Inquiry Search
Rec-ID | Code | Recommendation |
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REC324-4303 | 39 - Disaster Risk Management | Risk-based approach to calculating flood planning: That, to take account of greater knowledge of climate change, Government reinforce its adoption of a risk-based approach to calculating the flood planning level for planning purposes and, through the NSWRA, immediately start a process of revising all flood planning level calculations in the state’s high-risk catchments. Flood planning level re-determinations for all high-risk catchments should be completed within 3 years. These revised flood planning levels will need to be factored into all development applications (in-progress and new) in those high-risk catchments. The risk profile of high-risk catchments should be revisited at appropriate time intervals to check that levels are current. A review should take place if there has been a significant trigger event (i.e. changed rainfall, development) or at least every 5 years. As well as reviewing the flood planning level, this 5-yearly review should include reviewing any floodplain lease conditions and adjusting them as necessary in the light of better knowledge of climate change impacts. In working out a tolerable, risk-based flood planning level, consideration should be given to the PMF, 1% AEP, 0.02% AEP, existing development, approved but not yet constructed developments, and existing and approved but not yet constructed evacuation routes. |
REC324-4304 | 1 - Land-use and building regs | Landholders can access information on previous disasters: That, to ensure there is a single source of ground truth to prepare for and respond to emergencies, and to provide people with a better understanding of their individual property and community risk exposure, an online visualisation tool be developed to display, for all land parcels (land titles) in NSW, the extent of known disasters that have affected each piece of land in NSW in the past. This information should be made available through the Planning Portal and, particularly in light of climate change, the data involved should be revised and updated at least every two years and after each major natural disaster. |
REC324-4305 | 39 - Disaster Risk Management | Cost benefit framework:That, to enable a more systematic prioritisation of investment options in risk mitigation before, during and immediately following a natural disaster event, Government adopt and utilise a Disaster Cost Benefit Framework. This Framework will enable Government to estimate the investment required for any given disaster, starting with flood events, and will enable the fast allocation of funding based on detailed and rapid analysis of flood and property modification, mitigation, preparation, response and finance related options including: |
REC324-4296 | 1 - Land-use and building regs | Caravan parks and manufactured home estates: That, to ensure that permanent residents of caravan parks and mobile housing estates are protected from flood, Government: • prohibit permanent residency in caravan parks and mobile housing estates situated below the risk-based flood planning level. Caravan parks for holiday makers could still be on the floodplain with the provision that, if a flood is imminent, they need to be evacuated • address the issues raised in the 2015 Discussion Paper (Improving the regulation of manufactured homes, caravan parks, manufactured home estates and camping grounds). |
REC324-4306 | 6 - Insurance and legal liability | NSW Reconstruction Authority: That, to provide rapid and effective recovery from floods (and other disasters) and to provide maximum mitigation of the impacts of future floods (and other disasters), Government establish a permanent state-wide agency, the NSW Reconstruction Authority (NSWRA) dedicated to disaster recovery, reconstruction and preparedness. The NSWRA should: |
REC324-4299 | 1 - Land-use and building regs | Relocating communities most at risk with good homes and amenities: That, to empower vulnerable people and communities to relocate, Government through the NSWRA: |
REC324-4307 | 9 - Community education | Flood education: That, to build disaster resilience in future generations as floods and other natural disasters are a fact of Australian life, the Department of Education should design, implement and deliver an evidence-based, targeted education campaign (like sun exposure) in schools (new disaster curriculum). |
REC324-4300 | 1 - Land-use and building regs | Simplify the planning system disaster provisions: That, to simplify and improve the state planning processes especially when anticipating and recovering from a disaster, Government: |
REC324-4310 | 41 - Emergency Management exercises | Task Force Hawk: That, to ensure disaster readiness, Government establish a high-level Government standing committee, Task Force ‘Hawk’, comprising key Cabinet Ministers, Secretaries and Commissioners that meets, trains and exercises to ensure Government is prepared to respond to any emergency. Task Force ‘Hawk’ should resonate with the community in difficult times to ensure the highest level of confidence in Government’s response. |
Rec-ID | Code | Recommendation |
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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. |
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). |
REC314-3264 | 6 - Insurance and legal liability | Consider removing stamp duty from home insurance to encourage a wider section of the community to take out insurance. South Australian government agencies should share their risk modelling data with the Insurance Council of Australia. |
REC314-3263 | 4 - Fire season preparation | Clarify and streamline processes and educate the community about their roles and responsibilities in managing native vegetation to improve hazard reduction on both public and private land. Provide additional resources to manage fuel in a shorter off fire season and develop a risk reduction target linked to prioritised objectives. |
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. |
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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REC301-2392 | 39 - Disaster Risk Management | TFS should engage in discussions with government about the construction of purpose-built State Control Centre facilities for emergency management in Tasmania. |
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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REC297-1251 | 9 - Community education | That all councils include an easily identifiable website link for the public to locate their Municipal Emergency Management Plan and community safety information. |
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. |
REC297-1270 | 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. |
REC297-1250 | 22 - Role of local Gvt | That in flood-prone municipalities, the respective Municipal Committee develops or reviews flood-related sub-plans within a Municipal Emergency Management Plan at least every two years and submits each sub-plan to the Regional Controller for approval. In addition, that each Municipal Committee maintains a current flood plan, in a standardised format, which at least identifies: • flood-prone parts of their locality, particularly those where lives may be at risk; • required actions to be taken in the event of a flood threat, especially timely evacuation; • trigger points for taking required actions and how those trigger points will be monitored; and • how the community can access flood-plan information |
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. |
REC297-1269 | 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. |
REC297-1268 | 24 - Govt responsibility | That DPAC becomes the Management Authority for recovery in Tasmania. |
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. |
REC297-1256 | 9 - Community education | That SES and Tasmania Fire Service share resources and align their community education programs and adopt an all-hazards approach to awareness. |
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. |
REC297-1272 | 1 - Land-use and building regs | That, to provide greater clarity for building development, design and approval within tolerable risk levels, the Tasmanian Planning Scheme, including a relevant Riverine Flood Hazard Code, is finalised and approved as soon as practicable. |
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. |
REC297-1261 | 28 - Personal responsibility | That heightened awareness and action is needed by communities when BoM issues flood watches and related warnings. Councils and SES need to facilitate this. |
REC297-1271 | 1 - Land-use and building regs | That the organisations responsible for construction, maintenance and ownership of bridges review their design guidelines and, if necessary, update them to specifically include consideration of debris and flood impacts on bridge design. A review of existing bridges by the responsible organisations could also be undertaken to highlight any potential issues. |
Rec-ID | Code | Recommendation |
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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. |
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. |
Rec-ID | Code | Recommendation |
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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. |
REC295-1302 | 28 - Personal responsibility | That the State Emergency Service together with the Local Government Association and Country Fire Service establish a plan for coordinated provision of sandbags to the public, including options for what is provided, where and when, and the process for effective communication of availability to the public. |
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 |
REC295-1328 | 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. |
REC295-1276 | 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 |
REC295-1297 | 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. |
REC295-1315 | 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. |
REC295-1327 | 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. |
REC295-1274 | 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. |
REC295-1291 | 24 - Govt responsibility | That the Flood Reform Task Group, as proposed by the Department |
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. |
REC295-1319 | 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. |
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. |
REC295-1308 | 24 - Govt responsibility | That the Department of the Premier and Cabinet revise the ministerial documents relating to emergency management. |
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. |
REC295-1286 | 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. |
REC295-1306 | 9 - Community education | Develop practical policy outcomes to support resilience (e.g. the 72- hour model) and promote this broadly to community through media, awareness campaigns, policies etc. Research should be undertaken to gain insight into the types of messaging and activities that have the most impact on sustained behaviour change within the community before committing to a particular model. |
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. |
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. |
REC287-1186 | 9 - Community education | The Tasmanian fire agencies review: • their pre-season engagement with groups such as (but not limited to) environmental groups who might beneft from a greater understanding of fire management tactics, in order to inform them of and receive feedback on intended approaches to firefghting and fire management the work of the Public Information Section at incident management, regional and State level, to develop an increased appreciation of what information management might be most appropriate to serve the public interest in understanding the progress of the incident and to identify ways of providing surge capacity to resource effective information management in protracted and signifcant incidents. |
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. |
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. |
Rec-ID | Code | Recommendation |
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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. |
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. |
Rec-ID | Code | Recommendation |
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REC273-1141 | 21 - Role of Commonwealth Government | SACFS and the BoM review current weather, fuel loads and curing rates to determine the most appropriate and accurate forecast is prepared, issued and validated against current conditions. |
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. |
REC258-2526 | 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. |
REC258-2543 | 6 - Insurance and legal liability | The Civil Aviation Safety Authority reintroduces a ‘use of discretion’ procedure that gives operators or individuals the opportunity to discuss and, if necessary, remedy a perceived breach prior to CASA taking any formal action. This procedure is to be followed in all cases, except where CASA identifies a Serious and Imminent Risk to Air Safety. |
REC258-2552 | 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. |
REC258-2540 | 6 - Insurance and legal liability | The Civil Aviation Safety Authority continues to provide appropriate indemnity to all industry personnel with delegations of authority. |
REC258-2551 | 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. |
REC258-2539 | 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. |
REC258-2550 | 6 - Insurance and legal liability | The Civil Aviation Safety Authority introduces grading of Non-Compliance Notices on a scale of seriousness. |
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. |
REC258-2530 | 24 - Govt responsibility | The Australian Government appoints an additional Australian Transport Safety Bureau Commissioner with aviation operational and safety management experience. |
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. |
REC258-2557 | 6 - Insurance and legal liability | The Civil Aviation Safety Authority reassesses the penalties in the Civil Aviation Safety Regulations. |
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. |
REC258-2544 | 6 - Insurance and legal liability | The Australian Transport Safety Bureau transfers information from Mandatory Occurrence Reports to the Civil Aviation Safety Authority, without redaction or de-identification. |
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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REC256-1568 | 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. |
REC256-1575 | 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. |
REC256-1567 | 24 - Govt responsibility | State and territory governments should: |
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: |
REC256-1566 | 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. |
REC256-1572 | 6 - Insurance and legal liability | Insurers should provide additional standardised information to households regarding their insurance policies, the natural hazards they face and indicative costs of rebuilding after a natural disaster. This work should be led by the Insurance Council of Australia developing guidelines, within one year, to ensure consistency in the provision and presentation of this information across insurers. |
REC256-1564 | 6 - Insurance and legal liability | State and territory governments, local governments and insurers should explore opportunities for collaboration and partnerships. Partnerships, for example, could be formed through the Insurance Council of Australia and state-based local government associations (or regional organisations of councils). Consideration could be given to the Trusted Information Sharing Network model. Partnerships could involve: |
REC256-1571 | 24 - Govt responsibility | State and territory taxes and levies on general insurance should be phased out and replaced with less distortionary taxes. |
REC256-1561 | 24 - Govt responsibility | State and territory governments should be required to report on the following accountability requirements: |
REC256-1570 | 1 - Land-use and building regs | All governments should put in place best-practice institutional and governance arrangements for the provision of public infrastructure, including road infrastructure. These should include: |
REC256-1576 | 21 - Role of Commonwealth Government | Within three years, the Australian Government should develop and implement a framework for untied grants for community recovery assistance to state and territory governments. This framework should take into account factors such as the type, location and scale of a disaster, and the number of people affected. |
Rec-ID | Code | Recommendation |
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REC247-0934 | 4 - Fire season preparation | That the State Fire Management Committee considers developing a structured, systemic and proactive bushfire hazard reduction program with municipal councils and Tasmania Fire Service; and advises the Government on any legislative or other changes required to implement such a program. |
REC247-0891 | 9 - Community education | That emergency management plans specifically include processes for effectively engaging with local communities and using community resources, including volunteers. |
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. |
REC247-0923 | 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. |
REC247-0933 | 4 - Fire season preparation | That the Government considers whether a peak body should be established, with authority to effectively implement a bushfire mitigation plan. |
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. |
REC247-0939 | 5 - Hazard reduction burns | That Tasmania Fire Service conducts a review of the fire permit system in the Fire Service Act 1979, and implements change to improve the efficiency and effectiveness of the system by: • considering whether it is appropriate to authorise persons or organisations to conduct fuel reduction burning during a permit period • providing a better match between the period, area and fire risk • maintaining a timely and efficient process for issuing permits • naming the period in a way that draws attention to bushfire risk • establishing a reporting and accountability process. |
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. |
REC247-0951 | 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. |
REC247-0931 | 4 - Fire season preparation | That a specific risk prevention and mitigation advisory body be established for the State Emergency Management Committee. |
REC247-0938 | 5 - Hazard reduction burns | That Tasmania Fire Service or another suitable agency provides information to the community which shows, in simple form, the legislation applicable to approvals for lighting fires on private property and the various relationships between that legislation. |
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. |
REC247-0944 | 9 - Community education | That the State Emergency Management Committee develops and coordinates a whole-of-government community resilience strategy for emergencies in a form that can be practically implemented, as a priority. |
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. |
REC247-0937 | 19 - Offences | That the legislation and enforcement arrangements are reviewed to ensure there are suitable offences and penalties, investigation and enforcement capabilities, and a rigorous approach is taken to breaches of the law. |
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. |
REC247-0943 | 9 - Community education | That a bushfire community education and information strategy be professionally developed and coordinated across the fire authorities by Tasmania Fire Service. |
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. |
REC247-0935 | 4 - Fire season preparation | That the State Emergency Management Committee includes in its planning, the development of contingency emergency management plans for areas of high risk due to local conditions. |
REC247-0895 | 6 - Insurance and legal liability | That action be taken as a priority to resolve any legal issues on mutual assistance arrangement for fire services. |
REC247-0942 | 1 - Land-use and building regs | That the Government makes land use planning and building construction to prevent and mitigate bushfire risk a high priority and establishes a means to progress improvements in this area, such as a designated body or group, as soon as possible. |
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 |
---|---|---|
REC244-2605 | 39 - Disaster Risk Management | A thorough consultative process be developed and implemented between the CFS and local government. This will determine how bushfire management planning can enable improved process and practice to mitigate bushfire risk, and ensure that fire permits are issued and complied with. |
REC244-2627 | 4 - Fire season preparation | Government in conjunction with the CFS identify the ownership of disused railway corridors which may pose a significant fire risk and ensure the agency or individual responsible for the land complies with legislative requirements. |
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. |
REC244-2620 | 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. |
REC244-2600 | 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. |
REC244-2617 | 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. |
REC244-2616 | 6 - Insurance and legal liability | That once the review of the Emergency Management Act has been finalised, any reference to the liability of councils should be mirrored in both the EM Act and the F&ES Act. |
REC244-2606 | 22 - Role of local Gvt | The Act be amended to require the mandatory appointment of Authorised Officers by each rural council or council that has within its area a Designated Urban Bushfire Risk Area(s) with an option for the CFS Chief Officer to exempt council from this requirement (similar to Section 105B). |
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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC237-0825 | 1 - Land-use and building regs | That the NSW Rural Fire Service hold discussions with the Department of Planning and Infrastructure and Local Government NSW on ways to improve compliance with development consents under section 76A of the Environmental Planning and Assessment Act 1979. |
REC237-0830 | 9 - Community education | That Bush Fire Risk Management Plans be tabled at Local Emergency Management Committees for comment. |
REC237-0829 | 9 - Community education | That Bush Fire Risk Management Plans be posted on the NSW Rural Fire Service website. |
REC237-0828 | 9 - Community education | That the NSW Rural Fire Service develop a strategy to better inform the community and NSW Rural Fire Service members about the NSW bush fire management system and its components. |
Rec-ID | Code | Recommendation |
---|---|---|
REC207-2882 | 39 - Disaster Risk Management | Review disaster recovery and business continuity plans. |
REC207-2894 | 21 - Role of Commonwealth Government | Phase out seasonal prediction development and modelling and rely on products generated elsewhere |
REC207-2898 | 21 - Role of Commonwealth Government | Upgrade to the Bureau’s supercomputing capacity: |
REC207-2878 | 21 - Role of Commonwealth Government | Complete workforce planning project and succession plans as a matter of urgency. |
REC207-2891 | 21 - Role of Commonwealth Government | Cease or reduce the Ionospheric Prediction Service or offer it as a commercial service. |
REC207-2897 | 21 - Role of Commonwealth Government | Additional frontline meteorologists and specialised centres and systems: |
REC207-2876 | 21 - Role of Commonwealth Government | Focus the Bureau’s evolving environmental information role on natural hazards in the first instance. |
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 |
REC207-2896 | 21 - Role of Commonwealth Government | Lower yield options identified by the Bureau: |
REC207-2873 | 21 - Role of Commonwealth Government | Boost the Bureau’s flood warning capacity by: |
REC207-2887 | 21 - Role of Commonwealth Government | Centralise media services and establish protocols for media activity. |
REC207-2896 | 21 - Role of Commonwealth Government | Lower yield options identified by the Bureau: |
REC207-2872 | 21 - Role of Commonwealth Government | Boost the number of frontline meteorologists to build response capacity in regional forecasting centres. |
REC207-2900 | 21 - Role of Commonwealth Government | Explore use of social media to enhance data gathering from authorised and informal sources and to disseminate weather information |
REC207-2886 | 21 - Role of Commonwealth Government | Explore options to limit forecaster intervention in site-specific web forecasts. |
REC207-2895 | 21 - Role of Commonwealth Government | Fund delivery of improved seasonal forecasting services by: |
REC207-2899 | 21 - Role of Commonwealth Government | Improved seasonal forecasting capabilities: |
Rec-ID | Code | Recommendation |
---|---|---|
REC205-1905 | 6 - Insurance and legal liability | The Australian Government should only proceed with reforms that require all household insurers to offer flood cover if it can be demonstrated that the benefits to the wider community would exceed the costs. |
REC205-1899 | 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. |
REC205-1904 | 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. |
REC205-1898 | 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: |
REC205-1897 | 9 - Community education | The Australian Government initiative to improve the coordination and dissemination of flood-risk information should proceed in the most cost-effective way, be regularly updated and be expanded over time to encompass other natural hazards. Guidelines to improve the quality and consistency of risk information should also be regularly updated and take climate change into account where feasible. |
REC205-1902 | 25 - Inquiry, audit, lessons management and after action review | The Council of Australian Governments should commission an independent public inquiry to develop an appropriate response to managing the risks of climate change to existing settlements. The inquiry should: |
REC205-1896 | 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: |
REC205-1901 | 1 - Land-use and building regs | The Council of Australian Governments’ Building Ministers’ Forum should provide formal direction to the Australian Building Codes Board to: |
REC205-1906 | 6 - Insurance and legal liability | Governments should not subsidise household or business property insurance, whether directly or by underwriting risks. |
REC205-1900 | 1 - Land-use and building regs | As a priority, state and territory governments should ensure that land-use planning systems are sufficiently flexible to enable a risk management approach to incorporating climate change risks into planning decisions at the state, territory, regional and local government levels. Consideration should be given to: |
Rec-ID | Code | Recommendation |
---|---|---|
REC189-2913 | 21 - Role of Commonwealth Government | In developing and improving its policies and practices for stakeholder engagement, NOPSA should ensure that: |
REC189-2910 | 21 - Role of Commonwealth Government | NOPSA should: |
REC189-2908 | 21 - Role of Commonwealth Government | To ensure that NOPSEMA is in a strong position to perform its functions effectively: |
REC189-2906 | 21 - Role of Commonwealth Government | In order to improve the effectiveness of National Offshore Petroleum Safety and Environmental Management Authority (NOPSEMA), with similar benefits for State or Territory regulators, attention should be given to the following actions. |
Rec-ID | Code | Recommendation |
---|---|---|
REC177-3376 | 21 - Role of Commonwealth Government | In carrying out a review of PTTEPAA’s permit and licence, the Minister should have regard to this Report, particularly (i) the adverse findings set out in this Chapter; and (ii) the extent to which PTTEPAA has implemented the Action Plan submitted to the Inquiry, or otherwise addressed the matters canvassed in this Report. |
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. |
REC177-3274 | 21 - Role of Commonwealth Government | The Minister should appoint a senior policy adviser to investigate and report on the best means to implement the recommendations contained in this Chapter 3 of this report. |
REC177-3351 | 21 - Role of Commonwealth Government | In the future, and in the interests of ensuring that all possible well control options are comprehensively pursued to exhaustion, decisions as to well control response options should be the result of collaboration between the regulator and the operator rather than leaving one party to make unilateral judgements as to the appropriateness of various well control operations. The regulator should provide transparent and contemporaneous explanations to the public of all well control options under consideration at any particular time. |
REC177-3365 | 6 - Insurance and legal liability | The National Plan should specify that the cost of responding to an oil spill, or other damage to the offshore marine environment, will be totally met by the owner/operator. This would be consistent with the Inquiry’s recommendation for legislative changes to the regulatory framework concerning owner/operators meeting the cost of monitoring and remediation of environmental damage. |
REC177-3375 | 21 - Role of Commonwealth Government | For the purposes of that review, the Minister should issue a ‘show cause’ notice to PTTEPAA under s 276 of the OPGGS Act. |
REC177-3330 | 39 - Disaster Risk Management | Decision‐making about well control issues should be professionalised. Industry participants must recognise that decision‐makers owe independent duties to the public, not just their employer or principal, in relation to well control. Risk management in the context of well control needs to be understood as an ethical/professional duty. Self‐regulation contemplates self‐regulation by the industry, not just by individual licensees and operators. |
REC177-3349 | 21 - Role of Commonwealth Government | In the meantime, the Minister should: |
REC177-3360 | 42 - Culture and Heritage | DEWHA should participate in training programs and exercises relevant to an oil spill in the marine environment. |
REC177-3289 | 39 - Disaster Risk Management | The use/type of barriers (including any change requests relating thereto) must be the subject of consultation between licensees and rig operators prior to installation. A proper risk assessment should be carried out, agreed upon, and documented in writing before installation. Joint written certification as to the appropriateness of the use of particular barriers should take place before installation. Senior onshore representatives of stakeholder entities should be involved in that certification process. |
REC177-3374 | 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. |
REC177-3310 | 6 - Insurance and legal liability | Consideration should be given to ways to ensure that contractors who are involved in barrier installation (such as cementing companies) have a direct interest in the performance of works to a proper standard. In particular, consideration should be given to (i) preventing contractors from avoiding the economic consequences of negligent installation of barriers; and/or (ii) imposing specific legislative standards of workmanship on contractors with respect to well control (similar to those which presently apply to licensees). |
REC177-3348 | 21 - Role of Commonwealth Government | Responsibility for well integrity should be moved to NOPSA (as also proposed by the Productivity Commission). |
REC177-3358 | 21 - Role of Commonwealth Government | The body established to undertake a central coordination and facilitation role in the event of any future blowout in Commonwealth waters should undertake to make all relevant information publically available from one, authoritative and easy to access source. |
REC177-3287 | 38 - Agency/Department Reporting | Licensees should be subject to an express obligation to inform regulators of problems which arise in the course of installing barriers, even if they consider that well integrity is not thereby compromised. The information should be provided by way of special report, rather than included in a standard reporting document (such as a DDR). The information provided should include risk assessment details. |
REC177-3372 | 21 - Role of Commonwealth Government | OSCPs should be endorsed by AMSA prior to regulatory approval to ensure that they align with the National Plan. Once field operations commence, the capability of operators should be assessed against their plans, and exercises conducted to ensure the plans remain effective. |
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. |
REC177-3347 | 21 - Role of Commonwealth Government | The proposal of the Productivity Commission’s Research Report (Review of Regulatory Burden on the Upstream Petroleum (Oil and Gas) Sector, April 2009) to establish a NOPR should be pursued at a minimum. |
REC177-3357 | 21 - Role of Commonwealth Government | In any future similar blowout or offshore emergency situation, the Minister appoint (through either a NOPR or the relevant Department) a senior public servant to establish and oversight a central coordinating body that will facilitate interaction between regulators, industry, AMSA and the owner/operator. Primary responsibility for stopping a blowout should remain with the owner/operator but should be subject to direction from the central coordinating body in consultation with stakeholders (including the owner/operator). |
REC177-3286 | 39 - Disaster Risk Management | Problems which arise in the course of installing barriers must be the subject of consultation between licensees, rig operators, and contractors (if used). A proper risk assessment should then be carried out and remedial steps (including further testing/verification) should be agreed upon, and documented in writing before the performance of remedial work whenever practicable. Joint written certification as to resolution of the problem should take place before resumption of drilling operations. Senior onshore representatives of stakeholder entities should be involved in that certification process. |
REC177-3371 | 21 - Role of Commonwealth Government | The Government should examine the scope for a single environment plan to meet the regulatory requirements of both the OPGGS Act and the EPBC Act. This could possibly be achieved by way of bilateral agreements and accreditation arrangements and/or legislative amendment. |
REC177-3291 | 39 - Disaster Risk Management | Removal of a barrier must be the subject of consultation between licensees and rig operators prior to removal. A proper risk assessment should be carried out and agreed upon, and documented in writing before removal. Joint written certification as to the appropriateness of removal should take place before removal. Senior onshore representatives of stakeholder entities should be involved in that certification process. |
REC177-3378 | 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. |
REC177-3346 | 21 - Role of Commonwealth Government | A single, independent regulatory body should be created, looking after safety as a primary objective, well integrity and environmental approvals. Industry policy and resource development and promotion activities should reside in government departments and not with the regulatory agency. The regulatory agency should be empowered (if that is necessary) to pass relevant petroleum information to government departments to assist them to perform the policy roles. |
REC177-3285 | 39 - Disaster Risk Management | Pre‐drilling assessments should include a risk assessment of the worst‐case blowout scenario. |
REC177-3356 | 39 - Disaster Risk Management | The regulator should pre‐assess and review in a generic sense, and in conjunction with the offshore petroleum industry, available options for well control in the event of a blowout. Being ‘match fit’ in this sense will enable a quicker and more effective response in terms of safety assessment, and will ensure that expectations of both operator and regulator are more readily aligned. |
REC177-3369 | 6 - Insurance and legal liability | The obligation of companies involved in an incident to meet the full costs of monitoring and remediation should be made a condition of approval of proposals under the EPBC Act and OPGGS Act. Suitable arrangements (insurance or otherwise) need to be in place to ensure that companies have this capacity. |
REC177-3290 | 38 - Agency/Department Reporting | The successful installation of every barrier should be the subject of written verification within and between licensees and rig operators; and should be the subject of explicit reporting to the relevant regulator(s). |
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 |
REC164-0074 | 9 - Community education | SERCon consider a review of existing community-based educational programs, with a view to informing the community |
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. |
REC161-3030 | 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. |
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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC151-3092 | 19 - Offences | Expiation fees be reviewed so as to be consistent with the seriousness of the offences. |
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. |
REC151-3095 | 24 - Govt responsibility | SAFECOM re-evaluate and determine a more meaningful definition of fire districts. |
Rec-ID | Code | Recommendation |
---|---|---|
REC149-3138 | 38 - Agency/Department Reporting | The current KPI measures used by the Regulator and industry need to be reassessed and the performance indicators need to be related to the risk profiles of the industry. The industry needs to develop the indicators, which need to be agreed and measured by the industry in discussion with other stakeholders. The KPI's selected should be published in comparison with the worldwide offshore industry and with other industries. NOPSA should continue discussions with Australian Safety and Compensation Council (ASCC) with a view to adopting their goals. |
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. |
REC149-3133 | 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. |
REC149-3145 | 25 - Inquiry, audit, lessons management and after action review | NOPSA should consider an audit regime that targets Greenfields operations at commencement of operations. |
REC149-3132 | 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. |
REC149-3143 | 21 - Role of Commonwealth Government | The role of the advisory Board, namely to give advice to Ministers and NOPSA when asked, should be made clear to Board members and all stakeholders. The Board and NOPSA should consider the need for a clear description of who does what based on the legislated responsibilities of the NOPSA CEO. |
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. |
REC149-3142 | 19 - Offences | NOPSA should use encouragement as the primary tool of enforcing compliance provided willingness to improve is exhibited by the players. |
REC149-3139 | 39 - Disaster Risk Management | The industry should develop in conjunction with the Regulator a process for addressing the need to maintain the risk profile of a facility moving into extended life operation at the same risk profile as when it was within design life. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC140-3574 | 38 - Agency/Department Reporting | Formation of a subcommittee of the DHHS Tasmanian Medical Retrieval Services Committee to identify risk exposures, system problems and potential solutions. The subcommittee should review data, problem cases, system issues and generate a risk register. Meetings should occur at least quarterly. |
REC140-3558 | 6 - Insurance and legal liability | DHHS need to confirm adequate accident insurance coverage for staff working in retrieval medicine. Coverage specific to helicopter and fixed wing duties is required. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC121-3729 | 38 - Agency/Department Reporting | All reports of the Chief Investigator of OTSI should be delivered, upon completion and without being reviewed, to ITSRR and the Minister for Transport Services. |
REC121-3700 | 39 - Disaster Risk Management | Maintenance plans on all trains should be revised annually. |
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. |
REC121-3657 | 10 - Infrastructure | All signal telephones must be maintained by RailCorp in proper working order. |
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. |
REC121-3776 | 38 - Agency/Department Reporting | The Minister for Transport Services should retain, independently of ITSRR, safety auditors to provide a report to the Minister confirming or qualifying the contents of each such ITSRR quarterly report. |
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. |
REC121-3726 | 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. |
REC121-3697 | 38 - Agency/Department Reporting | All train drivers’ defects reports should be entered by RailCorp into a computerised record and tracked to finalisation. |
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. |
REC121-3653 | 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. |
REC121-3712 | 38 - Agency/Department Reporting | RailCorp and ITSRR should co-operate with national programs for the collection, collation, trend analysis and dissemination of safety critical information. |
REC121-3775 | 38 - Agency/Department Reporting | The Minister for Transport Services must table in Parliament, each such quarterly report by ITSRR. |
REC121-3684 | 39 - Disaster Risk Management | The ITSRR should conduct its own risk assessment in relation to the risk of any such high consequence, low probability accident and, if necessary, direct RailCorp to conduct a further risk assessment to reduce the level of residual risk to a level ITSRR regards as acceptable. |
REC121-3723 | 38 - Agency/Department Reporting | All ATSB accident investigation reports should be made public. |
REC121-3695 | 10 - Infrastructure | There should be interoperability of communications equipment between all trains operating on the New South Wales rail network. |
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. |
REC121-3651 | 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. |
REC121-3710 | 39 - Disaster Risk Management | The ITSRR should have permanent access to the RailCorp intranet. |
REC121-3774 | 38 - Agency/Department Reporting | The ITSRR must provide a quarterly report to the Minister for Transport Services on the progress made by RailCorp in implementing these recommendations, including: |
REC121-3683 | 39 - Disaster Risk Management | RailCorp should undertake risk assessments of each of its activities as follows: |
REC121-3722 | 38 - Agency/Department Reporting | The ATSB should deliver any report of any such rail accident which it investigates to the Board of any rail organisation involved in the accident, ITSRR and the Minister for Transport Services. |
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. |
REC121-3753 | 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. |
REC121-3704 | 28 - Personal responsibility | RailCorp should continue its system of voluntary self-identification and rehabilitation of employees with alcohol or drug related problems. |
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. |
REC121-3678 | 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. |
REC121-3721 | 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. |
REC121-3693 | 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. |
REC121-3742 | 19 - Offences | The risk of abuse of internal passenger emergency door releases should be further reduced by introducing significant penalties for any improper use of such an emergency facility. It should be a criminal offence for anyone to use or tamper improperly with an emergency escape facility in a train. |
REC121-3703 | 6 - Insurance and legal liability | Alcohol and drug testing should be mandatory for any train driver or guard involved in any accident or incident. |
REC121-3767 | 24 - Govt responsibility | All accredited rail organisations should be required to re-apply every three years to ITSRR for accreditation. |
REC121-3673 | 41 - Emergency Management exercises | Regular field training exercises should be conducted by RailCorp with the emergency services to ensure that the incident command system and rail displan are able to be fully implemented as quickly as possible and are reviewed and improved. |
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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC118-3644 | 21 - Role of Commonwealth Government | That the Prime Minister’s Science, Engineering and Innovation Council requests that the Australian Government, through the Australian Emergency Management Committee, develops an effective pathway to incorporate hazard science into emergency management policy. |
REC118-3643 | 21 - Role of Commonwealth Government | Consolidate the Australian Government decision to establish an Australian Tsunami Warning System through a long-term government commitment to ensure a sustainable and effective national tsunami warning system beyond the current four-year initiative. |