Inquiry Search
Rec-ID | Code | Recommendation |
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REC326-4340 | 24 - Govt responsibility | To promote integrity and transparency, the Department of Regional NSW should ensure that for all future grant programs it: documents all key decisions and approvals in line with record keeping obligations. |
REC326-4341 | 24 - Govt responsibility | To promote integrity and transparency, the Department of Regional NSW should ensure that for all future grant programs it: ensures regular monitoring is in place as part of funding deeds. |
REC326-4342 | 24 - Govt responsibility | To promote integrity and transparency, the Department of Regional NSW should ensure that for all future grant programs it: ensures staff declare conflicts of interest prior to the commencement of a grants stream, and that these conflicts of interest are recorded and managed. |
REC326-4343 | 24 - Govt responsibility | To promote integrity and transparency, the Department of Regional NSW should ensure that for all future grant programs it: ensures a communications plan is in place, including the communication of guidelines to potential applicants. |
REC326-4344 | 24 - Govt responsibility | To promote integrity and transparency, the Department of Regional NSW should ensure that for all future grant programs it: establishes and follows guidelines that align with relevant good practice guidance including accountabilities, key assessment steps and clear assessment criteria. |
Rec-ID | Code | Recommendation |
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REC316-4033 | 25 - Inquiry, audit, lessons management and after action review | The BFC Terms of Reference be reviewed to ensure they are contemporary and reflect learnings from this and recent bushfire seasons. |
REC316-4018 | 25 - Inquiry, audit, lessons management and after action review | The five year review of the Emergencies Act examine amendments to better define the rationale for a State of Alert / State of Emergency whilst ensuring that the relevant Minister / Chief Minister still has sufficient discretion to make a declaration based on advice from relevant Government officials and committees. |
REC316-4014 | 25 - Inquiry, audit, lessons management and after action review | That Justice and Community Safety Directorate (JACS) lead a working group from across relevant organisations to undertake the five year review of the Emergencies Act in conjunction with a wholistic review of the Emergency Plan and relevant sub-plans; and recommendations from this review, to the extent they are accepted by Government. Bringing together a small Taskforce of staff from across government for a set period would assist the working group in delivering the work needed to address these and other recommendations. |
REC316-4042 | 25 - Inquiry, audit, lessons management and after action review | ACT Government undertake a detailed legislative review to ensure that information regarding vulnerable community members can be appropriately accessed, provided and used during an emergency event. |
REC316-4038 | 25 - Inquiry, audit, lessons management and after action review | The CCIP be reviewed in conjunction with the review of the Emergency Plan and the two synchronised. A workable approach to delivering operational emergency communications and strategic WhoG communications is developed with simple and clear reporting arrangements. |
Rec-ID | Code | Recommendation |
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REC315-3859 | 25 - Inquiry, audit, lessons management and after action review | That, in order to ensure State Emergency Operations Centre (SEOC) interoperability during all natural disasters, Resilience NSW review the current SEOC arrangements and location including responsibilities for ongoing resourcing and maintenance. |
REC315-3842 | 24 - Govt responsibility | That, in order to prioritise early suppression and keep fires small: |
REC315-3856 | 10 - Infrastructure | That, in order to improve response times to Triple Zero calls, the NSW RFS implements the integrated dispatch system before the 2020-21 fire season commences. |
REC315-3858 | 25 - Inquiry, audit, lessons management and after action review | That, in order to improve cross-agency communication and coordination during bush fires, the NSW RFS review Fire Control Centres (FCCs) in areas that were heavily affected by fire. The results should be combined with the Emergency Operations Centre (EOC) Facilities Review to identify areas that would benefit from a purpose-built FCC, enabling co-location with the EOC. |
REC315-3810 | 24 - Govt responsibility | That, to ensure updated resource-sharing arrangements are in place, the NSW and Victorian Governments progress and finalise a multi-agency Memorandum of Understanding before the 2020-21 fire season commences. |
REC315-3851 | 10 - Infrastructure | That, to ensure mobile generators are sourced and distributed on a priority basis during natural disasters, the EUSFAC work with the NSW Telco Authority, relevant NSW government agencies and commercial stakeholders to develop a mobile asset deployment strategy. The strategy should reduce duplication in purchasing, maintaining and housing mobile generators and improve agility in deployment. |
REC315-3812 | 25 - Inquiry, audit, lessons management and after action review | That Government commit to: |
REC315-3840 | 29 - Operational Health and Safety | That, in order to ensure firefighter sustenance is of sufficient volume and quality, the NSW RFS reviews food standards and procedures in consultation with volunteers. The review should include catering service standards, including food safety, as well as the viability of sourcing commercial contracts and providing 12-hour food packs to firefighters. |
REC315-3827 | 10 - Infrastructure | That, in order to minimise communication outages and extend basic communication coverage during bush fires, the NSW Government work directly, or together with other Australian governments and/or their relevant power and telecommunications regulatory, policy and market bodies, to: |
REC315-3798 | 25 - Inquiry, audit, lessons management and after action review | That, in order to ensure recommendations accepted by the Government are implemented in a timely and transparent manner, Government establish a central accountability mechanism to track implementation of recommendations from bush fire-related reviews and inquiries and consider expanding this to other policy areas. |
REC315-3873 | 25 - Inquiry, audit, lessons management and after action review | That Resilience NSW review existing functional area arrangements to ensure they are closely aligned to agencies responsible for direct service delivery. |
REC315-3839 | 29 - Operational Health and Safety | That, to ensure firefighters can access mental health support through GPs, Government work with the Commonwealth Government to: |
REC315-3826 | 10 - Infrastructure | That, in order to maximise the protection of critical infrastructure in a bush fire, Australian governments revise the regulatory framework for the provision to government authorities of information about all critical infrastructure (public and private) including a possible change to compel the owners of critical assets to provide all needed metadata, updated annually, for appropriate planning, preparation and response for bush fire. This would include information about location, ownership, access, details of service the infrastructure supports, and fire treatments of building and surrounding zones. |
REC315-3860 | 25 - Inquiry, audit, lessons management and after action review | That, in order to ensure the guiding principles and approval processes are contemporary, streamlined and more flexible, the NSW and Commonwealth Governments review the Defence Assistance to the Civil Community (DACC) arrangements. This review should include the circumstances in which the State can request Commonwealth assistance, and the level of information provided by the ADF to the State on available resources and capabilities. |
REC315-3838 | 29 - Operational Health and Safety | That, in order to ensure all NSW RFS members can access the mental health support they need, the NSW RFS expands in-house mental health support for members. |
Rec-ID | Code | Recommendation |
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REC314-3262 | 10 - Infrastructure | Invest in upgrading and integrating ICT platforms to eliminate manual data transfers, and ensure IT and radio communication interoperability across the agencies, together with a dedicated focus on the development of a coordinated risk intelligence capability to provide all stakeholders with a common operating picture and rapid damage assessments. |
REC314-3272 | 10 - Infrastructure | Clarify business continuity and restoration of critical infrastructure in the planning and response phases to facilitate water replenishment, fireground remediation and access to businesses (including farming properties). |
REC314-3261 | 24 - Govt responsibility | Consider amending the Fire and Emergency Services Act 2005 to align SAFECOM Board operations with accepted governance standards with the Minister appointing an Independent Chair of the SAFECOM Board. The SAFECOM Chief Executive (CE) should report to the Board and maintain SAFECOM’s role at the direction of the Board. Alternatively, SAFECOM could be abolished, moving to a model of a Department of Fire and Emergency Services where the departmental head reports to the Minister but the value proposition of any such machinery of government change would need to be thoroughly examined. |
Rec-ID | Code | Recommendation |
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REC302-2399 | 24 - Govt responsibility | Implement a fully integrated civilianised single call and dispatch centre, that includes a redundancy option outside the Sydney CBD, which will adopt an agnostic approach to deploy the quickest most suitable resource to an emergency. Such a centre should be managed by either a non uniformed public servant staffed organisation like the Office for Emergency Management, or the NSW Police Force |
Rec-ID | Code | Recommendation |
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REC301-2385 | 25 - Inquiry, audit, lessons management and after action review | TFS should initiate a policy review (seeking support from government as appropriate) to clearly identify what body or agency is responsible for planning, carrying out and enforcing fuel management on private property at a township level. If current arrangements are unclear or ineffective, TFS should request government to consider making this a statutory responsibility of TFS and provide any additional funding required to support this function. |
Rec-ID | Code | Recommendation |
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REC297-1273 | 25 - Inquiry, audit, lessons management and after action review | That the State Emergency Management Committee allocates resources to reviewing all findings and recommendations in the Productivity Commission Report No. 74 relevant to Tasmania and, for those identified as relevant, actions taken and, if none, why not. |
REC297-1264 | 25 - Inquiry, audit, lessons management and after action review | That the Flood Warning Consultative Committee reviews flood classification levels in the Service Level Specifications with BoM specifically relating to flood level triggers on gauges. |
REC297-1270 | 24 - Govt responsibility | That, in the event of a major emergency such as the June floods, a government department (DPAC or State Growth) be appointed to coordinate infrastructure repair, to the extent that funding allows, for the whole state. Individual entities will still have the right and responsibility to repair and maintain their own assets, but some central oversight and coordination is, in our view, likely to be beneficial. |
REC297-1259 | 25 - Inquiry, audit, lessons management and after action review | That DPIPWE examines the Forest Practice Code 2015 for relevance of its concepts to farming and other business activities near rivers, streams and naturally occurring dams and makes recommendations to Government accordingly. |
REC297-1268 | 24 - Govt responsibility | That DPAC becomes the Management Authority for recovery in Tasmania. |
REC297-1258 | 25 - Inquiry, audit, lessons management and after action review | That DPIPWE examines the WMAwater report along with its own, analyses the differences, consults with the Forest Practices Authority and Environment Protection Authority, and proposes an appropriate course of action to Government. |
REC297-1255 | 24 - Govt responsibility | That Government establishes a central flood policy unit responsible for coordinating flood policy across all government agencies, including Government Businesses, and ensures that such a unit has a whole-of-government and community focus. |
Rec-ID | Code | Recommendation |
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REC296-1357 | 10 - Infrastructure | Monthly test results need to be accurately recorded. |
REC296-1362 | 10 - Infrastructure | Carry out a detailed audit of the current Hospital essential loads to determine the current load requirements of the Hospital. |
REC296-1351 | 10 - Infrastructure | From the above assessment determine the existing generator load requirements and provide a new generator to meet those loads. |
REC296-1356 | 10 - Infrastructure | Accurate records need to be provided as to what is done for each service. |
REC296-1361 | 10 - Infrastructure | Prepare and carry out a testing regime and testing strategy and ensure testing of the generator is done every month for 4 hours over that month and under full Hospital load with test result recorded every 15 minutes. |
REC296-1350 | 10 - Infrastructure | Remove any loads that do not need to be on essential power. |
REC296-1355 | 10 - Infrastructure | Replacement of all original pipes and hoses not yet done. |
REC296-1360 | 10 - Infrastructure | Carry out regular load bank testing on the generator with a load bank large enough to fully load the generator to 110% which will clean out the engine and also identify whether the generator is capable of providing full load for a sustained length of time. |
REC296-1349 | 10 - Infrastructure | Conduct an assessment of the current essential loads and determine if there are loads that should not be on essential power. |
REC296-1354 | 10 - Infrastructure | Monthly and annual maintenance servicing needs to be scheduled for the generator to DPTI or CHSA schedule requirements. |
REC296-1359 | 10 - Infrastructure | Renegotiate the maintenance contract at the end of the current contract and have DPTI through AGFMA take on the maintenance contract. |
REC296-1353 | 10 - Infrastructure | Regular annual testing at 100% on a load bank needs to be scheduled into a maintenance schedule. |
REC296-1358 | 10 - Infrastructure | If the existing generator is capable of providing the current essential power requirements then the generator needs a major inspection and overhaul all items that may need to be replaced due to age and condition. This includes checking compression, oil pressure, coolant pumping and all other critical components and may actually require providing a temporary generator while the Hospital generator receives a major inspection and possible re build. A ball park figure to do this would be $50,000.00 plus cranage and transport to Detroit workshop probably another $10,000.00 then a temporary generator would need to be hired and installed which could run into $10’s of thousands of dollars depending on how long the engine was out of service. For the money that would be spent checking and rebuilding the existing engine it would be recommended to replace the generator with a new generator. |
REC296-1363 | 10 - Infrastructure | Due to the age of the generator, reliability and reparability risk due to age and the apparent under capacity of the generator it is recommend to replace the generator with a new generator and associated control system designed for the current load requirements and allowance for some future expansion. |
REC296-1352 | 10 - Infrastructure | A monthly testing regime needs to be developed that will allow the generator to be tested at full essential load capacity and to ensure that 4 hour monthly testing can be done every month. |
Rec-ID | Code | Recommendation |
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REC295-1288 | 24 - Govt responsibility | That Attorney General’s Department explore options to overcome fatigue and welfare issues of SAGRN staff associated with emergency events of extended duration. |
REC295-1327 | 25 - Inquiry, audit, lessons management and after action review | Establish a lessons management capability across the SA emergency management sector to collect, analyse and track lessons identified during debriefs and reviews following events and other sources such as interstate and oversees reviews and inquiries. |
REC295-1318 | 24 - Govt responsibility | That the recommendation made following the Pinery bushfire, ‘to review control facilities at State, region and incident level’, be expanded to include all emergency services facilities that will be utilised for major incidents other than bushfire e.g. flood and earthquake and to also be extended into metropolitan areas, and implemented. |
REC295-1317 | 25 - Inquiry, audit, lessons management and after action review | Review representation in the State Emergency Centre including: a) determining if there is a more suitable functional support group e.g. the Procurement Functional Support Group, to replace the Logistics Functional Support Group, and if so, Chief Procurement Officer, DPC, has responsibility for the management of this role within the State Emergency Centre. b) That when the State Crisis Centre is not operating from a physical location, a State Crisis Centre liaison officer is attached to the State Emergency Centre. |
REC295-1316 | 24 - Govt responsibility | That the position of Deputy Director, Office for Digital Government is dedicated to the Office for Digital Government; and that people throughout DPC are identified and trained to perform appropriate roles within the State Crisis Centre |
REC295-1315 | 25 - Inquiry, audit, lessons management and after action review | That a review of the role and effectiveness of the State Emergency Management Committee (SEMC) including: the legislative functions; membership including the chair; roles and responsibilities; and, SEMC Advisory Groups be undertaken. |
REC295-1312 | 24 - Govt responsibility | That the Department of Education and Child Development be included as a member of State Emergency Management Council and represented in the State Emergency Centre. |
REC295-1297 | 25 - Inquiry, audit, lessons management and after action review | Engage an independent business analyst to review the current call, receipt and dispatch process for emergency services i.e. the Metropolitan Fire Service, Country Fire Service and State Emergency Service, from the initial call for assistance through to response of emergency service resources, including the allocation and coordination of multiple taskings. |
REC295-1308 | 24 - Govt responsibility | That the Department of the Premier and Cabinet revise the ministerial documents relating to emergency management. |
REC295-1286 | 10 - Infrastructure | That the Attorney General’s Department consult with local government regarding potential for them to provide logistical support associated with backup power supply to SA Government Radio Network towers in the event of an emergency. |
REC295-1276 | 25 - Inquiry, audit, lessons management and after action review | That SA Health undertake a review of their emergency management arrangements. Health State Controllers should be consulted during this review and arrangements should be consistent throughout the department and across the State and compatible with State emergency management arrangements and information systems |
REC295-1291 | 24 - Govt responsibility | That the Flood Reform Task Group, as proposed by the Department |
REC295-1279 | 10 - Infrastructure | Install UPS on traffic lights on main Central Business District (CBD) and arterial roads to allow an effective movement of traffic during a loss of power. |
REC295-1328 | 25 - Inquiry, audit, lessons management and after action review | Update the SEMP Part 3, Annex F ‘Debriefs’ to provide more guidance regarding the types of debriefs, when they are required to be undertaken and at what level and guidance for undertaking and recording debriefs, and implementing lessons identified. |
REC295-1319 | 24 - Govt responsibility | That a single emergency service multi-agency control centre be established with sufficient capacity and capability to deal with all types of emergency incidents in SA. Also consider Police and State Emergency Centre. |
Rec-ID | Code | Recommendation |
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REC291-1233 | 25 - Inquiry, audit, lessons management and after action review | The State Government to explore options for streamlining the functions and the independence of the State Emergency Management Committee Secretariat and the Office of Bushfire Risk Management with a view to including an inspectorate function, and appointing a person who is dedicated to that role. The purpose is to provide assurance and reporting, and to inquire into, monitor and report transparently on emergency management standards, preparedness, capability, service delivery and investment performance outcomes. Within two years of the establishment of this arrangement the State Government to review and assess whether it is meeting the desired outcomes. |
REC291-1249 | 25 - Inquiry, audit, lessons management and after action review | The Department of the Premier and Cabinet to conduct an independent review of the current arrangement for the management and distribution of the Emergency Services Levy. The review will have the specific purpose of: · seeking input from key entities including the Departments of Treasury, Finance, Fire and Emergency Services, Lands, and Parks and Wildlife, WA Local Government Association, and the Office of Bushfire Risk Management. · ensuring the arrangement has the flexibility and agility to deal with emerging bushfire risk priorities. · establishing a budget process that enables a shift in investment towards prevention, mitigation and building community resilience and capability. |
REC291-1248 | 24 - Govt responsibility | The State Emergency Management Committee to establish a State Bushfire Coordinating Committee as a sub-committee of SEMC. The State Bushfire Coordinating Committee will be chaired by the Director of the Office of Bushfire Risk Management and will have the primary responsibility to: · develop a State Bushfire Management Policy and a set of long term bushfire risk management objectives; · provide a forum for key bushfire risk management stakeholder agencies; · advise the SEMC on matters pertaining to bushfire, in particular, to report against the investment in, and achievement of the bushfire risk management objectives; · provide advice and support to the proposed Chief Officer of the Rural Fire Service on bushfire risk management matters; and · report to SEMC and to the community on bushfire risk management matters on at least an annual basis. |
Rec-ID | Code | Recommendation |
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REC287-1184 | 24 - Govt responsibility | The Tasmanian fire agencies think more broadly about how staff who are already employed by Government could support the management of future emergencies. |
REC287-1188 | 25 - Inquiry, audit, lessons management and after action review | The Tasmanian fire agencies commission a review into the efectiveness of aerial firefghting in the 2016 fires, in order to better understand and to document for future reference the cost-efectiveness of specifc fire suppression strategies and tactics in different vegetation types. The Review should include a comparative analysis of fire suppression options whether aerial or ground-based. |
REC287-1185 | 25 - Inquiry, audit, lessons management and after action review | The Tasmanian fire agencies take steps at a national level to share learnings from the 2016 fires about the administration of interstate assistance and support the codifcation of the workings, structure and reporting lines of an Interstate and International Liaison Unit for future complex deployments within Australia and New Zealand. |
Rec-ID | Code | Recommendation |
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REC286-2019 | 24 - Govt responsibility | Assess water supply resilience in the case of an interruption. |
REC286-2071 | 29 - Operational Health and Safety | Implement a social marking program to promote improved respiratory etiquette and hygiene. |
REC286-2067 | 24 - Govt responsibility | Improve integration of health information systems. |
REC286-2055 | 29 - Operational Health and Safety | Personal protective equipment (masks, gowns, gloves, goggles) – review fit-testing vs fit-checking. |
REC286-2063 | 24 - Govt responsibility | Review Tas Govt interoperability arrangements. |
REC286-1460 | 25 - Inquiry, audit, lessons management and after action review | Review seismic monitoring network alert systems to ensure emergency managers are on the contact lists. |
REC286-2059 | 24 - Govt responsibility | Enhance business continuity planning by the Tasmanian Health Service. |
REC286-2084 | 10 - Infrastructure | Establish emergency services ICT redundancy arrangements for damage loss of communications infrastructure. |
REC286-2070 | 25 - Inquiry, audit, lessons management and after action review | Test the Biosecurity Act 2015. |
REC286-1442 | 25 - Inquiry, audit, lessons management and after action review | Review legislation relating to Fuel Stove only areas, Fire Permit System and Total Fire Bans to ensure appropriate incentives to modify individuals’ behaviour. |
REC286-2058 | 24 - Govt responsibility | Clarify the relationship between the DHHS and THS in the establishment of flu services. |
REC286-2031 | 10 - Infrastructure | Improve information about electricity demand during heatwaves. |
REC286-2069 | 24 - Govt responsibility | Implement a database management approach for notifiable disease record systems. |
REC286-1438 | 25 - Inquiry, audit, lessons management and after action review | Consider outcomes of national review of warnings and review resilience of warning systems’ infrastructure. |
REC286-2033 | 24 - Govt responsibility | Incorporate heatwave surge response planning into business continuity planning. |
REC286-2068 | 24 - Govt responsibility | Develop a disaster client record system. |
Rec-ID | Code | Recommendation |
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REC284-1374 | 10 - Infrastructure | Provide walls around critical electrical infrastructure within the main plant area to provide security and protection from catastrophic water system failures. |
REC284-1368 | 10 - Infrastructure | Improvements to installation to be implemented as follows: - Lighting within the generator enclosure and immediately adjacent to be emergency battery-backed type. - Improvements to the spatial layout within the main generator enclosure should be investigated, including allowance for the control panel door to open 180o (only 90o currently); moving the fuel pumps to a more accessible location, and ensuring clear access to the day tank for manual filling if required. - Improvements to communications facilities between critical areas, including fixed phone line connections between the main control room, main generator control panel in the P (energy) Building, and the generator enclosure, and allowing link to offsite specialist advice. - Where generator maintenance requires operations outdoors (not applicable to main generator, but applicable to others), a shelter over the relevant area should be provided to allow safe work during wet or hot weather. - Written emergency procedures to be prepared covering credible failure scenarios with step by step checklists and recommended actions. |
REC284-1373 | 10 - Infrastructure | Review generator installations details as noted in report and implement physical improvements where possible. |
REC284-1367 | 10 - Infrastructure | Add to generator test procedure a checklist at the end of testing which includes checking that all systems are back to normal positions and includes a requirement to leave the day tank full where there is a bulk tank/day tank arrangement. |
REC284-1372 | 10 - Infrastructure | As part of the electrical master plan update recommended above, a complete and consistent set of single line diagrams describing the electrical distribution network be prepared. Relevant diagrams to be laminated and displayed in the main substations. Labelling to all main electrical equipment be reviewed and updated in accordance with the final documents. |
REC284-1366 | 10 - Infrastructure | A detailed review of the fuel control and BMS systems (for all generators) be carried out and actions taken to: 1) Ensure that the fuel alarm system is operational and properly calibrated, and ensure that the alarms are connected to the BMS. 2) Ensure that the BMS transmits these alarms effectively to the maintenance staff. 3) If this review demonstrates risk of fuel control systems not adequately reporting alarms, consider an independent day tank level switch to be installed in each generator fuel tank, directly connected to the BMS. 4) Consider the feasibility of adding a “fuel system not in auto” or “fuel system fault/fail safe watchdog” or “pre-alarm identifying that the generator is about to shut down without intervention” feature to current systems – subject to details of each individual generator system. |
REC284-1371 | 10 - Infrastructure | Generator dual redundant starter systems should be considered. |
REC284-1365 | 10 - Infrastructure | The electrical master plan for the site should be updated to include planning for the scheduled replacement or refurbishment of those parts of the infrastructure that have not been renewed in the last 10 years. This planning to consider other upgrades or plans for the FMC overall. |
REC284-1370 | 10 - Infrastructure | Review control system for the main generator normal/essential changeover system and ensure that it has effective backup/manual or redundant operations, and suitable testing facilities. The Essential board that supplies the main generator power to Blocks A, B, C (except theatres), D, E (except certain critical engineering plant) (MD-1-4P-10E), is a potential single point of failure of a significant portion of the emergency power system and as part of the Master Plan update should be considered as a priority. |
REC284-1369 | 10 - Infrastructure | Review all generator locations for arrangements for temporary generator installation, including design of modifications as required for electrical connections and spatial requirements at installation locations, to be documented in an emergency procedure. |
Rec-ID | Code | Recommendation |
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REC264-1085 | 10 - Infrastructure | GDF Suez establish enhanced back-up power supply arrangements that do not depend wholly on mains power, to: • ensure that the Emergency Command Centre can continue to operate if mains power is lost; and • ensure that the reticulated fre services water system can operate with minimal disruption if mains power is lost. |
REC264-1087 | 25 - Inquiry, audit, lessons management and after action review | GDF Suez: • practice and ensures that, by taking a risk management approach, it is suitable for fire prevention, mitigation and suppression in all parts of the Hazelwood mine; and review its ‘Mine Fire Service Policy and Code of Practice’ so that it refects industry best • work plan for the Hazelwood mine. incorporate the revised ‘Mine Fire Service Policy and Code of Practice’ into the approved |
REC264-1086 | 25 - Inquiry, audit, lessons management and after action review | GDF Suez: • consequences of fire in the worked out areas of the Hazelwood mine, and an assessment of the most effective fre protection for the exposed coal surfaces; conduct, assisted by an independent consultant, a risk assessment of the likelihood and • controls are in place to eliminate or reduce the risk of fre; and prepare an implementation plan that ensures the most effective and reasonably practicable • implement the plan |
REC264-1072 | 25 - Inquiry, audit, lessons management and after action review | The State empower and require the Auditor-General or another appropriate agency, to: • oversee the implementation of these recommendations and the commitments made by the State and GDF Suez during this Inquiry; and • report publicly every year for the next three years on the progress made in implementing recommendations and commitments. |
Rec-ID | Code | Recommendation |
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REC258-2526 | 24 - Govt responsibility | The Australian Government develops the State Safety Program into a strategic plan for Australia’s aviation safety system, under the leadership of the Aviation Policy Group, and uses it as the foundation for rationalising and improving coordination mechanisms. |
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. |
REC258-2556 | 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. |
REC258-2552 | 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. |
REC258-2561 | 24 - Govt responsibility | The Australian Government amends regulations so that background checks and the requirement to hold an Aviation Security Identification Card are only required for unescorted access to Security Restricted Areas, not for general airside access. This approach would align with international practice. |
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. |
REC258-2530 | 24 - Govt responsibility | The Australian Government appoints an additional Australian Transport Safety Bureau Commissioner with aviation operational and safety management experience. |
REC258-2560 | 29 - Operational Health and Safety | The Civil Aviation Safety Authority devolve to Designated Aviation Medical Examiners the ability to renew aviation medical certificates (for Classes 1, 2, and 3) where the applicant meets the required standard at the time of the medical examination. |
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. |
Rec-ID | Code | Recommendation |
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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. |
REC257-1539 | 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: |
Rec-ID | Code | Recommendation |
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REC256-1571 | 24 - Govt responsibility | State and territory taxes and levies on general insurance should be phased out and replaced with less distortionary taxes. |
REC256-1568 | 24 - Govt responsibility | State governments, where they have not already done so, should provide local governments with statutory protection from liability for releasing natural hazard information and making changes to local planning schemes where such actions have been taken ‘in good faith’ and in accordance with state planning policy and legislation. |
REC256-1567 | 24 - Govt responsibility | State and territory governments should: |
REC256-1566 | 24 - Govt responsibility | State and territory governments should prioritise and accelerate implementation of the Enhancing Disaster Resilience in the Built Environment Roadmap, including reviewing the regulatory components of vendor disclosure statements. The Land Use Planning and Building Codes Taskforce should be tasked to identify and consider options for regular, low-cost dissemination of hazard information to households by governments and insurers. |
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: |
REC256-1561 | 24 - Govt responsibility | State and territory governments should be required to report on the following accountability requirements: |
REC256-1575 | 24 - Govt responsibility | State and territory governments should develop benchmark prices for the reconstruction of essential public assets and submit these to the Australian Government for approval within one year. In developing these prices, they should consult with local governments and relevant experts, and draw on asset management plans. The prices should be reviewed and updated over time. |
Rec-ID | Code | Recommendation |
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REC247-0923 | 25 - Inquiry, audit, lessons management and after action review | That a process be established for the timely implementation of approved recommendations from the 2009 Victorian Bushfires Royal Commission. |
REC247-0909 | 25 - Inquiry, audit, lessons management and after action review | That the plans for social recovery be reviewed, and plans and procedures are established ready for implementation. |
REC247-0904 | 10 - Infrastructure | That the Department of Infrastructure Energy and Resources consult Aurora Energy on the use of wooden poles for overhead infrastructure with a view to mitigating the risk in bushfires. |
REC247-0951 | 25 - Inquiry, audit, lessons management and after action review | That an independent means of monitoring and reporting on the implementation of approved recommendations is established. |
REC247-0903 | 25 - Inquiry, audit, lessons management and after action review | That the role of Red Cross in emergency management plans and procedures for the activation of Red Cross be reviewed. |
REC247-0941 | 25 - Inquiry, audit, lessons management and after action review | That the Strategic Fuel Management Plan includes measurable targets and they are actively monitored and reported on to the community. |
REC247-0873 | 25 - Inquiry, audit, lessons management and after action review | If it is considered more information is required on action to suppress the fires in Dunalley and why fire operations did not continue, the Department of Justice should conduct an independent examination of this matter. |
REC247-0927 | 25 - Inquiry, audit, lessons management and after action review | That an accountability process be established for managing improvement in the emergency management arrangements, including annual State of Readiness Reports by relevant departments and agencies and on the overall emergency management arrangements. |
REC247-0928 | 24 - Govt responsibility | That the Government take into account demographic change in its assessment of the consequences of climate change on emergency events. |
REC247-0926 | 25 - Inquiry, audit, lessons management and after action review | That membership of the State Emergency Management Committee, and other processes to link in appropriate agencies and organisations to emergency management, be included in the recommended review of the emergency management arrangements. |
Rec-ID | Code | Recommendation |
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REC244-2601 | 25 - Inquiry, audit, lessons management and after action review | That an independent review of the operational and geographic boundaries of the ESOs be conducted recognising the limitations of the current governance structures to adequately address such issues. Such a review needs to be performed periodically, but not less than every 8 years. |
REC244-2600 | 25 - Inquiry, audit, lessons management and after action review | An external audit of shared services performed by SAFECOM and services now provided by the three ESOs which have the potential to be shared, be undertaken to determine the most efficient and cost effective way such services can be delivered to the sector. The three ESO Chiefs need to have input into this process. |
REC244-2631 | 25 - Inquiry, audit, lessons management and after action review | Review Section 134 to ensure that it is not a deterrent to a group of farm fire units operating at an incident. |
REC244-2620 | 25 - Inquiry, audit, lessons management and after action review | Review employment conditions under the F&ES Act to align with those under the Public Sector Act unless there is a compelling reason to the contrary. |
REC244-2617 | 25 - Inquiry, audit, lessons management and after action review | When judging major incidents in the future, consideration be given to Eburn and Dover’s proposal to establish processes with a statutory basis that sufficiently balance the community’s interests in ensuring that true lessons, including lessons of error or neglect, are identified, whilst also protecting members of the emergency services. Processes need to be developed for emergency services such as those used in aviation and medicine, to facilitate open and honest disclosure of errors. |
Rec-ID | Code | Recommendation |
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REC241-0965 | 29 - Operational Health and Safety | That the number of Bushfire Safety Officer positions be, over time, increased so that one BSO operates out of each District office. |
REC241-1030 | 25 - Inquiry, audit, lessons management and after action review | That Rural Fire Brigades only be required to conduct an audit of finances if the Brigades income exceeds $5,000 for a financial year. RFSQ District offices should investigate options for savings on the costs of auditing Brigades in their district through either an in-house or external provider. Legal Status of Brigades |
REC241-1001 | 24 - Govt responsibility | That the extent of forest and plantation fuel load fire risk in South East Queensland requires a designated government resources fire team to manage this risk and proactively conduct fuel mitigation burning; and provide a wildfire response to government land. |
REC241-0979 | 24 - Govt responsibility | That the Queensland Government liaise with the Federal Government with a view to securing incentives for employers that recognise loss of income and employee time for emergency operations. |
REC241-0954 | 24 - Govt responsibility | That a Ministerial Advisory Council be established to inform the Minister of matters relating to Rural Fire Service and SES volunteers. |
REC241-1022 | 29 - Operational Health and Safety | That Rural Fire Service Queensland in consultation with the Rural Fire Brigades Association Queensland will undertake a full review of the medical and health protocols to support the new Volunteer organisation. |
REC241-1015 | 29 - Operational Health and Safety | That the First Officer or Brigade Officer retain the ability to seek assistance from any person whose services are available at the fire. Any person appointed to provide this assistance should be protected under relevant Workplace Health and Safety and Workcover legislation. |
Rec-ID | Code | Recommendation |
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REC239-2708 | 24 - Govt responsibility | That the role of the Inspector General Emergency Management not extend to conducting reviews on behalf of agencies and that the role consider the effectiveness of all agencies and how their work contributes to a whole of Government response. |
REC239-2725 | 25 - Inquiry, audit, lessons management and after action review | That the Queensland Fire and Rescue Service community safety operations be joined in the efficiency review of the Queensland Police Service focussing on both the community safety outcomes achieved and the extent to which they support the Government’s economic priorities. |
REC239-2660 | 24 - Govt responsibility | That Queensland Corrective Services be transferred to the Department of Justice and Attorney-General by a machinery-of-Government change as soon as is practicable. |
REC239-2759 | 24 - Govt responsibility | That the new Chief Executive Officer Portfolio Business be accountable for delivering the reformed Communications Centre arrangement by the 2017–18 financial year in time for the Commonwealth Games of 2018. |
REC239-2776 | 25 - Inquiry, audit, lessons management and after action review | That the proposed efficiency review of the Queensland Police Service examine whether: |
REC239-2685 | 24 - Govt responsibility | That primacy of control for disaster operations remains with the Queensland Police Service and be reinforced. |
REC239-2701 | 24 - Govt responsibility | That the Inspector General Emergency Management provide continuing advice to Government on the level of interoperability in disaster management arrangements, as well as the level of interoperability being achieved within the new portfolio. |
REC239-2724 | 25 - Inquiry, audit, lessons management and after action review | That the Queensland Fire and Rescue Service undertake a review of all standing orders, incident directives and guidelines regarding response protocols with a view to reducing risk to staff and other road users associated with urgent duty driving. |
REC239-2657 | 24 - Govt responsibility | That negotiation takes place between Queensland Health and the Queensland Ambulance Service to determine the broad governance requirements of any such arrangements. |
REC239-2749 | 24 - Govt responsibility | That the Prostitution Licensing Authority be moved to the Department of Justice and Attorney General Office of Fair Trading. |
REC239-2764 | 25 - Inquiry, audit, lessons management and after action review | That the proposed efficiency review consider whether special service functions are core business, whether this practice is sustainable, and other options such as the use of casual employees. |
REC239-2679 | 24 - Govt responsibility | To remove the Queensland Ambulance Service and Queensland Corrective Services from the Department of Community Safety—we recommend that it be renamed the Department of Fire and Emergency Services and be led by a Commissioner. |
REC239-2700 | 24 - Govt responsibility | That the position of Inspector General Emergency Management (in addition to some of the responsibilities of the chief executive officer under the current Disaster Management Act 2003) will: |
REC239-2655 | 24 - Govt responsibility | That the Queensland Ambulance Service is transferred to Queensland Health by a machinery-of-Government change as soon as is practicable and that the Commissioner report directly to the Director General Queensland Health. |
REC239-2732 | 24 - Govt responsibility | There be a formation of an Office of Portfolio Business, providing support and governance across a range of corporate functions, which are essential to the delivery of frontline services. The Review team considers that the functions of the Operations Business and Strategy Directorate should become part of that Office and that any exception should be carefully considered by those charged with implementation of approved recommendations. |
REC239-2763 | 25 - Inquiry, audit, lessons management and after action review | That the proposed efficiency review includes a focus on the rank structure of both the Queensland Police Service and the proposed Fire and Emergency Services. |
REC239-2678 | 24 - Govt responsibility | That probation and parole should continue to work together with the Queensland Police Service to reduce the risk of reoffending and reduce crime. |
REC239-2699 | 24 - Govt responsibility | That the Minister establish a public sector office to be headed by an Inspector General of Emergency Management. The Inspector General of Emergency Management will be responsible for most of the functions listed under part 16A of the current Disaster Management Act 2003. |
REC239-2721 | 24 - Govt responsibility | That the Chief Executive Officer Portfolio Business collaborate with the two portfolio Commissioners to: |
REC239-2737 | 29 - Operational Health and Safety | That the workplace health and safety reporting system be reviewed to facilitate ease of reporting. |
REC239-2758 | 25 - Inquiry, audit, lessons management and after action review | That the Chief Executive Officer Portfolio Business leads an efficiency review of portfolio agencies beginning with the Queensland Police Service. |
REC239-2662 | 24 - Govt responsibility | That responsibility for prisoner transport and non-managerial roles within the larger watch-houses is transferred to Queensland Corrective Service. |
REC239-2687 | 24 - Govt responsibility | That funding, staffing and responsibility associated with administration of the NDRP be transferred from Emergency Management Queensland to the Department of Local Government, Community Recovery and Resilience. |
REC239-2712 | 24 - Govt responsibility | That Emergency Management Queensland be integrated with the current Queensland Fire and Rescue to become the Department of Fire and Emergency Services. |
REC239-2727 | 25 - Inquiry, audit, lessons management and after action review | That as part of its efficiency review, the Queensland Fire and Rescue Service instigate an independent review of commercial operations in terms of statutory obligations and current ‘full cost pricing’ methodology to ensure: |
REC239-2661 | 24 - Govt responsibility | That Queensland Corrective Service remains a separate program within the Department of Justice and Attorney-General so that while opportunities for improved services and efficacy can be realised, there is a clear separation from the youth justice services. |
REC239-2782 | 24 - Govt responsibility | That transparency of the Ministerial direction be achieved through publishing and monitoring for effectiveness. |
REC239-2777 | 25 - Inquiry, audit, lessons management and after action review | That the review of this Queensland Fire and Rescue Services business unit be done in conjunction with the efficiency review proposed for the Queensland Police Service. |
REC239-2686 | 24 - Govt responsibility | That primacy of control should rest with the State Disaster Coordinator. This position should, by default, be the Deputy Commissioner, Regional Operations, Queensland Police Service. |
Rec-ID | Code | Recommendation |
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REC223-0523 | 25 - Inquiry, audit, lessons management and after action review | The Government consider enacting legislation to facilitate the review of all future major incidents, including but not limited to fire, earthquake, storm and marine inundation, and the emergency response to them. |
REC223-0522 | 25 - Inquiry, audit, lessons management and after action review | The response operation to the Margaret River bushfire in November 2011 be the subject of a review with independent oversight. |
REC223-0516 | 25 - Inquiry, audit, lessons management and after action review | The Department of Environment and Conservation review its implementation of the findings of the Ferguson Review conducted in 2010. |
Rec-ID | Code | Recommendation |
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REC205-1904 | 24 - Govt responsibility | State and territory taxes and levies on general insurance constitute a barrier to effective adaptation to climate change. State and territory governments should phase out these taxes and replace them with less distortionary taxes. |
REC205-1899 | 24 - Govt responsibility | Local governments’ uncertainty about their legal liability is a barrier to effective climate change adaptation. State governments should clarify the legal liability of councils with respect to climate change adaptation matters and the processes required to manage that liability. |
REC205-1898 | 24 - Govt responsibility | To help clarify roles and responsibilities of local government for climate change adaptation, the state and Northern Territory governments should publish and maintain a comprehensive list of laws that delegate regulatory roles to local governments. This would assist both state and local governments to assess whether local governments have the capacity to discharge their roles effectively. |
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: |
REC205-1896 | 24 - Govt responsibility | Australian governments should implement policies that help the community deal with the current climate by improving the flexibility of the economy. This would also build adaptive capacity to deal with future climate change. This includes reforms to: |
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: |
Rec-ID | Code | Recommendation |
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REC201-0257 | 29 - Operational Health and Safety | FESA needs to place greater priority on the appointment of Safety Advisors to Level 3 incidents as is reflected in WESTPLAN Bushfire. |
Rec-ID | Code | Recommendation |
---|---|---|
REC200-1699 | 24 - Govt responsibility | The State Government ensure that the continued development of the Fire and Emergency Service Authority's Integrated Bushfire Risk Management System is dependent on an independent comparative assessment of its functionality and cost-effectiveness against the Spatial Support System used by the Department of Environment and Conservation. |
REC200-1727 | 24 - Govt responsibility | The State Government transfer responsibility for the installation, removal, maintenance of fire hydrants to the Water Corporation, in accordance with the recommendations of the 2006 CDJSC Inquiry into Fire and Emergency Services Legislation. |
REC200-0392 | 25 - Inquiry, audit, lessons management and after action review | The State Government review implementation of the Special Inquiry’s Recommendations in two years. |
REC200-1732 | 25 - Inquiry, audit, lessons management and after action review | The State Government review implementation of the Special Inquiry's recommendations in two years. |
REC200-1694 | 24 - Govt responsibility | The State Government give its full support to the Western Australian Local Government Association's Send to Solve initiative. |
REC200-1723 | 24 - Govt responsibility | The State Government restructure the Fire and Emergency Services Authority as a Department. As part of this restructure, Emergency Management Western Australia should either |
REC200-0384 | 25 - Inquiry, audit, lessons management and after action review | Emergency Management Western Australia develop mechanisms to calculate the estimated total cost of a fire to the community. |
REC200-1705 | 29 - Operational Health and Safety | The Fire and Emergency Services Authority (FESA) review its program to decommission vehicles and ensure that when such vehicles are offered during an incident that FESA staff adhere to FESA‟s own policy of „Use of Private Vehicles in Fires‟ |
REC200-1701 | 25 - Inquiry, audit, lessons management and after action review | The Fire and Emergency Services Authority convene a facilitated debriefing session between the families who remained behind to protect their properties, and the incident controllers. |
REC200-1682 | 24 - Govt responsibility | The State Government give legislative effect to the Planning for Bush Fire Protection Guidelines. |
REC200-1719 | 24 - Govt responsibility | The State Government recognise the projected changes in climate and potential impact on future fire events. |
REC200-0361 | 25 - Inquiry, audit, lessons management and after action review | The Fire and Emergency Services Authority convene a facilitated debriefing session between the families who remained behind to protect their properties, and the incident controllers. This session should include open discussion and explain the decisions of all parties – including how the incident controllers determined priorities, and why residents chose not follow their advice to evacuate. The learning outcomes should be promulgated across all agencies and incorporated in future level 3 incident controller training programs. |
REC200-1681 | 24 - Govt responsibility | The State Government transfer responsibility for declaring bushfire prone areas from local government to the Western Australian Planning Commission. The Western Australian Planning Commission should urgently assess those areas that should be declared bushfire prone. |
REC200-1717 | 24 - Govt responsibility | The State Government mandate that the title deeds for relevant properties be amended to indicate if the property is in a declared bushfire prone area. |
REC200-1712 | 10 - Infrastructure | FESA and local governments jointly review radio communications capability prior to the 2011/12 bushfire season with a view to improving the current delivery of service to firefighters. |
REC200-1716 | 24 - Govt responsibility | State and locals governments: |
REC200-0379 | 24 - Govt responsibility | The State Government recognise the projected changes in climate and potential impact on future fire events. |
REC200-1728 | 24 - Govt responsibility | The Water Corporation immediately review the outstanding orders for hydrant repairs and develop strategies to reduce the backlog. |
Rec-ID | Code | Recommendation |
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REC199-0466 | 24 - Govt responsibility | the Departments of Health and Human Services finalise the definition of ‘vulnerable person’ and the list of facility types where vulnerable people are located and ensure that the definition and associated policy(ies) are applicable across ‘all hazards’. |
REC199-0482 | 25 - Inquiry, audit, lessons management and after action review | the state task the Emergency Services Commissioner with the responsibility to develop and undertake the regular audit of emergency management plans at all levels. |
REC199-0465 | 24 - Govt responsibility | the state undertake major reform of Victoria’s emergency management arrangements to bring about an effective ‘all hazards, all agencies’ approach, incorporating: • clarity of command and control in all emergencies • common operating platforms, including communications and information technology • interoperability between all agencies • regular joint training and exercising by all agencies • the development and implementation of performance standards for each emergency management agency • the development and maintenance of effective planning arrangements at all levels of emergency management • a meaningful monitoring and audit regime for designated standards and planning requirements; and • an effective accountability mechanism to support the maintenance of legislative and other agency obligations. |
REC199-0450 | 25 - Inquiry, audit, lessons management and after action review | the state ensure that appropriate record management processes are developed and implemented and that these processes also provide record accountability for multi-agency operations. Agency processes should be standardised to the fullest extent possible |
REC199-0455 | 24 - Govt responsibility | the state conduct an ‘all hazards’ needs analysis to determine requirements for level 3 Incident Control Centres with a focus on ‘all hazards’ and multi-agency capability. Following this analysis, the state take steps to ensure the availability of sufficient and functional level 3 Incident Control Centres across the state with an ‘all hazards’ and multi-agency capability |
REC199-0445 | 25 - Inquiry, audit, lessons management and after action review | the state develop and implement operational performance standards for each state agency involved in emergency management response and recovery and that: • each agency be assessed by the Emergency Services Commissioner periodically against these performance standards for both capability and capacity; and • where performance against these standards for either capability or capacity cannot be demonstrated by any agency – appropriate advice is communicated to the relevant Minister, departmental/agency head and State Emergency Response Coordinator; and – an action plan is developed and implemented to address the relevant capability or capacity deficiency in both the short and longer term. |
REC199-0406 | 24 - Govt responsibility | the state expand the Regional Water Monitoring Partnerships model to include all flood warning gauges. |
REC199-0428 | 25 - Inquiry, audit, lessons management and after action review | the state clarify which agency is responsible for collecting post-flood extent and related data. This should include: • the development of guidelines to ensure consistent standards are applied to post-flood data collection; and • an appropriate process to ensure funding availability for such activities. |
REC199-0400 | 24 - Govt responsibility | The state take the necessary measures to clarify roles, responsibilities and cost-sharing arrangements for flood warning systems, including tasking state and regional bodies to be responsible for the flood warning system. This will require engaging with the commonwealth to amend the 2001 arrangements, updating the 1998 floodplain management strategy accordingly and continuing to support commonwealth initiatives designed to improve flood mapping standards and associated issues. |
REC199-0407 | 25 - Inquiry, audit, lessons management and after action review | the state: • undertake a strategic review to identify areas at risk from flash or riverine flooding. Shortcomings in the flood gauging networks identified in the review should then be the focus of remedial action • seek to address as a priority any notable gaps in the total flood warning system as apparent in the 2010–11 floods (including south west Victoria, Wimmera and north central region) by enhancing mapping, gauging and education programs; and • seek a commitment from the Bureau of Meteorology to ensure any new gauges installed are utilised to enhance flood prediction capability and coverage. |
REC199-0481 | 24 - Govt responsibility | the state (consistent with recommendation 46) develop a model for determining the capability and capacity of departments and agencies with roles and responsibilities in large scale or protracted emergencies. The issues of capability and capacity should be addressed at all levels of emergency management planning. |
REC199-0401 | 25 - Inquiry, audit, lessons management and after action review | the state task the Emergency Services Commissioner with the responsibility to establish an effective audit regime of the total flood warning system. |
Rec-ID | Code | Recommendation |
---|---|---|
REC197-1733 | 25 - Inquiry, audit, lessons management and after action review | That a review of the Country Fire Authority Act 1958 and the Country Fire Authority Regulations 2004 be undertaken. |
Rec-ID | Code | Recommendation |
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REC189-2912 | 29 - Operational Health and Safety | The review team recommend that the safety case system be strengthened by including provisions for a design notification scheme along the lines of that under the British Offshore Safety Case Regulations. |
REC189-2911 | 29 - Operational Health and Safety | The review team recommend that: |
REC189-2907 | 29 - Operational Health and Safety | a) For the purposes of designing and implementing its regulatory activities, National Offshore Petroleum Safety Authority (NOPSA) should continue to identify priority hazards and risks and their underlying causes, in consultation with the NOPSA Advisory Board and stakeholders (see Theme 9, Stakeholder engagement). |
Rec-ID | Code | Recommendation |
---|---|---|
REC182-0133 | 29 - Operational Health and Safety | FESA reviews its approach to safety and safety culture. |
Rec-ID | Code | Recommendation |
---|---|---|
REC177-3279 | 29 - Operational Health and Safety | Well construction and management plans, and drilling programs, should include provision for testing and verifying the integrity of all barriers as soon as practicable after installation. |
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. |
REC177-3294 | 29 - Operational Health and Safety | Perceived time and cost savings relating to any matters impacting upon well control should be subjected to rigorous safety assessment. |
REC177-3278 | 29 - Operational Health and Safety | Well construction and management plans should include provision(s) for reviewing the integrity of barriers at safety‐critical times or milestones, such as (i) prior to suspension involving departure of the rig from the platform; (ii) prior to re‐entry of a well after suspension; (iii) prior to removal of any barrier. |
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. |
REC177-3293 | 29 - Operational Health and Safety | If a dispute arises between a licensee and a rig operator in relation to a well control issue, and is not resolved between them, the matter must be raised with the relevant regulator before discretionary operations proceed. |
REC177-3321 | 29 - Operational Health and Safety | Careful consideration must be given to equipment compatibility as part of well construction design. |
REC177-3288 | 29 - Operational Health and Safety | As soon as a risk of barrier failure arises, no other activities should take place in the well other than those directed to removal of the risk. |
REC177-3303 | 29 - Operational Health and Safety | Tracking and analysis of cementing problems/failures should occur to assess industry trends, principal causes, remedial techniques and so on. |
REC177-3282 | 29 - Operational Health and Safety | If a risk assessment or compliance review is triggered by the happening of a predetermined event, specific consideration should be given to whether a ‘hold point’ should be introduced such that work must cease until the problem is resolved (and the subject of appropriate certification). |
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. |
REC177-3299 | 29 - Operational Health and Safety | Regulatory approval to rely on only one barrier should not be given unless (i) a proper risk assessment is carried out; (ii) exceptional circumstances exist; and (iii) risks involved are reduced to ‘as low as reasonably practicable’. The default position must be that well integrity must be assured. |
REC177-3281 | 29 - Operational Health and Safety | Wellbore gas bubbling should be regarded as a trigger for independent review of well integrity. Industry and regulators should identify and document other triggers. |
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. |
REC177-3295 | 29 - Operational Health and Safety | Wells drilled into hydrocarbon zones should be treated as live wells, with the potential to blowout unless a documented risk assessment establishes otherwise. |
Rec-ID | Code | Recommendation |
---|---|---|
REC165-0098 | 24 - Govt responsibility | The SDMG take into account key improvement initiatives and change processes suggested when deciding on an effective implementation strategy for agreed recommendations. |
REC165-0097 | 24 - Govt responsibility | Revised governance arrangements be implemented involving Disaster Management Groups at the three levels supported by EMQ as outlined in this report to achieve continuous improvement in the Disaster Management arrangements in the State. A new provision in Section 5 emphasise the discretion available to all involved in the Disaster Management system to take action to prevent impending loss of life even if contrary to the agreed arrangements. |
Rec-ID | Code | Recommendation |
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REC164-0073 | 25 - Inquiry, audit, lessons management and after action review | SERCon consider that the proposed State Recovery Committee provide an interim report to government on these and |
Rec-ID | Code | Recommendation |
---|---|---|
REC161-3035 | 24 - Govt responsibility | That Ministerial Council on Mineral and Petroleum Resources liaise with Ministers with environmental and planning responsibilities, and if necessary Council of Australian Governments, to ensure that environmental requirements for oil and gas projects are not imposed subsequent to safety assessments and do not increase the risk of major accident events. |
REC161-3028 | 24 - Govt responsibility | That Ministerial Council on Mineral and Petroleum Resources continue to support a duty of care safety case regime for best practice offshore petroleum industry regulation augmented to include regulation of integrity. Since the safety case is at the centre of the duty of care co-regulatory regime, we consider that the requirement for the implementation of the safety case at facilities involved in the exploitation of petroleum resources should be provided for within the Offshore Petroleum and Greenhouse Gas Storage Act 2006 itself. |
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 |
---|---|---|
REC151-3095 | 24 - Govt responsibility | SAFECOM re-evaluate and determine a more meaningful definition of fire districts. |
REC151-3071 | 24 - Govt responsibility | The comprehensive prevention, preparedness, response and recovery (PPRR) approach to the management of bushfires as recommended by the Ministerial Review of Bushfire Management in South Australia is supported: its implementation should consider issues raised by councils and should also be considerate of the recommendations of the Wangary Coronial Inquest. |
Rec-ID | Code | Recommendation |
---|---|---|
REC149-3147 | 29 - Operational Health and Safety | As all stakeholders have responsibility for safe outcomes, decisions regarding target subjects for safety promotion need to have the support of all stakeholders including NOPSA and the workforce. Industry, which ultimately has the responsibility for managing risk as well as funding the promotion, should take a leadership role in implementation. |
REC149-3144 | 29 - Operational Health and Safety | The Safety Case proponent should be allowed some flexibility to involve appropriate experience matched with the proposed workforce competencies to enable the Safety Case to be developed with value adding processes. Subsequent to the hiring of the workforce Final Government Response Offshore Petroleum Safety Regulation Inquiry and 2008 Review of NOPSA Operational Activities and preferably before the commencement of operations a review of the Safety Case should take place with the new workforce to ensure they understand the accepted Safety Case, its risks and Safety Management Plan. |
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. |
REC149-3135 | 29 - Operational Health and Safety | The initial acceptance of a new facility Safety Case should be in conjunction with inspection of a facility upon commencement of operations. |
REC149-3128 | 29 - Operational Health and Safety | National Offshore Petroleum Safety Authority (NOPSA) should develop guidelines in consultation with stakeholders to provide clarity and consistency to the process which ultimately will result in better safety outcomes. |
Rec-ID | Code | Recommendation |
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REC140-3575 | 24 - Govt responsibility | The preferred model for the Tasmanian Medical Retrieval Services is to have TMRS and NETS staff based in RHH. The fixed wing would remain based in Launceston (for the present) with the helicopter to remain based in Hobart. |
Rec-ID | Code | Recommendation |
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REC136-3529 | 24 - Govt responsibility | The Queensland Government should consider the endorsement of transitional arrangements proposed in this report, in order to ensure as far as possible the smooth completion of the recovery and the ultimate return to government operations as usual in the cyclone-affected area. |
REC136-3525 | 24 - Govt responsibility | In any future disaster of comparable proportions, consideration should be given to the co-location of the Building Coordination Centre and the principal One Stop Shop. |
Rec-ID | Code | Recommendation |
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REC121-3706 | 29 - Operational Health and Safety | RailCorp should establish a comprehensive safety document management system. |
REC121-3748 | 29 - Operational Health and Safety | All new rail cars must have appropriate signage and lighting identifying escape routes in the case of emergency. |
REC121-3694 | 25 - Inquiry, audit, lessons management and after action review | The ITSRR should conduct random audits of accredited rail organisations for compliance with communications protocols. |
REC121-3732 | 29 - Operational Health and Safety | If ITSRR accepts such a plan as an appropriate response to the existing weak safety culture, ITSRR should approve it and monitor the effectiveness of the plan. |
REC121-3764 | 29 - Operational Health and Safety | The ITSRR should not grant accreditation to any rail organisation unless it has an integrated safety management system in accordance with any safety management system regulation and the guidelines published from time to time by ITSRR. |
REC121-3687 | 10 - Infrastructure | There must be compatibility of communications systems throughout the rail network. It is essential that all train drivers, train controllers, signallers, train guards and supervisors of trackside work gangs in New South Wales be able to communicate using the same technology. |
REC121-3680 | 29 - Operational Health and Safety | All trains must be fitted with a minimum of two independent engineering defences to minimise the risk of derailment or collision in the event of train driver incapacitation. |
REC121-3758 | 25 - Inquiry, audit, lessons management and after action review | Following completion of any external audit, a corrective action plan to remedy any identified safety deficiencies should be developed by RailCorp, implemented and followed up within the business groups affected, to ensure appropriate and timely completion of the action plan, by a formal examination of the effectiveness of the controls put in place. Senior management personnel should certify that the corrective action plan has been implemented and is effective. Senior management personnel should be accountable for any such certification. |
REC121-3738 | 29 - Operational Health and Safety | All passenger trains must be fitted with an internal passenger emergency door release. |
REC121-3747 | 29 - Operational Health and Safety | All trains should have windows available through which passengers can escape. |
REC121-3693 | 25 - Inquiry, audit, lessons management and after action review | ITSRR should ensure that, as a condition of accreditation, each of these recommendations is carried into effect and should audit against them to enforce compliance. |
REC121-3731 | 29 - Operational Health and Safety | RailCorp should develop a plan to be submitted to ITSRR to address the deficiencies in the safety culture of RailCorp, including: |
REC121-3759 | 29 - Operational Health and Safety | A Safety Reform Program Director (hereafter referred to as SRPD), reporting directly to the Chief Executive of RailCorp, should be retained to manage, as head of a Safety Reform Program Office, any safety reform program being undertaken by RailCorp. The SRPD should work with the Chief Executive and senior management to ensure the implementation of an integrated safety management system and the cultural change required. The SRPD must have qualifications suitable for recognition by the Australian Institute of Project Management as a master program director. He or she should report to and be under the control of the Chief Executive, to ensure that the accountability of the Chief Executive is not reduced. The SRPD should co-ordinate and integrate any existing rail safety reform programs and, in consultation with and with the authority of the Chief Executive he or she should: |
REC121-3657 | 10 - Infrastructure | All signal telephones must be maintained by RailCorp in proper working order. |
REC121-3757 | 25 - Inquiry, audit, lessons management and after action review | RailCorp should conduct internal and external safety audits to evaluate the adequacy of its safety management system and to ensure that any risk control measures are effective. |
REC121-3737 | 29 - Operational Health and Safety | There must be a minimum of two independent methods of self-initiated emergency escape for passengers from all trains at all times. |
REC121-3743 | 29 - Operational Health and Safety | All passenger trains operating in New South Wales must have the external emergency door release clearly marked with the words “Emergency Door Release”. |
REC121-3691 | 25 - Inquiry, audit, lessons management and after action review | The ITSRR should audit the RMC to ensure communications protocols are being followed. The sanction for non-compliance with communications protocols should be identical to that in the aviation industry and involve immediate removal from duty. Any RailCorp employee not following communications protocols should be required to undertake further training. If, following return to duties after such training, the officer continues to fail to comply with communications protocols, that officer is not to be employed in communications related work. |
REC121-3711 | 29 - Operational Health and Safety | The ITSRR should establish an electronic document control system to enable effective and reliable information to be gathered for monitoring the safety of the New South Wales rail system. |
REC121-3755 | 29 - Operational Health and Safety | The RailCorp Board should require a full review of the safety competence of RailCorp managers to ensure that each has the ability to bring about those safety reforms recommended in this report which are applicable to his or her position. |
REC121-3767 | 24 - Govt responsibility | All accredited rail organisations should be required to re-apply every three years to ITSRR for accreditation. |
REC121-3653 | 10 - Infrastructure | The RMC should be equipped by RailCorp with a transcriber system, or mimic board, or such other system as is necessary to enable identification of the precise location at any time of any train on the RailCorp network. |
REC121-3753 | 25 - Inquiry, audit, lessons management and after action review | The RailCorp Board should establish independent external safety auditing processes to regularly audit and report to the Board on the implementation of an integrated safety management system by RailCorp and on safety performance generally. |
REC121-3735 | 29 - Operational Health and Safety | Risk assessments of occupational health and safety issues by RailCorp should include an analysis of broader public safety risks and not be confined to narrow occupational health and safety issues. |
REC121-3702 | 29 - Operational Health and Safety | Random alcohol testing should be continued. |
REC121-3741 | 29 - Operational Health and Safety | The operation of the train doors should have an override facility whereby the train driver or the guard can override an internal passenger emergency door release system if the door release is interfered with when there is no emergency. There should be an alarm, together with an intercom, in the train guard’s compartment so that, if a passenger attempts to initiate an emergency door release, there is an appropriate delay during which time an alarm sounds in the train guard’s compartment and the guard can then, after first attempting to speak via the intercom to the person concerned, if necessary, override the door release, and make an appropriate announcement over the intercom system in the train. |
REC121-3709 | 29 - Operational Health and Safety | RailCorp should provide access to electronic versions of safety documentation for all operational staff at their workplace. |
REC121-3754 | 29 - Operational Health and Safety | The RailCorp Board should ensure that RailCorp has an adequate and integrated safety management system, including adequate systems for risk assessment, clearly defined safety responsibilities and accountabilities for persons holding management positions, and specific performance criteria against which evaluations can be made of safety performance and accountability for safety performance of all managers. |
REC121-3721 | 24 - Govt responsibility | The ITSRR should ensure that OTSI, as a division of ITSRR, co-operates and assists the ATSB in the conduct of any independent investigation by the ATSB of any rail accident or incident in New South Wales. |
REC121-3651 | 10 - Infrastructure | A dedicated telephone line should be established by RailCorp between the RMC and any Emergency Services Control Centre for use during any emergency. |
REC121-3726 | 25 - Inquiry, audit, lessons management and after action review | The OTSI should continue to conduct rail accident investigations on behalf of ITSRR and report directly to the Chief Executive of ITSRR. |
REC121-3734 | 29 - Operational Health and Safety | RailCorp should integrate its management of occupational health and safety into its overall safety management. |
REC121-3682 | 29 - Operational Health and Safety | All new rolling stock should be designed to be compatible with at least level 2 automatic train protection discussed in chapter 7 of this report. |
REC121-3768 | 25 - Inquiry, audit, lessons management and after action review | The ITSRR, when considering a re-application for accreditation, should conduct a field audit of the organisation to ensure that it is carrying on its activities in accordance with the basis upon which it seeks accreditation. |
REC121-3740 | 29 - Operational Health and Safety | The internal passenger emergency door release should be fitted with a facility which prevents it from operating unless the train is stationary. |
REC121-3707 | 29 - Operational Health and Safety | The safety document management system should provide for the distribution of electronic versions of safety documentation to relevant staff. |
REC121-3749 | 29 - Operational Health and Safety | All new rolling stock must be designed with an area of the roof through which emergency services personnel can access a rail car without encountering wiring or other equipment. That access point must be clearly marked with words such as “emergency services cut here”. |
REC121-3720 | 24 - Govt responsibility | The New South Wales Government should make the necessary arrangements with the Australian Government, including any necessary legislation, for the Australian Transport Safety Bureau (ATSB) to have the power to investigate all rail accidents occurring on the New South Wales rail network the investigation of which may advance the knowledge of the causes of rail accidents in Australia. |
REC121-3713 | 25 - Inquiry, audit, lessons management and after action review | Recommendations one to seven of the final report of the Special Commission of Inquiry into the Glenbrook Rail Accident should be fully implemented, save that the random auditing referred to in recommendations five and seven should be carried out by ITSRR. |
REC121-3733 | 29 - Operational Health and Safety | RailCorp’s approach to occupational health and safety should be proactive and involve the systematic analysis of all current hazards, risks and controls and an assessment of their adequacy to reduce the risk of injury to, or death of, employees to an acceptable level. |
REC121-3695 | 10 - Infrastructure | There should be interoperability of communications equipment between all trains operating on the New South Wales rail network. |
REC121-3681 | 29 - Operational Health and Safety | RailCorp should progressively implement, within a reasonable time, level 2 automatic train protection with the features identified in chapter 8 of this report. |
REC121-3765 | 25 - Inquiry, audit, lessons management and after action review | The ITSRR should conduct field audits to satisfy itself that all accredited rail organisations conduct their activities in accordance with the safety management system on the basis of which each was accredited. |
REC121-3739 | 29 - Operational Health and Safety | All passenger trains operating in New South Wales must be fitted with external emergency door releases which do not require any special key or other equipment to operate. |
Rec-ID | Code | Recommendation |
---|---|---|
REC116-2109 | 24 - Govt responsibility | The Working Group recommends that participants in the exercises designed to test continuity of executive government plans and procedures should be the office holders themselves. |
REC116-2107 | 10 - Infrastructure | The Working Group recommends that State/Territory emergency management plans should explicitly take the need for rapid assessment of damaged physical infrastructure into account. The importance of rapid physical infrastructure assessment in ensuring the supply of utilities including sewerage and drainage, electricity, water and gas to residential structures and other types should be recognised and considered. |
REC116-2108 | 24 - Govt responsibility | The Working Group recommends that all States/Territories and the Australian Government should regularly (annually) test their continuity of executive government plans and contingencies. |
REC116-2126 | 24 - Govt responsibility | The Working Group recommends the Australian Emergency Management Committee note that: |
REC116-2105 | 24 - Govt responsibility | The Working Group recommends that the adequacy of existing national mortuary capability to meet the likely demands of a catastrophic disaster be assessed by State/Territory Coroners. This assessment should also consider the need for a mobile mortuary capability and involve discussions with the Australian Federal Police. |
REC116-2125 | 24 - Govt responsibility | The Working group recommends that the Australian Government take a leadership role with regard to addressing the national capability issues identified within this review. Further, that the States/Territories recognise and accept the collaborative nature of developing national capability and commit through engagement and consultation to assisting the Australian Government in this task. |
REC116-2123 | 24 - Govt responsibility | The Working Group recommends that the Australian Government consider developing an overarching whole of government disaster plan that clearly articulates authority, roles and responsibilities of agencies, inter-departmental committees and key officials, to link the range of existing Australian Government disaster plans. |
REC116-2118 | 24 - Govt responsibility | The Working Group recommends that State/Territory Recovery Committees review their membership to ensure that it is reflective of community needs, including representation from the Insurance Disaster Response Organisation. |