Bushfire Prone Areas, for the ACT urban area |
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 |
REC126-2011 | 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 |
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 |
REC126-1995 | 12 - EM agency and authority | That the Emergency Services Agency staff the Media Unit within its planning Section with profesisonal, experienced information officers skilled in dissemination of information and media management and liaison |
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 |
REC126-2010 | 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 |
REC126-1973 | 5 - Hazard reduction burns | If it is not part of the proposed version 2 of the Strategic Bushfire Management Plan, that the plan be revised to provide for a fuel-reduction burning regime in the ‘Land Management Zone’ that is equivalent to that contemplated for the corridors designated as the ‘Landscape Division Zone’ and that the regime involve burning areas in rotation to achieve an appropriately varying fire age spectrum across the entire landscape |
REC126-1988 | 39 - Disaster Risk Management | That protocols and arrangements between the ACT and NSW require that each jurisdiction be fully involved in examining and planning for the threat posed by any fire likely to affect one or other jurisdiction and in coordinating the response to that fire |
REC126-1950 | 39 - Disaster Risk Management | That the Emergency Services Agency adopt a more rigorous risk management approach to incident management and prediction – with particular emphasis on the development of improved community information strategies and protocols |
REC126-2008 | 34 - Local knowledge | That, if he is willing to participate, Mr John Lowe be made a member of the implementation taskforce to which I refer in recommendation 70 |
REC126-1972 | 5 - Hazard reduction burns | That clarification be provided and information be made public in connection with the hazard reduction proposed under the Strategic Bushfire Management Plan for the area designated ‘Land Management Zone’, which appears to cover about 70 per cent of the ACT landscape and might be excluded from fuel-reduction burning |
REC126-1986 | 39 - Disaster Risk Management | That the ACT and NSW authorities conduct a comprehensive risk analysis based on the most up to date knowledge relating to fire behaviour and spread in order to establish the degree of risk to each others' jurisdiction from fires ignitting in the other jurisdiction and to ensure that both jurisdictions remain fully informed and participate in risk assessments, the development of suppression strategies, and the development and dissemination of community information messages or warnings |
REC126-1949 | 12 - EM agency and authority | That the Emergency Services Agency be relocated into accommodation that is purpose-built and more sited to the agency’s operations than the current facility at Curtin |
REC126-2007 | 34 - Local knowledge | That the views and concerns expressed by the ACT Sustainable Rural Lands Group be taken into account when implementing the recommendations in this report |
REC126-1971 | 5 - Hazard reduction burns | That a hazard-reduction program be introduced, involving regular and strategic burning in all areas of the ACT – including the catchment areas – with a view to having fuel-reduced areas in a pattern across the landscape, excluding only small areas of particular ecological or conservation importance |
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 |