Inquiry Search
Rec-ID | Code | Recommendation |
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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). |
REC324-4310 | 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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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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REC264-1087 | 25 - Inquiry, audit, lessons management and after action review | GDF Suez: • practice and ensures that, by taking a risk management approach, it is suitable for fire prevention, mitigation and suppression in all parts of the Hazelwood mine; and review its ‘Mine Fire Service Policy and Code of Practice’ so that it refects industry best • work plan for the Hazelwood mine. incorporate the revised ‘Mine Fire Service Policy and Code of Practice’ into the approved |
REC264-1086 | 25 - Inquiry, audit, lessons management and after action review | GDF Suez: • consequences of fire in the worked out areas of the Hazelwood mine, and an assessment of the most effective fre protection for the exposed coal surfaces; conduct, assisted by an independent consultant, a risk assessment of the likelihood and • controls are in place to eliminate or reduce the risk of fre; and prepare an implementation plan that ensures the most effective and reasonably practicable • implement the plan |
REC264-1083 | 9 - Community education | The State, led by Emergency Management Victoria, develop a community engagement model for emergency management to ensure all State agencies and local governments engage with communities and already identifed trusted networks as an integral component of emergency management planning. |
REC264-1072 | 25 - Inquiry, audit, lessons management and after action review | The State empower and require the Auditor-General or another appropriate agency, to: • oversee the implementation of these recommendations and the commitments made by the State and GDF Suez during this Inquiry; and • report publicly every year for the next three years on the progress made in implementing recommendations and commitments. |
Rec-ID | Code | Recommendation |
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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 |
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REC199-0419 | 21 - Role of Commonwealth Government | the Bureau of Meteorology provide Incident Control Centres with real-time access to flood data held by the Bureau of Meteorology. This will require Bureau of Meteorology staff making themselves available to respond to enquiries from Incident Control Centres during a flood event. |
REC199-0465 | 24 - Govt responsibility | the state undertake major reform of Victoria’s emergency management arrangements to bring about an effective ‘all hazards, all agencies’ approach, incorporating: • clarity of command and control in all emergencies • common operating platforms, including communications and information technology • interoperability between all agencies • regular joint training and exercising by all agencies • the development and implementation of performance standards for each emergency management agency • the development and maintenance of effective planning arrangements at all levels of emergency management • a meaningful monitoring and audit regime for designated standards and planning requirements; and • an effective accountability mechanism to support the maintenance of legislative and other agency obligations. |
REC199-0401 | 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. |
REC199-0427 | 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. |
REC199-0481 | 24 - Govt responsibility | the state (consistent with recommendation 46) develop a model for determining the capability and capacity of departments and agencies with roles and responsibilities in large scale or protracted emergencies. The issues of capability and capacity should be addressed at all levels of emergency management planning. |
REC199-0407 | 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. |
REC199-0446 | 7 - Inter-agency communication | the state commit to securing effective multi-agency interoperable communications as a high level priority and that all future communications projects and upgrades incorporate compliance provisions mandating interoperability requirements. |
REC199-0418 | 7 - Inter-agency communication | the state develop an efficient process to ensure that, during flood events, temporary construction of flood mitigation works, such as levees, is controlled so as not to unacceptably impact on flood intelligence. |
REC199-0458 | 7 - Inter-agency communication | the state ensure: • a common, functional and accessible system be introduced to enable effective Municipal Emergency Coordination Centre and Incident Control Centre communications • a regime of regular Municipal Emergency Coordination Centre exercising is introduced with oversight by an appropriate independent body. Such exercising should include testing of systems utilised for Incident Control Centre and Municipal Emergency Coordination Centre communications • those required to perform Emergency Management Liaison Officer roles have undertaken appropriate training; and • resource requesting arrangements are clarified and documented so that control and coordination functions do not overlap. |
REC199-0400 | 24 - Govt responsibility | The state take the necessary measures to clarify roles, responsibilities and cost-sharing arrangements for flood warning systems, including tasking state and regional bodies to be responsible for the flood warning system. This will require engaging with the commonwealth to amend the 2001 arrangements, updating the 1998 floodplain management strategy accordingly and continuing to support commonwealth initiatives designed to improve flood mapping standards and associated issues. |
REC199-0426 | 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. |
REC199-0477 | 21 - Role of Commonwealth Government | the state review the potential for National Registration and Inquiry System 6 to provide a single point of information collection to both register individuals and plan the delivery of recovery services. If the review determines National Registration and Inquiry System 6 is unable to fulfil this function, the state should work with the commonwealth and other states to implement the necessary changes to National Registration and Inquiry System 6. If National Registration and Inquiry System 6 is unable to be developed as a single information collection system: the state should develop and implement a single point of information collection system, including how information obtained from outreach activities can be incorporated into this system and how such information may be linked into the Rapid Impact Assessment process. |
REC199-0406 | 24 - Govt responsibility | the state expand the Regional Water Monitoring Partnerships model to include all flood warning gauges. |
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. |
REC199-0413 | 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 |
REC199-0455 | 24 - Govt responsibility | the state conduct an ‘all hazards’ needs analysis to determine requirements for level 3 Incident Control Centres with a focus on ‘all hazards’ and multi-agency capability. Following this analysis, the state take steps to ensure the availability of sufficient and functional level 3 Incident Control Centres across the state with an ‘all hazards’ and multi-agency capability |
REC199-0425 | 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. |
REC199-0470 | 21 - Role of Commonwealth Government | the commonwealth consider including (as part of its review of standards for aged care services) requirements for: • robust ‘all hazards’ evacuation plans that include current after-hour contact details of people who are able to make authoritative decisions during an emergency; and • rehearsal of those plans. |
REC199-0405 | 21 - Role of Commonwealth Government | the state and the Bureau of Meteorology liaise to ensure the existence of appropriate quality control processes for gauges and contingency measures in the event that gauges are damaged during flood events. |
REC199-0431 | 9 - Community education | the state allocate core funding for the ongoing delivery of the ‘FloodSafe’ program to flood prone communities across Victoria. |
REC199-0486 | 22 - Role of local Gvt | the state, following the completion of the Municipal Association of Victoria Improving Emergency Management in Local Government program, work with municipalities to revise the role and responsibilities of local government in emergency management. The issue of capability and capacity of each local government should be addressed in all related emergency management arrangements. |
REC199-0412 | 21 - Role of Commonwealth Government | the Bureau of Meteorology adjust its flood prediction models to incorporate water storage conditions (to enable it to issue more timely and useful flood predictions for communities based downstream of water storages). |
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 |
REC199-0424 | 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. |
REC199-0468 | 22 - Role of local Gvt | municipal councils undertake a risk assessment of caravan parks and decide if any should be included in the list of facilities where vulnerable people may be located. |
REC199-0404 | 21 - Role of Commonwealth Government | the state engage with the Bureau of Meteorology to establish a joint initiative to review existing flash flood warning systems in Victoria and identify where additional systems are needed, with a particular focus on urban centres with a history of flash flooding. This review should seek to achieve outcomes similar to those implemented in NSW. Subject to those outcomes being implemented, the state should determine which agency is responsible for flash flood warnings. |
REC199-0430 | 9 - Community education | the state undertake a community education program to inform households of their respective flood risk. This may include information on rate notices of heights of houses above flood level and educating people about flash flooding. |
REC199-0483 | 9 - Community education | the state ensure: • where external assistance is provided to Victoria during emergencies, communities are advised of the specific purpose of that assistance, through media and other information channels; and • all agencies provide incident management personnel with information regarding the arrangements for tasking Australian Defence Force resources and that this advice is reinforced during emergencies where Australian Defence Force support is provided. |
REC199-0411 | 21 - Role of Commonwealth Government | the Bureau of Meteorology undertake a review of its radar coverage in the context of flash and riverine flood warnings for Victoria, with a particular focus on known gap areas such as the Horsham/Nhill region. |
REC199-0449 | 7 - Inter-agency communication | the state ensure that interoperable information management practices are developed and implemented by emergency management agencies. Common systems should be utilised to the fullest extent possible. |
REC199-0423 | 21 - Role of Commonwealth Government | the Bureau of Meteorology expand its volunteer amateur weather watch groups to enhance its weather and flood information gathering procedures. |
REC199-0466 | 24 - Govt responsibility | the Departments of Health and Human Services finalise the definition of ‘vulnerable person’ and the list of facility types where vulnerable people are located and ensure that the definition and associated policy(ies) are applicable across ‘all hazards’. |
REC199-0403 | 21 - Role of Commonwealth Government | the state and commonwealth undertake a review into the appropriate institutional arrangements for the forecasting and predictions function currently undertaken by Melbourne Water for the Port Phillip and Westernport region. |
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. |
REC199-0482 | 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. |
REC199-0409 | 21 - Role of Commonwealth Government | the Bureau of Meteorology should present water levels in both local datum and Australian Height Datum (gauge zero) for all its published information and warnings |
REC199-0447 | 7 - Inter-agency communication | the state ensure that common and interoperable resource management systems are developed and implemented by emergency management agencies. Common systems should be utilised to the fullest extent possible. |
Rec-ID | Code | Recommendation |
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REC197-1741 | 9 - Community education | A. The CFA further develop community education programs to specifically engage culturally and linguistically diverse (CALD) communities to address the importance of ethnic diversity. |
REC197-1733 | 25 - Inquiry, audit, lessons management and after action review | That a review of the Country Fire Authority Act 1958 and the Country Fire Authority Regulations 2004 be undertaken. |
Rec-ID | Code | Recommendation |
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REC164-0074 | 9 - Community education | SERCon consider a review of existing community-based educational programs, with a view to informing the community |
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 |
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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. |
REC121-3663 | 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. |
REC121-3723 | 38 - Agency/Department Reporting | All ATSB accident investigation reports should be made public. |
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. |
REC121-3757 | 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. |
REC121-3704 | 28 - Personal responsibility | RailCorp should continue its system of voluntary self-identification and rehabilitation of employees with alcohol or drug related problems. |
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: |
REC121-3652 | 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. |
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. |
REC121-3676 | 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. |
REC121-3753 | 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. |
REC121-3697 | 38 - Agency/Department Reporting | All train drivers’ defects reports should be entered by RailCorp into a computerised record and tracked to finalisation. |
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. |
REC121-3721 | 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. |
REC121-3673 | 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. |
REC121-3742 | 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. |
REC121-3694 | 25 - Inquiry, audit, lessons management and after action review | The ITSRR should conduct random audits of accredited rail organisations for compliance with communications protocols. |
REC121-3767 | 24 - Govt responsibility | All accredited rail organisations should be required to re-apply every three years to ITSRR for accreditation. |
REC121-3720 | 24 - Govt responsibility | The New South Wales Government should make the necessary arrangements with the Australian Government, including any necessary legislation, for the Australian Transport Safety Bureau (ATSB) to have the power to investigate all rail accidents occurring on the New South Wales rail network the investigation of which may advance the knowledge of the causes of rail accidents in Australia. |
REC121-3666 | 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. |
REC121-3729 | 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. |
REC121-3693 | 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. |
REC121-3765 | 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. |
REC121-3713 | 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. |
REC121-3665 | 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. |
REC121-3726 | 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. |
REC121-3691 | 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. |
REC121-3758 | 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. |