Inquiry Search
Rec-ID | Code | Recommendation |
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REC324-4297 | 33 - Relief and recovery | Housing , especially social housing: That, to ease housing stress in flood prone areas and ensure new development is resilient and community-centred, Government pursue a multi-pronged, decadal strategy through: |
REC324-4311 | 33 - Relief and recovery | Transition initiatives: That, to improve the community’s experience during immediate disaster recovery phase, Government through the SEOCON, NSWRA, DCS/Service NSW and other state agencies as required provide greater support (financial, health [including mental health], temporary accommodation, administrative and other support services) to affected communities by: |
Rec-ID | Code | Recommendation |
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REC323-4277 | 33 - Relief and recovery | That the NSW Government develop a more proactive, rapid response to manage animal welfare following natural disasters which includes improved collaboration and communication with local veterinarians and animal welfare organisations. |
REC323-4262 | 33 - Relief and recovery | That the NSW Government provide an increased level of targeted support to flood affected communities contending with widespread mould. |
REC323-4269 | 33 - Relief and recovery | That the NSW Government address the mental health needs of local communities following the February-March 2022 floods by: • embedding within state emergency and recovery plans a strategy that provides surge capacity for mental health and social workers by: • prioritising funding for community groups that are currently providing social and mental health support to their local communities • ensuring all flood-impacted communities receive the mental health support they need to fully recover. |
REC323-4289 | 33 - Relief and recovery | That the NSW Government ensure that all emergency and recovery plans, including state plans, local emergency management plans and functional area plans, are reviewed and updated regularly and provide clarity on the role of non-government partners. |
REC323-4271 | 33 - Relief and recovery | That Service NSW establish teams of assessors that can be on the ground to assess and approve grant applications. |
REC323-4273 | 33 - Relief and recovery | That the NSW Government overhaul the way in which it conducts its grants process as it frustrated applicants and further traumatised them by repeatedly re-interviewing them and making them prove that they were flooded. |
Rec-ID | Code | Recommendation |
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REC314-3266 | 14 - Incident Mgt Teams | Engage with the Australian Defence Force (ADF) once or twice a year to understand the capabilities that could potentially be deployed. Educate IMTs about how to deploy ADF assistance effectively and develop a streamlined ‘call out’ procedure. |
REC314-3265 | 14 - Incident Mgt Teams | Prepare to ‘scale up’ capability during major bushfire events with senior representatives (including BoM staff) in the SEC 24/7, ensure adequate facilities for IMTs, base camps (e.g. Humanihuts) and recovery centres. Consider the resource implications of providing firefighters to interstate operations. |
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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REC299-1343 | 25 - Inquiry, audit, lessons management and after action review | That the Government conduct a review of fire prevention |
REC299-1344 | 25 - Inquiry, audit, lessons management and after action review | That a review of the cross‑tenure approach be undertaken to determine its effectiveness and to address issues that arise in fire prevention on private and public land. |
Rec-ID | Code | Recommendation |
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REC297-1269 | 35 - Business and Industry in relation to industry | That Government engages with non-government organisations that may provide services during emergency events to clarify the terms and conditions for support through a written arrangement (MOU or similar). |
REC297-1257 | 35 - Business and Industry in relation to industry | That in the event that Hydro Tasmania decides to start cloud seeding again, water managers, represented by DPIPWE, work with Hydro Tasmania to ensure appropriate, best practice application of the guidelines issued by the Agricultural and Resource Management Council of Australia and New Zealand. |
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. |
REC297-1259 | 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. |
REC297-1258 | 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. |
Rec-ID | Code | Recommendation |
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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. |
REC295-1276 | 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 |
REC295-1328 | 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. |
REC295-1327 | 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. |
REC295-1317 | 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. |
REC295-1334 | 33 - Relief and recovery | Conduct a review into South Australia’s arrangements for relief and recovery grant, Local Government Disaster Recovery Assistance Arrangements and Natural Disaster Relief and Recovery Arrangement claims, the review should include governance coordination and criteria for provision and processing of relief/recovery grants |
REC295-1274 | 35 - Business and Industry in relation to industry | That relevant agencies, such as the Department of State Development, SA Police and emergency services, collaborate to establish an education campaign to encourage businesses in South Australia to develop Business Continuity Plans which, among other potential hazards such as flood and fire, also take into account the potential impact of an extended power outage. |
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. |
REC295-1275 | 33 - Relief and recovery | That SA Health, develop an emergency plan to manage an extended power outage or black system event which, in addition to the requirements outlined in recommendation 16: |
REC295-1326 | 14 - Incident Mgt Teams | Establish a State-wide resourcing capability to support incident management teams, regional coordination centres, zone emergency centres, relief centres, recovery centres and State control centres. some of the features of such a capability should include: a) multi-agency, cross-government, State-wide pool of incident management and emergency management personnel building on the State incident management team concept currently facilitated by the Country Fire Service, and expanded to include all hazards, multiagency teams with a roster that provides year-round coverage b) a system that enables staff and volunteers from any agency to identify their availability for upcoming shifts c) a rostering system that enables one or more incident management teams, staging areas, regional coordination centres, State control centres and relief centres to develop, maintain and distribute rosters and structure charts in a more coordinated manner d) identifying areas of expertise for key incident and emergency management functions (e.g. public information, alerts and warning, media liaison, logistics and resource management) that would benefit from a coordinated and resource pooling approach and take steps to implement (consider the Mapping Functional Support Group model as a potential service delivery model). |
Rec-ID | Code | Recommendation |
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REC291-1240 | 14 - Incident Mgt Teams | The Departments of Parks and Wildlife and Fire and Emergency Services to adopt the policy that all bushfire Level 3 Incident Management Teams in the Perth Hills and the South West will be integrated and pre-formed from the start of the 2016/17 fire season with substantial involvement of both the Departments of Parks and Wildlife and Fire and Emergency Services personnel on all teams. |
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. |
REC291-1239 | 14 - Incident Mgt Teams | The State Government to establish an arrangement to develop a ‘network’ of Western Australian State Government agency personnel who can be called upon for bushfire and emergency incident management capability within Western Australia. The arrangement will be led by the State Emergency Management Committee and modelled on systems used by the Department of Parks and Wildlife. |
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. |
Rec-ID | Code | Recommendation |
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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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REC280-1396 | 25 - Inquiry, audit, lessons management and after action review | That the Minister for Police and Emergency Services review the communications technologies used by the NSW Rural Fire Service, Fire and Rescue NSW, the NSW National Parks and Wildlife Service and Forestry NSW during fire fighting operations, to ensure that systems are standardised and effective. Within this context, the potential value of satellite phone technology should be investigated. |
REC280-1388 | 25 - Inquiry, audit, lessons management and after action review | That the NSW Rural Fire Service: |
Rec-ID | Code | Recommendation |
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REC273-1139 | 14 - Incident Mgt Teams | SACFS appoint the Regional Controller and/or Coordinator as the IC for any Level 3 incident occurring within their Region to provide better continuity and improved coordination. The position of the regional controller and/or coordinator could then be backfilled by a suitably qualified individual as required. |
REC273-1138 | 14 - Incident Mgt Teams | Review the communication and request procedures within SACFS to ensure that the most effective chain of command and line of communications are established between the Incident Management Team, region and state. |
REC273-1135 | 14 - Incident Mgt Teams | That SACFS conduct a review of SIMT with a view to increasing the number of teams from four to six, aligning them with each of the six regions within SA. |
Rec-ID | Code | Recommendation |
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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. |
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 |
Rec-ID | Code | Recommendation |
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REC261-1508 | 25 - Inquiry, audit, lessons management and after action review | That the NSW Rural Fire Service review its procedures, systems and infrastructure for notifying community members of bush fires, both when a fire has broken out and as it proceeds, to ensure the provision of timely and adequate information. |
REC261-1505 | 25 - Inquiry, audit, lessons management and after action review | That the NSW Rural Fire Service: |
REC261-1520 | 33 - Relief and recovery | That the Ministry for Police and Emergency Services urgently review its policies for the provision of disaster welfare services to ensure that in the event of a bush fire emergency and the declaration of a fire under section 44 of the Rural Fires Act 1997, adequate funding and services, especially recovery centres and mental health services, are provided for an adequate length of time, with gradual transition to normal service delivery when those services are no longer required. |
Rec-ID | Code | Recommendation |
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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. |
REC258-2539 | 35 - Business and Industry in relation to industry | The Civil Aviation Safety Authority changes its regulatory philosophy and, together with industry, builds an effective collaborative relationship on a foundation of mutual understanding and respect. |
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. |
REC258-2560 | 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. |
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. |
Rec-ID | Code | Recommendation |
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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: |
REC257-1555 | 14 - Incident Mgt Teams | The lines of responsibility be made clearer and some individual, perhaps the Regional Environmental Officer, or agency be given overarching responsibility to ensure recommended works related to bushfire mitigation on Defence Estate are carried out in accordance with the Bushfire Management Plan which the Manual for Fire Protection Engineering directs be prepared. |
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. |
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: |
Rec-ID | Code | Recommendation |
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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. |
REC247-0911 | 14 - Incident Mgt Teams | That emergency management plans specifically include processes and resources for effectively engaging with and using local communities, including volunteers |
REC247-0910 | 33 - Relief and recovery | That suitable facilities are established from which to effectively control and coordinate immediate recovery operations. |
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. |
REC247-0862 | 14 - Incident Mgt Teams | That Tasmania Fire Service and its partner agencies establish a means of monitoring and reviewing the effectiveness of centralising the location of Incident Management Teams. |
REC247-0907 | 33 - Relief and recovery | That the State Emergency Management Committee ensures that a program of debriefing on recovery issues is completed by all relevant agencies and organisations, and detailed plans and operating procedures are established ready for implementation. |
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. |
REC247-0861 | 14 - Incident Mgt Teams | That Tasmania Fire Service examines options for developing and issuing fire management objectives and tactics from Incident Management Teams in a more timely way, including ‘quick’ plans. |
REC247-0896 | 33 - Relief and recovery | That the state level structural arrangements for managing recovery operations are reviewed. |
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. |
REC247-0853 | 14 - Incident Mgt Teams | That the State Controller (or an alternate if they are not available) be expected to personally take an active role in controlling and coordinating response and recovery operations, depending on the nature and scale of the emergency, and until other identified arrangements for ongoing operations are established. |
REC247-0857 | 2 - Emergency powers | That the Tasmania Emergency Management Plan enable, and all organisations with a role in emergency management activate, emergency plans at lower threshold events to practice their arrangements and achieve a ‘hot start’ in escalating events. |
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. |
REC247-0856 | 2 - Emergency powers | That the Government reconsider the current position on emergency declarations in the Emergency Management Act 2006 and the Act is amended to provide: • a graduated scale of emergency declarations; • the ability to make a declaration when an emergency has occurred, is occurring or is about to occur; • the ability for the State Controller (or whatever the person in overall control of response and recovery operations is called) to make one or more declarations; • a declaration to enable access to all emergency powers. |
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. |
Rec-ID | Code | Recommendation |
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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. |
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. |
Rec-ID | Code | Recommendation |
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REC242-2643 | 25 - Inquiry, audit, lessons management and after action review | That the Government consult broadly upon and review impediments to volunteering in the community and establish a taskforce to assist in removing barriers to volunteering, particularly with respect to: |
Rec-ID | Code | Recommendation |
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REC239-2675 | 35 - Business and Industry in relation to industry | That social benefit bonds and other opportunities with the business and not-for-profit sectors be developed to reduce reoffending and to provide rehabilitation programs. Such an instrument should be available to the market within two years. |
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. |
REC239-2737 | 29 - Operational Health and Safety | That the workplace health and safety reporting system be reviewed to facilitate ease of reporting. |
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: |
REC239-2777 | 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. |
REC239-2725 | 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. |
REC239-2776 | 25 - Inquiry, audit, lessons management and after action review | That the proposed efficiency review of the Queensland Police Service examine whether: |
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. |
REC239-2764 | 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. |
REC239-2763 | 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. |
Rec-ID | Code | Recommendation |
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REC236-2793 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that CASA processes in relation to matters highlighted by this investigation be reviewed. This could involve an evaluation benchmarked against a credible peer (such as FAA or CAA) of regulation and audits with respect to: non-RPT passenger carrying operations; approach to audits; and training and standardisation of FOI across regional offices. |
REC236-2792 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that the investigation be re-opened by the ATSB with a focus on organisational, oversight and broader systemic issues. |
REC236-2806 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that the relevant agencies investigate appropriate methods to ensure that information about the incidence of, and variable weather conditions at, Norfolk Island is available to assist flight crews and operators managing risk that may result from unforseen weather events. |
REC236-2783 | 2 - Emergency powers | The committee recommends that the Australian Transport Safety Bureau retrieve VH-NGA flight data recorders without further delay. |
REC236-2805 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that the relevant agencies review whether any equipment or other changes can be made to improve the weather forecasting at Norfolk Island. The review would include whether the Unicom operator should be an approved meteorological observer. |
REC236-2801 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that the ATSB review its process to track the implementation of recommendations or safety actions to ensure it is an effective closed loop system. This should be made public, and provided to the Senate Regional and Rural Affairs and Transport Committee prior to each Budget Estimates. |
REC236-2795 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that a short inquiry be conducted by the Senate Standing Committee on Rural and Regional Affairs and Transport into the current status of aviation regulatory reform to assess the direction, progress and resources expended to date to ensure greater visibility of the processes. |
Rec-ID | Code | Recommendation |
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REC232-2815 | 25 - Inquiry, audit, lessons management and after action review | The Department of Health and Ageing review the existing evidence base to evaluate the cost-effectiveness of its policy to use heat scanners at ports of entry as a measure to mitigate the risk of infectious disease importation. |
REC232-2828 | 25 - Inquiry, audit, lessons management and after action review | The Australian Government, in consultation with state and territory governments, commission an independent review to assess the case for establishing a national centre for communicable disease control in Australia. The review should outline the role of a national centre and how it might be structured to build on and enhance existing systems. It should examine different models, considering a range of options for location, governance and staffing. The review should incorporate a cost-benefit analysis for each of the models presented. |
REC232-2827 | 25 - Inquiry, audit, lessons management and after action review | The Australian Government, in consultation with state and territory governments, conduct a comprehensive national audit and mapping exercise to: |
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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REC222-1858 | 29 - Operational Health and Safety | The Ministers for Environment, Police, Child Protection and Emergency Services fund additional chaplaincy services, particularly for staff and volunteers based in rural and regional Western Australia. |
REC222-1869 | 25 - Inquiry, audit, lessons management and after action review | The Ministers for Emergency Services, Environment and Police ensure their departments include provisions for regular external audits of invoices for payment in their next round of Employee Assistance Program contract negotiations. |
REC222-1852 | 29 - Operational Health and Safety | The Minister for Health immediately establish the road trauma counselling service to be funded by the Road Trauma Trust Account. |
REC222-1862 | 25 - Inquiry, audit, lessons management and after action review | The Minister for Emergency Services request the State Emergency Management Committee to review by June 2013 the sharing of data between the State’s emergency response agencies using the WebEOC software and any further enhancements that can be made to this process. |
REC222-1850 | 29 - Operational Health and Safety | The Ministers for Emergency Services, Environment and Police ensure that their departments develop as a high priority a computer system for tracking their staff and the number of traumatic events they have attended over a particular period. |
REC222-1847 | 25 - Inquiry, audit, lessons management and after action review | The Ministers for Emergency Services, Environment and Police ensure their departments undertake a formal review by 30 June 2013 of the welfare services addressing stress and trauma provided to both their career and volunteer members. |
REC222-1849 | 29 - Operational Health and Safety | Departmental chief executives of the Western Australia Police, Department of Environment and Conservation and the Fire and Emergency Services Authority should be made personally responsible for the psychological health (as a result of critical incident trauma) of their staff and volunteers. This obligation should be reflected in their performance agreements. |
REC222-1848 | 29 - Operational Health and Safety | The Western Australian Government amend current State occupational health and safety legislation so that it includes a definition for ‘health’ that includes psychological health. |
REC222-1859 | 29 - Operational Health and Safety | The Attorney General and the Ministers for Health and Mental Health fund their departments to establish a peer support program by the end of 2013 for their staff undertaking stressful tasks during a disaster or critical incident. |
Rec-ID | Code | Recommendation |
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REC217-1840 | 25 - Inquiry, audit, lessons management and after action review | The state government implement the Victorian Floods Review recommendation 8, to review the flood gauging network. As part of the review, consideration should also be given to the use of portable telemetered river gauges, and to the replacement of manual gauges with telemetered gauges over time and where appropriate. |
Rec-ID | Code | Recommendation |
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REC208-0527 | 35 - Business and Industry in relation to industry | That the Office of Environment and Heritage require Orica to engage and fund appropriate independent experts to oversee any modifications to the plant in the next major maintenance overhaul of the plant in 2016 and in any upgrades to the plant prior to that date. |
REC208-0526 | 25 - Inquiry, audit, lessons management and after action review | That OEH’s testing procedures for determining the impact of pollution incidents incorporate additional requirements for the checking and verification of results before those results are released. |
Rec-ID | Code | Recommendation |
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REC207-2888 | 35 - Business and Industry in relation to industry | Foster private sector service providers who can offer tailored services or broadcast high quality presentation of general purpose weather information |
Rec-ID | Code | Recommendation |
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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: |
Rec-ID | Code | Recommendation |
---|---|---|
REC204-1916 | 25 - Inquiry, audit, lessons management and after action review | Local Emergency Management Committee (LEMC) processes should be reviewed to ensure that: |
REC204-1909 | 35 - Business and Industry in relation to industry | Eventscorp should ensure that organisers of events its sponsors are directed to all appropriate authorities and stakeholders to ensure the responsible, safe and efficient planning and conduct of the event. |
REC204-1913 | 25 - Inquiry, audit, lessons management and after action review | The Department of the Attorney General consider conducting a review of the Civil Liability Act 2002 (WA) in light of the 2011 Kimberley Ultramarathon. Such a review should consider issues such as the effectiveness given to competitor waivers under the Act and the potential difficulties of establishing proceedings and enforcing a judgement against foreign‐based providers of recreational activities. |
Rec-ID | Code | Recommendation |
---|---|---|
REC202-0497 | 25 - Inquiry, audit, lessons management and after action review | The Minister for Local Government have urgent discussions with the Western Australian Local Government Association (WALGA) as to why they are not supporting the full Recommendations addressed to local government in the Keelty Report. The Minister ensure that by May 2012 WALGA and its member councils have the resources to fully implement theimplementation of the Recommendations. |
REC202-0495 | 25 - Inquiry, audit, lessons management and after action review | At the conclusion to the 2011-12 bushfire season, the Minister for Emergency Services institute a thorough review of the operations of FESA, the Police and DEC in protecting the State from bushfires and other natural disasters, with a primary focus on: · staffing levels; · equipment levels and coordination; and · training needs. The Minister report to Parliament by June 2012 on any changes that need to be made to the current departmental structures to optimise the State’s preparedness for the 2012-13 bushfire season. |
REC202-0493 | 25 - Inquiry, audit, lessons management and after action review | The Minister for Emergency Services report to Parliament every six months on the progress made in completing all of the outstanding Recommendations of the Keelty Report. |
REC202-0501 | 2 - Emergency powers | The Minister for Emergency Services amend section 50 of the Emergency Management Act 2005 by June 2012 to allow the State Emergency Coordinator, as well as a hazard management agency, to make an emergency situation declaration. |
Rec-ID | Code | Recommendation |
---|---|---|
REC201-0248 | 14 - Incident Mgt Teams | To provide Level 3 IC‘s (and FESA) with a level of confidence and to maintain currency across the pool of accredited IC‘s, regular exercising of IC‘s and Level 3 IMT‘s is required. |
REC201-0258 | 14 - Incident Mgt Teams | FESA should review the size of the existing pre-formed IMT to include additional Information and Planning officers and increased resourcing of scribes and management support for all Level 3 incidents. |
REC201-0255 | 14 - Incident Mgt Teams | FESA and DEC need to appoint accredited Level 3 IC‘s based on experience, competency and currency. |
REC201-0254 | 14 - Incident Mgt Teams | FESA should continue to develop with DEC and Local Government a number of rostered pre-formed IMT‘s available throughout the fire season, regardless of predicted weather. |
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. |
REC201-0253 | 14 - Incident Mgt Teams | Review the command function of the MROC for Level 3 incidents when the SOC is activated. |
REC201-0251 | 14 - Incident Mgt Teams | All responding crews and the incident command appointments should adopt a ‘Size Up‘ reporting format. |
Rec-ID | Code | Recommendation |
---|---|---|
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‟ |
REC200-0384 | 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. |
REC200-1732 | 25 - Inquiry, audit, lessons management and after action review | The State Government review implementation of the Special Inquiry's recommendations in two years. |
REC200-0373 | 33 - Relief and recovery | The Department for Child Protection, the Western Australian Police and the Fire and Emergency Services Authority develop improved arrangements for communicating the loss of home and possessions to persons gathered at evacuation centres with a view to increasing privacy. |
REC200-0381 | 2 - Emergency powers | The State Government amend section 50 of the Emergency Management Act 2005 to allow the Chair of the State Emergency Coordination Group to declare an emergency situation. |
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. |
REC200-1701 | 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. |
REC200-1706 | 14 - Incident Mgt Teams | The Fire and Emergency Services Authority and the Department of Environment and Conservation ensure that their Incident Controllers identify critical infrastructure as part of their initial assessment and preparation of Incident Action Plans when attending major incidents. |
REC200-1718 | 35 - Business and Industry in relation to industry | Western Power and the Water Corporation continue to work collaboratively to assess options to better protect the power supply to water pumping stations in bushfire prone areas. |
REC200-0391 | 14 - Incident Mgt Teams | The Interagency Bushfire Management Committee develop a consistent program of education, training (including media), testing and review of Level 3 Incident Controllers. This should include provision for a formal review of the performance of individual Level 3 Incident Controllers after every incident. |
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. |
REC200-0366 | 14 - Incident Mgt Teams | The Fire and Emergency Services Authority and the Department of Environment and Conservation ensure that their Incident Controllers identify critical infrastructure as part of their initial assessment and preparation of Incident Action Plans when attending major incidents. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC199-0479 | 33 - Relief and recovery | the state review the way early outreach occurs and implement changes that will ensure that there is a consistency of approach regardless of which agency undertakes the service. |
REC199-0491 | 33 - Relief and recovery | the state: • ensure that the concerns raised by Victorians regarding the Natural Disaster Relief and Recovery Arrangements are provided to the national review, including the issues of: – betterment (what it means and how it is applied); and – the 51 per cent income rule for eligibility of businesses for grants. • establish a single point of information (such as the single web portal referred to in recommendation 33) on all emergency related financial assistance available to individuals, businesses and local government. The means of accessing this information should be widely circulated in the community. |
REC199-0427 | 35 - Business and Industry in relation to industry | the state require dam owners and operators provide regular situational reports to the relevant control agency where dam issues may impact incident management. |
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. |
REC199-0478 | 33 - Relief and recovery | the state amend the current protocol governing National Registration and Inquiry System information collection and sharing to: • clarify the role of councils and Centrelink during and after emergencies • ensure the amended protocol is written in plain English and easily understood; and • coordinate, in conjunction with the state and federal privacy commissioners, the development of a new National Registration and Inquiry System information sharing protocol in line with the proposed National Registration and Inquiry System 6 and state or federal privacy legislation. |
REC199-0490 | 33 - Relief and recovery | the state finalise the 2008 review of Victoria’s municipal assistance. This should include addressing: • the provision of upfront funding for local councils for repair of community assets • packages for early relief and recovery to be included in both the Natural Disaster Funding Arrangements and the Natural Disaster Relief and Recovery Arrangements, including outreach packages; and • the process of reimbursement of local councils after floods. |
REC199-0426 | 35 - Business and Industry in relation to industry | the state require that dam owners and operators inform people situated downstream of water storages if the owners/operators become aware of an immediate threat arising from the dam to the safety of those people. The owner/operators should provide this information as soon as the owner/operators become aware of the threat. |
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. |
REC199-0474 | 33 - Relief and recovery | the state, in respect of the Rapid Impact Assessment process: • resolve which agency/ies has policy and operational responsibility for this process • define the purpose of Rapid Impact Assessment; and • review the process, in light of the 2010–11 floods, to examine options to improve the efficiency of the collection of information. |
REC199-0489 | 33 - Relief and recovery | the state implement arrangements to improve the support provided to local government on disaster financing before, during and after emergency events. |
REC199-0425 | 35 - Business and Industry in relation to industry | the state require that dam owners and operators inform the control agency and the Bureau of Meteorology about the management and operation of dams and weirs consistent with the flood warning requirements of the relevant river systems, including providing telemetry at sites as necessary. This may require the state proactively liaising with other states to ensure equivalent obligations are placed on interstate dam operators where the dam may impact Victorian communities. |
REC199-0413 | 14 - Incident Mgt Teams | the state clarify the role of intelligence cell staff (for example, hydrologists and/or Catchment Management Authority) who are utilised in Incident Control Centres during flood events |
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. |
REC199-0473 | 33 - Relief and recovery | the state make available to the public a clear guide of who is responsible for: • clean-up and recovery of various types of infrastructure that straddle the public/private boundary; and • the policies agencies will follow in determining whether to repair infrastructure under their control. |
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. |
REC199-0488 | 33 - Relief and recovery | the Department of Human Services develop proactive strategies to provide information and assistance for people applying for emergency grants. |
REC199-0424 | 35 - Business and Industry in relation to industry | the state require dam owners and operators to review storage operating manuals to incorporate lessons from the 2010–11 floods and make this information publicly available. The manuals should include a clear policy on dam surcharging and pre-release. |
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 |
REC199-0472 | 33 - Relief and recovery | the state review the legislation and policies that set out clean-up and recovery responsibilities for infrastructure such as crossovers, culverts, drains, bridges and waterways, including consideration of: • whether the entities who are given obligations or powers to undertake clean-up works have the capacity to do so; and • the appropriateness of having different legal regimes for what is essentially the same piece of infrastructure. If the review reveals that the current responsibility matrix is inadequate, the state develop an action plan to address the identified shortcomings. |
REC199-0480 | 33 - Relief and recovery | the state clarify the transition to recovery arrangements including the processes for approving and funding of essential works after transition to recovery has been formalised. |
REC199-0444 | 2 - Emergency powers | the state, as a matter of urgency, develop a multi-agency Incident Control Team capability to be readily available for statewide deployment to establish incident control or to relieve functioning control structures. |
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 |
---|---|---|
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). |
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: |
Rec-ID | Code | Recommendation |
---|---|---|
REC188-2916 | 33 - Relief and recovery | The committee recommends that the Department of Regional Australia and DIAC liaise with the Christmas Island community to explore options for a permanent memorial to be erected on the island, at a site of the residents' choosing, for the victims of the tragedy. |
REC188-2915 | 33 - Relief and recovery | The committee recommends that Department of Immigration and Citizenship (DIAC) and its relevant contractors continue to monitor the wellbeing of the survivors and that counselling and support services should be provided for as long as is necessary. |
REC188-2917 | 33 - Relief and recovery | The committee recommends that relevant Commonwealth agencies continue to monitor the wellbeing of their personnel and that counselling and support services should be provided for as long as necessary. |
Rec-ID | Code | Recommendation |
---|---|---|
REC183-0111 | 14 - Incident Mgt Teams | Conducting a pre-fire season exercise for each Pre-Formed Incident Management Team could be used to “re-accrediting” each team on an annual basis. |
REC183-0114 | 14 - Incident Mgt Teams | Higher level DEC guidance to Level 3 Incident Controllers could be improved by introducing a more explicit and robust process of questioning, engagement, monitoring and oversight of Level 3 Incident Controllers. |
REC183-0113 | 14 - Incident Mgt Teams | A summary Incident Action Plan could allow the Incident Controller to more quickly appreciate the situation and articulate a plan early in an incident. |
REC183-0112 | 14 - Incident Mgt Teams | DEC’s incident management capability could be enhanced by: – Appointing a Deputy Incident Controller for every Level 3 IMT. – Establishing a fast response “short” IMT capability for each Level 3 IMT. – Establish clear triggers to initiate sending in a “short” IMT to a fire. – Including FESA officers in pre-formed Level 3 IMT’s. – Establishing additional pre-formed Level 3 IMT’s with FESA. – Where appropriate, appointing a local Bush Fire Brigade officer as Deputy Operations Officer. |
Rec-ID | Code | Recommendation |
---|---|---|
REC182-0131 | 14 - Incident Mgt Teams | FESA establishes a dedicated intelligence function in Incident Management Teams for major bushfires and ensure this function is appropriately supported with threat based tools and systems. |
REC182-0135 | 33 - Relief and recovery | FESA revises its standard operating procedures to provide guidance on the format and timing of post-incident community meetings. |
REC182-0133 | 29 - Operational Health and Safety | FESA reviews its approach to safety and safety culture. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC177-3378 | 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. |
REC177-3282 | 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). |
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. |
REC177-3374 | 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. |
REC177-3281 | 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. |
REC177-3295 | 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. |
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. |
REC177-3279 | 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. |
REC177-3294 | 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. |
REC177-3345 | 2 - Emergency powers | NOPSA’s prohibition powers should be extended such that a prohibition notice can be issued where a NOPSA Occupational Health and Safety Inspector believes, on reasonable grounds, that an activity is occurring or may occur at a facility involving an immediate threat to the health or safety of a person. |
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. |
REC177-3278 | 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. |
REC177-3293 | 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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC165-0086 | 2 - Emergency powers | Suggested escalation trigger points be discussed with District Disaster Coordinators and Local Disaster Coordinators, and if considered practical and useful, be incorporated in Local, District and State Disaster Management Plans. |
REC165-0081 | 2 - Emergency powers | District and State levels utilise the current Act to make pre-emptive declarations of a disaster event (likely disasters) so as to be proactive in leading and controlling disaster events. All levels of the system should immediately notify other levels if they activate the Disaster Management arrangements. The Public Safety Preservation Act 1986 be amended to provide powers for Police Officers to provide an immediate response in the event of a rapid onset disaster event such as a landslide. |
REC165-0089 | 33 - Relief and recovery | The SDMG lead an initiative to deal at all levels with offers of assistance and donations from the general public in the event of disasters. |
REC165-0082 | 33 - Relief and recovery | Current procedures to activate disaster recovery funding arrangements be retained and processes be reinforced. |
Rec-ID | Code | Recommendation |
---|---|---|
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 |
---|---|---|
REC161-3030 | 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 |
---|---|---|
REC155-3466 | 25 - Inquiry, audit, lessons management and after action review | A comprehensive review of the effectiveness of the increased prescribed burning target in meeting ecological and bushfire suppression needs should be conducted every three years. |
Rec-ID | Code | Recommendation |
---|---|---|
REC151-3079 | 2 - Emergency powers | Crown Law opinion be obtained to determine whether the FES Act gives the Minister power to direct and control individual Chief Officers and if that provision does not exist then the FES Act be amended to include that power. |
REC151-3107 | 2 - Emergency powers | Immunity be prescribed for persons (including volunteers) using force in the exercise of a power or function under the FES Act or carrying out any direction or requirement given or imposed at the scene of a fire or other emergency. |
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. |
REC149-3146 | 35 - Business and Industry in relation to industry | NOPSA should consider establishing a small forum for consultation consisting of representatives of relevant stakeholders. The representatives should have standing, with authority to participate in decision making and take on commitment on behalf of their stakeholder group. |
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. |
REC149-3133 | 35 - Business and Industry in relation to industry | Because some issues related to emergency response are beyond any single operator and usually occur outside the title area, there is a need for the representatives of the offshore industry to work together with other governments, interested and involved parties to develop the strategies to be utilised and the emergency planning model that will satisfy the requirements of all parties. |
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. |
REC149-3132 | 35 - Business and Industry in relation to industry | Coverage of the regime should be increased to cover the complete hydrocarbons production system from wells through to custody transfer point or reasonable physical/technical system boundary. If NOPSA is also to be responsible for Carbon Capture and Storage it needs to be resourced to ensure that this does not detract from NOPSA's current responsibilities. |
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. |
REC149-3131 | 35 - Business and Industry in relation to industry | The exploration/production operator making all major decisions related to petroleum activities (i.e. selection of rig, well design and selection of service companies) should be made responsible for demonstrating to the regulator that drilling operations can be conducted safely. Where the drilling contractor owns the rig and conducts the day-to-day management of safety on the rig, this duty can be described in a rig specific Safety Case that is owned by the drilling contractor. This rig specific Safety Case does not have to be submitted for every well/well operation. |
Rec-ID | Code | Recommendation |
---|---|---|
REC146-3193 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that the Australian National Audit Office audit CASA's implementation and administration of its Safety Management Systems approach. |
Rec-ID | Code | Recommendation |
---|---|---|
REC144-3379 | 25 - Inquiry, audit, lessons management and after action review | The Committee recommends that a thorough review be undertaken of the communications and coordination between the separate agencies which make up the Emergency Services Agency, to assess the extent to which cultural factors are detrimental to the effective operation of the ESA. |
Rec-ID | Code | Recommendation |
---|---|---|
REC143-3585 | 33 - Relief and recovery | That the Professional Assistance Grant is formally extended by WANDRA to include non rural businesses and that it be made available to assist with the clean up of disaster related damage to farms and businesses. (The Committee recognises that the amendments to WANDRA as of March 2007 address this recommendation). |
REC143-3583 | 33 - Relief and recovery | That the newly proposed index linked limits for Personal Hardship and Distress Relief Payments as outlined in the paper “National Disaster Relief Arrangements - An Analysis and Recommendations for Personal Hardship Distress Measures” be accepted by government. |
REC143-3588 | 33 - Relief and recovery | That, in line with recommendations contained in the 2004 Report to the Council of Australian Governments, greater flexibility should be introduced to WANDRA to enable damaged infrastructure to be upgraded to a more resilient standard where that is both feasible and cost-effective. |
Rec-ID | Code | Recommendation |
---|---|---|
REC128-3598 | 25 - Inquiry, audit, lessons management and after action review | That the Department of Primary Industries incorporates reviews of plans and operating procedures as a result of emergency incidents and exercises and ensures that there is adequate commitment from all participants in the review process. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC121-3676 | 14 - Incident Mgt Teams | A direct line of communication should be established between the RMC and Emergency Services Operations Control Centre by a “tie line” or otherwise, so as to ensure that in the case of a serious rail accident there is an open line of communication between the officer in charge of the management of the incident at the RMC and the various emergency response services. |
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. |
REC121-3732 | 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. |
REC121-3753 | 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. |
REC121-3738 | 29 - Operational Health and Safety | All passenger trains must be fitted with an internal passenger emergency door release. |
REC121-3702 | 29 - Operational Health and Safety | Random alcohol testing should be continued. |
REC121-3747 | 29 - Operational Health and Safety | All trains should have windows available through which passengers can escape. |
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: |
REC121-3726 | 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. |
REC121-3737 | 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. |
REC121-3768 | 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. |
REC121-3682 | 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. |
REC121-3743 | 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”. |
REC121-3666 | 14 - Incident Mgt Teams | The rail commander should have complete authority to direct and control any rail employees attending the site of a rail accident, in accordance with directions given or arrangements put in place by the site controller, until the rescue phase of the emergency response to the rail accident has been completed. |
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. |
REC121-3713 | 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. |
REC121-3735 | 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. |
REC121-3765 | 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. |
REC121-3681 | 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. |
REC121-3741 | 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. |
REC121-3665 | 14 - Incident Mgt Teams | The role of the rail commander should be to provide support and assistance to the site controller and emergency services personnel until the rescue phase of the emergency response to any rail accident is completed. |
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. |
REC121-3694 | 25 - Inquiry, audit, lessons management and after action review | The ITSRR should conduct random audits of accredited rail organisations for compliance with communications protocols. |
REC121-3734 | 29 - Operational Health and Safety | RailCorp should integrate its management of occupational health and safety into its overall safety management. |
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. |
REC121-3680 | 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. |
REC121-3740 | 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. |
REC121-3663 | 14 - Incident Mgt Teams | The incident command system should clearly identify the roles of the rail commander, site controller, police commander and commanders of the other emergency services, and the way in which each is to work together during the recovery phase of any rail accident. |
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”. |
REC121-3693 | 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. |
REC121-3733 | 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. |
REC121-3757 | 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. |
REC121-3739 | 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. |
REC121-3678 | 35 - Business and Industry in relation to industry | All railway owners and operators should have a quality assurance program for the design and construction of rolling stock and regular review of construction to ensure that the rolling stock satisfies the original functional performance specifications. |
REC121-3652 | 14 - Incident Mgt Teams | A designated staff member at the RMC should act as the rail emergency management co-ordinator. He or she should be the sole point of contact at the RMC with other rail personnel involved in the rail accident and emergency services personnel during the rescue phase of the emergency response. |
Rec-ID | Code | Recommendation |
---|---|---|
REC098-2155 | 25 - Inquiry, audit, lessons management and after action review | The Committee recommends that Emergency Management Australia initiate a process involving Australasian Fire Authorities Council and the Australian Assembly of Volunteer Fire Brigades Association to review |
REC098-2168 | 2 - Emergency powers | The Committee recommends that the Commonwealth investigate, and where necessary, require the urgent enhancement of the provision of emergency power and telecommunications services for the purpose of |
REC098-2151 | 29 - Operational Health and Safety | The Committee recommends that the Commonwealth Attorney-General engage the Commonwealth, states and territories in a review of occupational health and safety legislation as it affects the proper and effective functioning of bush fire services. |
Rec-ID | Code | Recommendation |
---|---|---|
REC061-3423 | 25 - Inquiry, audit, lessons management and after action review | The Committee recommends that the Metropolitan Fire Brigades Board be reviewed five years from the tabling of this report in Parliament. |
REC061-3258 | 25 - Inquiry, audit, lessons management and after action review | The Committee recommends that the Metropolitan Fire Brigades Board be reviewed five years from the tabling of this report in Parliament. |