Inquiry Search
Rec-ID | Code | Recommendation |
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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). |
REC314-3262 | 10 - Infrastructure | Invest in upgrading and integrating ICT platforms to eliminate manual data transfers, and ensure IT and radio communication interoperability across the agencies, together with a dedicated focus on the development of a coordinated risk intelligence capability to provide all stakeholders with a common operating picture and rapid damage assessments. |
REC314-3263 | 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. |
Rec-ID | Code | Recommendation |
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REC296-1355 | 10 - Infrastructure | Replacement of all original pipes and hoses not yet done. |
REC296-1360 | 10 - Infrastructure | Carry out regular load bank testing on the generator with a load bank large enough to fully load the generator to 110% which will clean out the engine and also identify whether the generator is capable of providing full load for a sustained length of time. |
REC296-1349 | 10 - Infrastructure | Conduct an assessment of the current essential loads and determine if there are loads that should not be on essential power. |
REC296-1354 | 10 - Infrastructure | Monthly and annual maintenance servicing needs to be scheduled for the generator to DPTI or CHSA schedule requirements. |
REC296-1359 | 10 - Infrastructure | Renegotiate the maintenance contract at the end of the current contract and have DPTI through AGFMA take on the maintenance contract. |
REC296-1353 | 10 - Infrastructure | Regular annual testing at 100% on a load bank needs to be scheduled into a maintenance schedule. |
REC296-1358 | 10 - Infrastructure | If the existing generator is capable of providing the current essential power requirements then the generator needs a major inspection and overhaul all items that may need to be replaced due to age and condition. This includes checking compression, oil pressure, coolant pumping and all other critical components and may actually require providing a temporary generator while the Hospital generator receives a major inspection and possible re build. A ball park figure to do this would be $50,000.00 plus cranage and transport to Detroit workshop probably another $10,000.00 then a temporary generator would need to be hired and installed which could run into $10’s of thousands of dollars depending on how long the engine was out of service. For the money that would be spent checking and rebuilding the existing engine it would be recommended to replace the generator with a new generator. |
REC296-1363 | 10 - Infrastructure | Due to the age of the generator, reliability and reparability risk due to age and the apparent under capacity of the generator it is recommend to replace the generator with a new generator and associated control system designed for the current load requirements and allowance for some future expansion. |
REC296-1352 | 10 - Infrastructure | A monthly testing regime needs to be developed that will allow the generator to be tested at full essential load capacity and to ensure that 4 hour monthly testing can be done every month. |
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. |
Rec-ID | Code | Recommendation |
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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. |
REC295-1279 | 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. |
Rec-ID | Code | Recommendation |
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REC291-1236 | 4 - Fire season preparation | The Departments of Parks and Wildlife and Fire and Emergency Services to develop options for the expansion of the ‘Bushfire Mitigation Grant Scheme’ 20 January 2016 Waroona Fire Special Inquiry utilising both State and Commonwealth Government funding to enable the implementation of hazard reduction works identified through the Bushfire Risk Management Planning process. This will target hazard reduction projects on land owned by private landholders in rural-urban interface areas, critical infrastructure protection, local government land, roadsides and land managed by utilities. |
REC291-1237 | 5 - Hazard reduction burns | The Department of Fire and Emergency Services, utilising the Office of Bushfire Risk Management, to develop a simplified and fast track hazard reduction burn (and other fuel mitigation techniques) planning and approval process to ensure the timely conduct of township and asset protection burns by Bush Fire Brigades and individual property owners. The process is to be agile and adaptable for the range of stakeholders which may participate in low risk, small scale, low complexity burn planning and approvals. |
REC291-1235 | 5 - Hazard reduction burns | The Department of Parks and Wildlife to continue emphasis on landscape hazard reduction burning with the annual objective of treating 140,000 hectares per annum in Land Management Zone C. In combination with Recommendation 2 (above) the strategic objective will be that a fuel age of less than six years will be maintained across 45% of the landscape on State Forest, National Parks and other Parks and Wildlife managed lands in the South West and Perth Hills. This will address the current backlog (created from under achievements of the recent two decades of burn programs) by the end of the 2020-2021 burning season (i.e. within the next 5 years). |
REC291-1234 | 5 - Hazard reduction burns | The Department of Parks and Wildlife to plan for the highest priority hazard reduction burning effort around settlements and critical assets in the South West and Perth Hills. The annual objective is to treat a total of 60,000 hectares of priority hazard reduction per annum, comprising 20,000 hectares per annum of Land Management Zone A and 40,000 hectares per year of Land Management Zone B. |
Rec-ID | Code | Recommendation |
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REC284-1372 | 10 - Infrastructure | As part of the electrical master plan update recommended above, a complete and consistent set of single line diagrams describing the electrical distribution network be prepared. Relevant diagrams to be laminated and displayed in the main substations. Labelling to all main electrical equipment be reviewed and updated in accordance with the final documents. |
REC284-1366 | 10 - Infrastructure | A detailed review of the fuel control and BMS systems (for all generators) be carried out and actions taken to: 1) Ensure that the fuel alarm system is operational and properly calibrated, and ensure that the alarms are connected to the BMS. 2) Ensure that the BMS transmits these alarms effectively to the maintenance staff. 3) If this review demonstrates risk of fuel control systems not adequately reporting alarms, consider an independent day tank level switch to be installed in each generator fuel tank, directly connected to the BMS. 4) Consider the feasibility of adding a “fuel system not in auto” or “fuel system fault/fail safe watchdog” or “pre-alarm identifying that the generator is about to shut down without intervention” feature to current systems – subject to details of each individual generator system. |
REC284-1371 | 10 - Infrastructure | Generator dual redundant starter systems should be considered. |
REC284-1365 | 10 - Infrastructure | The electrical master plan for the site should be updated to include planning for the scheduled replacement or refurbishment of those parts of the infrastructure that have not been renewed in the last 10 years. This planning to consider other upgrades or plans for the FMC overall. |
REC284-1370 | 10 - Infrastructure | Review control system for the main generator normal/essential changeover system and ensure that it has effective backup/manual or redundant operations, and suitable testing facilities. The Essential board that supplies the main generator power to Blocks A, B, C (except theatres), D, E (except certain critical engineering plant) (MD-1-4P-10E), is a potential single point of failure of a significant portion of the emergency power system and as part of the Master Plan update should be considered as a priority. |
REC284-1369 | 10 - Infrastructure | Review all generator locations for arrangements for temporary generator installation, including design of modifications as required for electrical connections and spatial requirements at installation locations, to be documented in an emergency procedure. |
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. |
Rec-ID | Code | Recommendation |
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REC264-1085 | 10 - Infrastructure | GDF Suez establish enhanced back-up power supply arrangements that do not depend wholly on mains power, to: • ensure that the Emergency Command Centre can continue to operate if mains power is lost; and • ensure that the reticulated fre services water system can operate with minimal disruption if mains power is lost. |
Rec-ID | Code | Recommendation |
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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. |
REC247-0935 | 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. |
REC247-0934 | 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. |
REC247-0857 | 2 - Emergency powers | That the Tasmania Emergency Management Plan enable, and all organisations with a role in emergency management activate, emergency plans at lower threshold events to practice their arrangements and achieve a ‘hot start’ in escalating events. |
REC247-0937 | 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. |
REC247-0933 | 4 - Fire season preparation | That the Government considers whether a peak body should be established, with authority to effectively implement a bushfire mitigation plan. |
REC247-0904 | 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. |
REC247-0856 | 2 - Emergency powers | That the Government reconsider the current position on emergency declarations in the Emergency Management Act 2006 and the Act is amended to provide: • a graduated scale of emergency declarations; • the ability to make a declaration when an emergency has occurred, is occurring or is about to occur; • the ability for the State Controller (or whatever the person in overall control of response and recovery operations is called) to make one or more declarations; • a declaration to enable access to all emergency powers. |
REC247-0939 | 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. |
Rec-ID | Code | Recommendation |
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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. |
Rec-ID | Code | Recommendation |
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REC239-2674 | 38 - Agency/Department Reporting | That Queensland Corrective Service continues to develop its proposed recidivism index as a priority, including place and program based measures. |
REC239-2773 | 38 - Agency/Department Reporting | That should the Mobile Strategy in its current form be approved by government the CEO Portfolio Business and the Deputy Commissioner Operations: |
REC239-2673 | 38 - Agency/Department Reporting | That Queensland Corrective Service, in consultation with key partners in the criminal justice and social services sectors, develops specific performance indicators focused on efficiencies and customer/stakeholder outcomes across the criminal justice system. |
REC239-2772 | 38 - Agency/Department Reporting | That the roll-out of the mobile service program business case mentioned earlier |
REC239-2771 | 38 - Agency/Department Reporting | That the Queensland Police Service Commissioner addresses the situation regarding statistical reporting. The Commissioner, in collaboration with the Chief Executive Officer Portfolio Business and the Queensland Fire and Rescue Service Commissioner should also examine the opportunity to acquire the services of a qualified and experienced Chief Information Officer or Chief Digital Officer in line with other Queensland and Australian government agencies. |
REC239-2767 | 38 - Agency/Department Reporting | Recommendation: That the CEO Portfolio Business collaborates with the two portfolio Commissioners to: |
REC239-2684 | 38 - Agency/Department Reporting | The Chief Executive Officer Portfolio Business establishes a set of performance indicators to provide a transparent process for government to monitor its performance. |
Rec-ID | Code | Recommendation |
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REC223-0515 | 5 - Hazard reduction burns | The Department of Environment and Conservation urgently undertake a review of its risk management practices as they relate to prescribed burns including but not limited to: *reviewing risk management practices to ensure that they are in accordance with AS/NZS ISO 31000:2009; * finalising and implementing the new complexity model developed in house by the DEC; * considering a broader set of parameters of risk by conducting an environmental scan or similar tool for areas under consideration for a prescribed burn; *updating the prescribed fire plans to reflect the broader risk considerations discovered through environmental scanning; *better informing the risk considerations by updating the ‘Red Book’ to reflect current research on burning in coastal heath; and * reconsidering the utility of the ‘Red Flag Burn’ notification on files and either adopting it as a policy across the State or removing it as a consideration. |
REC223-0514 | 5 - Hazard reduction burns | The Department of Environment and Conservation review its current policies and operational guidelines in particular by: * strengthening the governance of operations by ensuring the Guidelines are relevant and practical; * ensuring the processes that are implemented for prescribed burns are: (a) value adding to the decisions and approvals required (b) informed by substantive input (c) focussed on outcome rather than process; *completing the draft management plan for the Leeuwin-Naturaliste Capes Area Parks and Reserves in accordance with the provisions of the Conservation and Land Management Act 1989; * exploring the possibility of automating and streamlining the various processes for formulating a prescription for prescribed burns for ease of access and updating; and * clarifying the guidance provided to decision makers as to the ‘edging’ and security of prescribed burns. |
Rec-ID | Code | Recommendation |
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REC200-1692 | 5 - Hazard reduction burns | The Fire and Emergency Services Authority, the Department of Environment and Conservation and local governments take proactive steps to conduct their prescribed burning programs as joint exercises. This will give effect to: |
REC200-1700 | 4 - Fire season preparation | The Interagency Bushfire Management committee develop and oversee a work program to: |
REC200-1691 | 5 - Hazard reduction burns | The State Government consider resourcing the Department of Environment and Conservation and local governments to develop and administer a comprehensive prescribed burning program in Perth‟s urban/rural interface to compliment DEC's existing landscape-scale program. |
REC200-1712 | 10 - Infrastructure | FESA and local governments jointly review radio communications capability prior to the 2011/12 bushfire season with a view to improving the current delivery of service to firefighters. |
REC200-0356 | 5 - Hazard reduction burns | The State Government reaffirm its 2009 decision to approve DEC exercising greater flexibility in managing smoke within national guidelines, in order to achieve its prescribed burn program. |
REC200-0360 | 4 - Fire season preparation | The Interagency Bushfire Management committee develop and oversee a work program to: conduct site specific assessments to assess current fuel loads assess, analyse and prioritise bushfire risk on land within and adjacent to communities develop a three year rolling mitigation works program with annual implementation and review. This work should commence independently of any decision on the most effective online integrated system. All data collected should be uploaded to the SLIP. |
REC200-0381 | 2 - Emergency powers | The State Government amend section 50 of the Emergency Management Act 2005 to allow the Chair of the State Emergency Coordination Group to declare an emergency situation. |
REC200-0351 | 5 - Hazard reduction burns | The Fire and Emergency Services Authority, the Department of Environment and Conservation and local governments take proactive steps to conduct their prescribed burning programs as joint exercises. This will give effect to: Reducing fuel load Improving inter-operability A mutual understanding of the fire fighting techniques of each agency. |
REC200-0350 | 5 - Hazard reduction burns | The State Government consider resourcing the Department of Environment and Conservation and local governments to develop and administer a comprehensive prescribed burning program in Perth’s urban/rural interface to compliment DEC’s existing landscape-scale program. |
Rec-ID | Code | Recommendation |
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REC199-0441 | 4 - Fire season preparation | the state undertake further trials to explore the opportunity for greater use of social media as a credible source of information to and from the public during an emergency |
REC199-0444 | 2 - Emergency powers | the state, as a matter of urgency, develop a multi-agency Incident Control Team capability to be readily available for statewide deployment to establish incident control or to relieve functioning control structures. |
Rec-ID | Code | Recommendation |
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REC177-3345 | 2 - Emergency powers | NOPSA’s prohibition powers should be extended such that a prohibition notice can be issued where a NOPSA Occupational Health and Safety Inspector believes, on reasonable grounds, that an activity is occurring or may occur at a facility involving an immediate threat to the health or safety of a person. |
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). |
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. |
Rec-ID | Code | Recommendation |
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REC165-0081 | 2 - Emergency powers | District and State levels utilise the current Act to make pre-emptive declarations of a disaster event (likely disasters) so as to be proactive in leading and controlling disaster events. All levels of the system should immediately notify other levels if they activate the Disaster Management arrangements. The Public Safety Preservation Act 1986 be amended to provide powers for Police Officers to provide an immediate response in the event of a rapid onset disaster event such as a landslide. |
REC165-0086 | 2 - Emergency powers | Suggested escalation trigger points be discussed with District Disaster Coordinators and Local Disaster Coordinators, and if considered practical and useful, be incorporated in Local, District and State Disaster Management Plans. |
Rec-ID | Code | Recommendation |
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REC151-3107 | 2 - Emergency powers | Immunity be prescribed for persons (including volunteers) using force in the exercise of a power or function under the FES Act or carrying out any direction or requirement given or imposed at the scene of a fire or other emergency. |
REC151-3079 | 2 - Emergency powers | Crown Law opinion be obtained to determine whether the FES Act gives the Minister power to direct and control individual Chief Officers and if that provision does not exist then the FES Act be amended to include that power. |
REC151-3092 | 19 - Offences | Expiation fees be reviewed so as to be consistent with the seriousness of the offences. |
Rec-ID | Code | Recommendation |
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REC149-3142 | 19 - Offences | NOPSA should use encouragement as the primary tool of enforcing compliance provided willingness to improve is exhibited by the players. |
REC149-3138 | 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. |
Rec-ID | Code | Recommendation |
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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. |
Rec-ID | Code | Recommendation |
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REC136-3523 | 38 - Agency/Department Reporting | This Report should be considered for publication so that the insights, data, conclusions and recommendations are available within Queensland and other jurisdictions to assist with disaster management issues in the future. |
Rec-ID | Code | Recommendation |
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REC121-3697 | 38 - Agency/Department Reporting | All train drivers’ defects reports should be entered by RailCorp into a computerised record and tracked to finalisation. |
REC121-3774 | 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: |
REC121-3695 | 10 - Infrastructure | There should be interoperability of communications equipment between all trains operating on the New South Wales rail network. |
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. |
REC121-3729 | 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. |
REC121-3687 | 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. |
REC121-3723 | 38 - Agency/Department Reporting | All ATSB accident investigation reports should be made public. |
REC121-3657 | 10 - Infrastructure | All signal telephones must be maintained by RailCorp in proper working order. |
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. |
REC121-3653 | 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. |
REC121-3776 | 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. |
REC121-3712 | 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. |
REC121-3651 | 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. |
REC121-3775 | 38 - Agency/Department Reporting | The Minister for Transport Services must table in Parliament, each such quarterly report by ITSRR. |