Inquiry Search
Rec-ID | Code | Recommendation |
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REC324-4311 | 33 - Relief and recovery | Transition initiatives: That, to improve the community’s experience during immediate disaster recovery phase, Government through the SEOCON, NSWRA, DCS/Service NSW and other state agencies as required provide greater support (financial, health [including mental health], temporary accommodation, administrative and other support services) to affected communities by: |
REC324-4297 | 33 - Relief and recovery | Housing , especially social housing: That, to ease housing stress in flood prone areas and ensure new development is resilient and community-centred, Government pursue a multi-pronged, decadal strategy through: |
Rec-ID | Code | Recommendation |
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REC314-3262 | 10 - Infrastructure | Invest in upgrading and integrating ICT platforms to eliminate manual data transfers, and ensure IT and radio communication interoperability across the agencies, together with a dedicated focus on the development of a coordinated risk intelligence capability to provide all stakeholders with a common operating picture and rapid damage assessments. |
REC314-3266 | 14 - Incident Mgt Teams | Engage with the Australian Defence Force (ADF) once or twice a year to understand the capabilities that could potentially be deployed. Educate IMTs about how to deploy ADF assistance effectively and develop a streamlined ‘call out’ procedure. |
REC314-3265 | 14 - Incident Mgt Teams | Prepare to ‘scale up’ capability during major bushfire events with senior representatives (including BoM staff) in the SEC 24/7, ensure adequate facilities for IMTs, base camps (e.g. Humanihuts) and recovery centres. Consider the resource implications of providing firefighters to interstate operations. |
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). |
Rec-ID | Code | Recommendation |
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REC301-2385 | 25 - Inquiry, audit, lessons management and after action review | TFS should initiate a policy review (seeking support from government as appropriate) to clearly identify what body or agency is responsible for planning, carrying out and enforcing fuel management on private property at a township level. If current arrangements are unclear or ineffective, TFS should request government to consider making this a statutory responsibility of TFS and provide any additional funding required to support this function. |
Rec-ID | Code | Recommendation |
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REC297-1273 | 25 - Inquiry, audit, lessons management and after action review | That the State Emergency Management Committee allocates resources to reviewing all findings and recommendations in the Productivity Commission Report No. 74 relevant to Tasmania and, for those identified as relevant, actions taken and, if none, why not. |
REC297-1261 | 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. |
REC297-1269 | 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). |
REC297-1264 | 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. |
REC297-1257 | 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. |
REC297-1259 | 25 - Inquiry, audit, lessons management and after action review | That DPIPWE examines the Forest Practice Code 2015 for relevance of its concepts to farming and other business activities near rivers, streams and naturally occurring dams and makes recommendations to Government accordingly. |
REC297-1258 | 25 - Inquiry, audit, lessons management and after action review | That DPIPWE examines the WMAwater report along with its own, analyses the differences, consults with the Forest Practices Authority and Environment Protection Authority, and proposes an appropriate course of action to Government. |
Rec-ID | Code | Recommendation |
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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. |
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. |
Rec-ID | Code | Recommendation |
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REC295-1326 | 14 - Incident Mgt Teams | Establish a State-wide resourcing capability to support incident management teams, regional coordination centres, zone emergency centres, relief centres, recovery centres and State control centres. some of the features of such a capability should include: a) multi-agency, cross-government, State-wide pool of incident management and emergency management personnel building on the State incident management team concept currently facilitated by the Country Fire Service, and expanded to include all hazards, multiagency teams with a roster that provides year-round coverage b) a system that enables staff and volunteers from any agency to identify their availability for upcoming shifts c) a rostering system that enables one or more incident management teams, staging areas, regional coordination centres, State control centres and relief centres to develop, maintain and distribute rosters and structure charts in a more coordinated manner d) identifying areas of expertise for key incident and emergency management functions (e.g. public information, alerts and warning, media liaison, logistics and resource management) that would benefit from a coordinated and resource pooling approach and take steps to implement (consider the Mapping Functional Support Group model as a potential service delivery model). |
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. |
REC295-1286 | 10 - Infrastructure | That the Attorney General’s Department consult with local government regarding potential for them to provide logistical support associated with backup power supply to SA Government Radio Network towers in the event of an emergency. |
REC295-1276 | 25 - Inquiry, audit, lessons management and after action review | That SA Health undertake a review of their emergency management arrangements. Health State Controllers should be consulted during this review and arrangements should be consistent throughout the department and across the State and compatible with State emergency management arrangements and information systems |
REC295-1302 | 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. |
REC295-1328 | 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. |
REC295-1274 | 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. |
REC295-1279 | 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. |
REC295-1327 | 25 - Inquiry, audit, lessons management and after action review | Establish a lessons management capability across the SA emergency management sector to collect, analyse and track lessons identified during debriefs and reviews following events and other sources such as interstate and oversees reviews and inquiries. |
REC295-1317 | 25 - Inquiry, audit, lessons management and after action review | Review representation in the State Emergency Centre including: a) determining if there is a more suitable functional support group e.g. the Procurement Functional Support Group, to replace the Logistics Functional Support Group, and if so, Chief Procurement Officer, DPC, has responsibility for the management of this role within the State Emergency Centre. b) That when the State Crisis Centre is not operating from a physical location, a State Crisis Centre liaison officer is attached to the State Emergency Centre. |
REC295-1334 | 33 - Relief and recovery | Conduct a review into South Australia’s arrangements for relief and recovery grant, Local Government Disaster Recovery Assistance Arrangements and Natural Disaster Relief and Recovery Arrangement claims, the review should include governance coordination and criteria for provision and processing of relief/recovery grants |
REC295-1315 | 25 - Inquiry, audit, lessons management and after action review | That a review of the role and effectiveness of the State Emergency Management Committee (SEMC) including: the legislative functions; membership including the chair; roles and responsibilities; and, SEMC Advisory Groups be undertaken. |
REC295-1275 | 33 - Relief and recovery | That SA Health, develop an emergency plan to manage an extended power outage or black system event which, in addition to the requirements outlined in recommendation 16: |
Rec-ID | Code | Recommendation |
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REC291-1249 | 25 - Inquiry, audit, lessons management and after action review | The Department of the Premier and Cabinet to conduct an independent review of the current arrangement for the management and distribution of the Emergency Services Levy. The review will have the specific purpose of: · seeking input from key entities including the Departments of Treasury, Finance, Fire and Emergency Services, Lands, and Parks and Wildlife, WA Local Government Association, and the Office of Bushfire Risk Management. · ensuring the arrangement has the flexibility and agility to deal with emerging bushfire risk priorities. · establishing a budget process that enables a shift in investment towards prevention, mitigation and building community resilience and capability. |
REC291-1240 | 14 - Incident Mgt Teams | The Departments of Parks and Wildlife and Fire and Emergency Services to adopt the policy that all bushfire Level 3 Incident Management Teams in the Perth Hills and the South West will be integrated and pre-formed from the start of the 2016/17 fire season with substantial involvement of both the Departments of Parks and Wildlife and Fire and Emergency Services personnel on all teams. |
REC291-1233 | 25 - Inquiry, audit, lessons management and after action review | The State Government to explore options for streamlining the functions and the independence of the State Emergency Management Committee Secretariat and the Office of Bushfire Risk Management with a view to including an inspectorate function, and appointing a person who is dedicated to that role. The purpose is to provide assurance and reporting, and to inquire into, monitor and report transparently on emergency management standards, preparedness, capability, service delivery and investment performance outcomes. Within two years of the establishment of this arrangement the State Government to review and assess whether it is meeting the desired outcomes. |
REC291-1239 | 14 - Incident Mgt Teams | The State Government to establish an arrangement to develop a ‘network’ of Western Australian State Government agency personnel who can be called upon for bushfire and emergency incident management capability within Western Australia. The arrangement will be led by the State Emergency Management Committee and modelled on systems used by the Department of Parks and Wildlife. |
Rec-ID | Code | Recommendation |
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REC287-1188 | 25 - Inquiry, audit, lessons management and after action review | The Tasmanian fire agencies commission a review into the efectiveness of aerial firefghting in the 2016 fires, in order to better understand and to document for future reference the cost-efectiveness of specifc fire suppression strategies and tactics in different vegetation types. The Review should include a comparative analysis of fire suppression options whether aerial or ground-based. |
REC287-1185 | 25 - Inquiry, audit, lessons management and after action review | The Tasmanian fire agencies take steps at a national level to share learnings from the 2016 fires about the administration of interstate assistance and support the codifcation of the workings, structure and reporting lines of an Interstate and International Liaison Unit for future complex deployments within Australia and New Zealand. |
Rec-ID | Code | Recommendation |
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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. |
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. |
Rec-ID | Code | Recommendation |
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REC273-1139 | 14 - Incident Mgt Teams | SACFS appoint the Regional Controller and/or Coordinator as the IC for any Level 3 incident occurring within their Region to provide better continuity and improved coordination. The position of the regional controller and/or coordinator could then be backfilled by a suitably qualified individual as required. |
REC273-1138 | 14 - Incident Mgt Teams | Review the communication and request procedures within SACFS to ensure that the most effective chain of command and line of communications are established between the Incident Management Team, region and state. |
REC273-1135 | 14 - Incident Mgt Teams | That SACFS conduct a review of SIMT with a view to increasing the number of teams from four to six, aligning them with each of the six regions within SA. |
Rec-ID | Code | Recommendation |
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REC264-1086 | 25 - Inquiry, audit, lessons management and after action review | GDF Suez: • consequences of fire in the worked out areas of the Hazelwood mine, and an assessment of the most effective fre protection for the exposed coal surfaces; conduct, assisted by an independent consultant, a risk assessment of the likelihood and • controls are in place to eliminate or reduce the risk of fre; and prepare an implementation plan that ensures the most effective and reasonably practicable • implement the plan |
REC264-1072 | 25 - Inquiry, audit, lessons management and after action review | The State empower and require the Auditor-General or another appropriate agency, to: • oversee the implementation of these recommendations and the commitments made by the State and GDF Suez during this Inquiry; and • report publicly every year for the next three years on the progress made in implementing recommendations and commitments. |
REC264-1085 | 10 - Infrastructure | GDF Suez establish enhanced back-up power supply arrangements that do not depend wholly on mains power, to: • ensure that the Emergency Command Centre can continue to operate if mains power is lost; and • ensure that the reticulated fre services water system can operate with minimal disruption if mains power is lost. |
REC264-1087 | 25 - Inquiry, audit, lessons management and after action review | GDF Suez: • practice and ensures that, by taking a risk management approach, it is suitable for fire prevention, mitigation and suppression in all parts of the Hazelwood mine; and review its ‘Mine Fire Service Policy and Code of Practice’ so that it refects industry best • work plan for the Hazelwood mine. incorporate the revised ‘Mine Fire Service Policy and Code of Practice’ into the approved |
Rec-ID | Code | Recommendation |
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REC258-2549 | 25 - Inquiry, audit, lessons management and after action review | The Civil Aviation Safety Authority provides full disclosure of audit findings at audit exit briefings in accordance with international best practice. |
REC258-2528 | 25 - Inquiry, audit, lessons management and after action review | The Australian Transport Safety Bureau investigates as many fatal accidents in the sport and recreational aviation sector as its resources will allow. |
REC258-2556 | 25 - Inquiry, audit, lessons management and after action review | The Civil Aviation Safety Authority structures all regulations not yet made with the three-tier approach, and subsequently reviews all other Civil Aviation Safety Regulation Parts (in consultation with industry) to determine if they should be remade using the three-tier structure. |
REC258-2552 | 25 - Inquiry, audit, lessons management and after action review | The Civil Aviation Safety Authority implements a system of using third-party commercial audits as a supplementary tool to its surveillance system. |
REC258-2551 | 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. |
Rec-ID | Code | Recommendation |
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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: |
REC257-1555 | 14 - Incident Mgt Teams | The lines of responsibility be made clearer and some individual, perhaps the Regional Environmental Officer, or agency be given overarching responsibility to ensure recommended works related to bushfire mitigation on Defence Estate are carried out in accordance with the Bushfire Management Plan which the Manual for Fire Protection Engineering directs be prepared. |
REC257-1546 | 25 - Inquiry, audit, lessons management and after action review | Defence undertake a review of its ability to respond to a fire within Marrangaroo Training Area, whether bushfire or structural. The underlying assumption should be that the only response available to fight a fire within Marrangaroo Training Area will be provided by Defence. Further, such response must occur while a fire is in its initial stages. A review must either acknowledge the risk of fire occurring in th future, or upgrade Defence's firefighting capability at Marrangaroo Training Area. |
Rec-ID | Code | Recommendation |
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REC256-1573 | 25 - Inquiry, audit, lessons management and after action review | The Australian Government should schedule an independent and public review of the progress of reforms to natural disaster funding arrangements five years after implementation has commenced. This review should examine the operation and efficacy of the arrangements, including the: |
Rec-ID | Code | Recommendation |
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REC247-0926 | 25 - Inquiry, audit, lessons management and after action review | That membership of the State Emergency Management Committee, and other processes to link in appropriate agencies and organisations to emergency management, be included in the recommended review of the emergency management arrangements. |
REC247-0911 | 14 - Incident Mgt Teams | That emergency management plans specifically include processes and resources for effectively engaging with and using local communities, including volunteers |
REC247-0910 | 33 - Relief and recovery | That suitable facilities are established from which to effectively control and coordinate immediate recovery operations. |
REC247-0923 | 25 - Inquiry, audit, lessons management and after action review | That a process be established for the timely implementation of approved recommendations from the 2009 Victorian Bushfires Royal Commission. |
REC247-0862 | 14 - Incident Mgt Teams | That Tasmania Fire Service and its partner agencies establish a means of monitoring and reviewing the effectiveness of centralising the location of Incident Management Teams. |
REC247-0907 | 33 - Relief and recovery | That the State Emergency Management Committee ensures that a program of debriefing on recovery issues is completed by all relevant agencies and organisations, and detailed plans and operating procedures are established ready for implementation. |
REC247-0909 | 25 - Inquiry, audit, lessons management and after action review | That the plans for social recovery be reviewed, and plans and procedures are established ready for implementation. |
REC247-0951 | 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. |
REC247-0861 | 14 - Incident Mgt Teams | That Tasmania Fire Service examines options for developing and issuing fire management objectives and tactics from Incident Management Teams in a more timely way, including ‘quick’ plans. |
REC247-0896 | 33 - Relief and recovery | That the state level structural arrangements for managing recovery operations are reviewed. |
REC247-0903 | 25 - Inquiry, audit, lessons management and after action review | That the role of Red Cross in emergency management plans and procedures for the activation of Red Cross be reviewed. |
REC247-0941 | 25 - Inquiry, audit, lessons management and after action review | That the Strategic Fuel Management Plan includes measurable targets and they are actively monitored and reported on to the community. |
REC247-0904 | 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. |
REC247-0853 | 14 - Incident Mgt Teams | That the State Controller (or an alternate if they are not available) be expected to personally take an active role in controlling and coordinating response and recovery operations, depending on the nature and scale of the emergency, and until other identified arrangements for ongoing operations are established. |
REC247-0873 | 25 - Inquiry, audit, lessons management and after action review | If it is considered more information is required on action to suppress the fires in Dunalley and why fire operations did not continue, the Department of Justice should conduct an independent examination of this matter. |
REC247-0927 | 25 - Inquiry, audit, lessons management and after action review | That an accountability process be established for managing improvement in the emergency management arrangements, including annual State of Readiness Reports by relevant departments and agencies and on the overall emergency management arrangements. |
Rec-ID | Code | Recommendation |
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REC244-2601 | 25 - Inquiry, audit, lessons management and after action review | That an independent review of the operational and geographic boundaries of the ESOs be conducted recognising the limitations of the current governance structures to adequately address such issues. Such a review needs to be performed periodically, but not less than every 8 years. |
REC244-2600 | 25 - Inquiry, audit, lessons management and after action review | An external audit of shared services performed by SAFECOM and services now provided by the three ESOs which have the potential to be shared, be undertaken to determine the most efficient and cost effective way such services can be delivered to the sector. The three ESO Chiefs need to have input into this process. |
REC244-2631 | 25 - Inquiry, audit, lessons management and after action review | Review Section 134 to ensure that it is not a deterrent to a group of farm fire units operating at an incident. |
REC244-2620 | 25 - Inquiry, audit, lessons management and after action review | Review employment conditions under the F&ES Act to align with those under the Public Sector Act unless there is a compelling reason to the contrary. |
REC244-2617 | 25 - Inquiry, audit, lessons management and after action review | When judging major incidents in the future, consideration be given to Eburn and Dover’s proposal to establish processes with a statutory basis that sufficiently balance the community’s interests in ensuring that true lessons, including lessons of error or neglect, are identified, whilst also protecting members of the emergency services. Processes need to be developed for emergency services such as those used in aviation and medicine, to facilitate open and honest disclosure of errors. |
Rec-ID | Code | Recommendation |
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REC239-2777 | 25 - Inquiry, audit, lessons management and after action review | That the review of this Queensland Fire and Rescue Services business unit be done in conjunction with the efficiency review proposed for the Queensland Police Service. |
REC239-2725 | 25 - Inquiry, audit, lessons management and after action review | That the Queensland Fire and Rescue Service community safety operations be joined in the efficiency review of the Queensland Police Service focussing on both the community safety outcomes achieved and the extent to which they support the Government’s economic priorities. |
REC239-2776 | 25 - Inquiry, audit, lessons management and after action review | That the proposed efficiency review of the Queensland Police Service examine whether: |
REC239-2724 | 25 - Inquiry, audit, lessons management and after action review | That the Queensland Fire and Rescue Service undertake a review of all standing orders, incident directives and guidelines regarding response protocols with a view to reducing risk to staff and other road users associated with urgent duty driving. |
REC239-2764 | 25 - Inquiry, audit, lessons management and after action review | That the proposed efficiency review consider whether special service functions are core business, whether this practice is sustainable, and other options such as the use of casual employees. |
REC239-2763 | 25 - Inquiry, audit, lessons management and after action review | That the proposed efficiency review includes a focus on the rank structure of both the Queensland Police Service and the proposed Fire and Emergency Services. |
REC239-2675 | 35 - Business and Industry in relation to industry | That social benefit bonds and other opportunities with the business and not-for-profit sectors be developed to reduce reoffending and to provide rehabilitation programs. Such an instrument should be available to the market within two years. |
REC239-2758 | 25 - Inquiry, audit, lessons management and after action review | That the Chief Executive Officer Portfolio Business leads an efficiency review of portfolio agencies beginning with the Queensland Police Service. |
REC239-2727 | 25 - Inquiry, audit, lessons management and after action review | That as part of its efficiency review, the Queensland Fire and Rescue Service instigate an independent review of commercial operations in terms of statutory obligations and current ‘full cost pricing’ methodology to ensure: |
Rec-ID | Code | Recommendation |
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REC223-0523 | 25 - Inquiry, audit, lessons management and after action review | The Government consider enacting legislation to facilitate the review of all future major incidents, including but not limited to fire, earthquake, storm and marine inundation, and the emergency response to them. |
REC223-0522 | 25 - Inquiry, audit, lessons management and after action review | The response operation to the Margaret River bushfire in November 2011 be the subject of a review with independent oversight. |
REC223-0516 | 25 - Inquiry, audit, lessons management and after action review | The Department of Environment and Conservation review its implementation of the findings of the Ferguson Review conducted in 2010. |
Rec-ID | Code | Recommendation |
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REC207-2888 | 35 - Business and Industry in relation to industry | Foster private sector service providers who can offer tailored services or broadcast high quality presentation of general purpose weather information |
Rec-ID | Code | Recommendation |
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REC205-1903 | 25 - Inquiry, audit, lessons management and after action review | The Australian Government should commission an independent public review of disaster prevention and recovery arrangements. This should be broader than the review currently being conducted by the Attorney-General’s Department. The review should cover the Natural Disaster Relief and Recovery Arrangements, as well as the funding mechanisms for disaster mitigation, including the National Partnership Agreement on Natural Disaster Resilience. This review should: |
REC205-1902 | 25 - Inquiry, audit, lessons management and after action review | The Council of Australian Governments should commission an independent public inquiry to develop an appropriate response to managing the risks of climate change to existing settlements. The inquiry should: |
Rec-ID | Code | Recommendation |
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REC201-0251 | 14 - Incident Mgt Teams | All responding crews and the incident command appointments should adopt a ‘Size Up‘ reporting format. |
REC201-0248 | 14 - Incident Mgt Teams | To provide Level 3 IC‘s (and FESA) with a level of confidence and to maintain currency across the pool of accredited IC‘s, regular exercising of IC‘s and Level 3 IMT‘s is required. |
REC201-0258 | 14 - Incident Mgt Teams | FESA should review the size of the existing pre-formed IMT to include additional Information and Planning officers and increased resourcing of scribes and management support for all Level 3 incidents. |
REC201-0255 | 14 - Incident Mgt Teams | FESA and DEC need to appoint accredited Level 3 IC‘s based on experience, competency and currency. |
REC201-0254 | 14 - Incident Mgt Teams | FESA should continue to develop with DEC and Local Government a number of rostered pre-formed IMT‘s available throughout the fire season, regardless of predicted weather. |
REC201-0253 | 14 - Incident Mgt Teams | Review the command function of the MROC for Level 3 incidents when the SOC is activated. |
REC201-0247 | 28 - Personal responsibility | Local residents must take a degree of shared responsibility to prepare their properties by reducing the risk of bushfire around their properties and planning for a bushfire emergency. |
Rec-ID | Code | Recommendation |
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REC200-0366 | 14 - Incident Mgt Teams | The Fire and Emergency Services Authority and the Department of Environment and Conservation ensure that their Incident Controllers identify critical infrastructure as part of their initial assessment and preparation of Incident Action Plans when attending major incidents. |
REC200-1718 | 35 - Business and Industry in relation to industry | Western Power and the Water Corporation continue to work collaboratively to assess options to better protect the power supply to water pumping stations in bushfire prone areas. |
REC200-1732 | 25 - Inquiry, audit, lessons management and after action review | The State Government review implementation of the Special Inquiry's recommendations in two years. |
REC200-1712 | 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. |
REC200-0392 | 25 - Inquiry, audit, lessons management and after action review | The State Government review implementation of the Special Inquiry’s Recommendations in two years. |
REC200-1701 | 25 - Inquiry, audit, lessons management and after action review | The Fire and Emergency Services Authority convene a facilitated debriefing session between the families who remained behind to protect their properties, and the incident controllers. |
REC200-0384 | 25 - Inquiry, audit, lessons management and after action review | Emergency Management Western Australia develop mechanisms to calculate the estimated total cost of a fire to the community. |
REC200-1706 | 14 - Incident Mgt Teams | The Fire and Emergency Services Authority and the Department of Environment and Conservation ensure that their Incident Controllers identify critical infrastructure as part of their initial assessment and preparation of Incident Action Plans when attending major incidents. |
REC200-0373 | 33 - Relief and recovery | The Department for Child Protection, the Western Australian Police and the Fire and Emergency Services Authority develop improved arrangements for communicating the loss of home and possessions to persons gathered at evacuation centres with a view to increasing privacy. |
REC200-0361 | 25 - Inquiry, audit, lessons management and after action review | The Fire and Emergency Services Authority convene a facilitated debriefing session between the families who remained behind to protect their properties, and the incident controllers. This session should include open discussion and explain the decisions of all parties – including how the incident controllers determined priorities, and why residents chose not follow their advice to evacuate. The learning outcomes should be promulgated across all agencies and incorporated in future level 3 incident controller training programs. |
REC200-0391 | 14 - Incident Mgt Teams | The Interagency Bushfire Management Committee develop a consistent program of education, training (including media), testing and review of Level 3 Incident Controllers. This should include provision for a formal review of the performance of individual Level 3 Incident Controllers after every incident. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC199-0474 | 33 - Relief and recovery | the state, in respect of the Rapid Impact Assessment process: • resolve which agency/ies has policy and operational responsibility for this process • define the purpose of Rapid Impact Assessment; and • review the process, in light of the 2010–11 floods, to examine options to improve the efficiency of the collection of information. |
REC199-0401 | 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. |
REC199-0489 | 33 - Relief and recovery | the state implement arrangements to improve the support provided to local government on disaster financing before, during and after emergency events. |
REC199-0482 | 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. |
REC199-0425 | 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. |
REC199-0473 | 33 - Relief and recovery | the state make available to the public a clear guide of who is responsible for: • clean-up and recovery of various types of infrastructure that straddle the public/private boundary; and • the policies agencies will follow in determining whether to repair infrastructure under their control. |
REC199-0488 | 33 - Relief and recovery | the Department of Human Services develop proactive strategies to provide information and assistance for people applying for emergency grants. |
REC199-0450 | 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. |
REC199-0472 | 33 - Relief and recovery | the state review the legislation and policies that set out clean-up and recovery responsibilities for infrastructure such as crossovers, culverts, drains, bridges and waterways, including consideration of: • whether the entities who are given obligations or powers to undertake clean-up works have the capacity to do so; and • the appropriateness of having different legal regimes for what is essentially the same piece of infrastructure. If the review reveals that the current responsibility matrix is inadequate, the state develop an action plan to address the identified shortcomings. |
REC199-0480 | 33 - Relief and recovery | the state clarify the transition to recovery arrangements including the processes for approving and funding of essential works after transition to recovery has been formalised. |
REC199-0445 | 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 |
REC199-0479 | 33 - Relief and recovery | the state review the way early outreach occurs and implement changes that will ensure that there is a consistency of approach regardless of which agency undertakes the service. |
REC199-0428 | 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. |
REC199-0491 | 33 - Relief and recovery | the state: • ensure that the concerns raised by Victorians regarding the Natural Disaster Relief and Recovery Arrangements are provided to the national review, including the issues of: – betterment (what it means and how it is applied); and – the 51 per cent income rule for eligibility of businesses for grants. • establish a single point of information (such as the single web portal referred to in recommendation 33) on all emergency related financial assistance available to individuals, businesses and local government. The means of accessing this information should be widely circulated in the community. |
REC199-0427 | 35 - Business and Industry in relation to industry | the state require dam owners and operators provide regular situational reports to the relevant control agency where dam issues may impact incident management. |
REC199-0478 | 33 - Relief and recovery | the state amend the current protocol governing National Registration and Inquiry System information collection and sharing to: • clarify the role of councils and Centrelink during and after emergencies • ensure the amended protocol is written in plain English and easily understood; and • coordinate, in conjunction with the state and federal privacy commissioners, the development of a new National Registration and Inquiry System information sharing protocol in line with the proposed National Registration and Inquiry System 6 and state or federal privacy legislation. |
REC199-0407 | 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. |
REC199-0490 | 33 - Relief and recovery | the state finalise the 2008 review of Victoria’s municipal assistance. This should include addressing: • the provision of upfront funding for local councils for repair of community assets • packages for early relief and recovery to be included in both the Natural Disaster Funding Arrangements and the Natural Disaster Relief and Recovery Arrangements, including outreach packages; and • the process of reimbursement of local councils after floods. |
Rec-ID | Code | Recommendation |
---|---|---|
REC197-1733 | 25 - Inquiry, audit, lessons management and after action review | That a review of the Country Fire Authority Act 1958 and the Country Fire Authority Regulations 2004 be undertaken. |
Rec-ID | Code | Recommendation |
---|---|---|
REC183-0111 | 14 - Incident Mgt Teams | Conducting a pre-fire season exercise for each Pre-Formed Incident Management Team could be used to “re-accrediting” each team on an annual basis. |
REC183-0114 | 14 - Incident Mgt Teams | Higher level DEC guidance to Level 3 Incident Controllers could be improved by introducing a more explicit and robust process of questioning, engagement, monitoring and oversight of Level 3 Incident Controllers. |
REC183-0113 | 14 - Incident Mgt Teams | A summary Incident Action Plan could allow the Incident Controller to more quickly appreciate the situation and articulate a plan early in an incident. |
REC183-0112 | 14 - Incident Mgt Teams | DEC’s incident management capability could be enhanced by: – Appointing a Deputy Incident Controller for every Level 3 IMT. – Establishing a fast response “short” IMT capability for each Level 3 IMT. – Establish clear triggers to initiate sending in a “short” IMT to a fire. – Including FESA officers in pre-formed Level 3 IMT’s. – Establishing additional pre-formed Level 3 IMT’s with FESA. – Where appropriate, appointing a local Bush Fire Brigade officer as Deputy Operations Officer. |
Rec-ID | Code | Recommendation |
---|---|---|
REC182-0135 | 33 - Relief and recovery | FESA revises its standard operating procedures to provide guidance on the format and timing of post-incident community meetings. |
REC182-0131 | 14 - Incident Mgt Teams | FESA establishes a dedicated intelligence function in Incident Management Teams for major bushfires and ensure this function is appropriately supported with threat based tools and systems. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC177-3344 | 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. |
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. |
REC177-3378 | 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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC165-0089 | 33 - Relief and recovery | The SDMG lead an initiative to deal at all levels with offers of assistance and donations from the general public in the event of disasters. |
REC165-0082 | 33 - Relief and recovery | Current procedures to activate disaster recovery funding arrangements be retained and processes be reinforced. |
Rec-ID | Code | Recommendation |
---|---|---|
REC164-0073 | 25 - Inquiry, audit, lessons management and after action review | SERCon consider that the proposed State Recovery Committee provide an interim report to government on these and |
Rec-ID | Code | Recommendation |
---|---|---|
REC161-3030 | 25 - Inquiry, audit, lessons management and after action review | That National Offshore Petroleum Safety Authority review the risk assessment of pipelines. National Offshore Petroleum Safety Authority should focus, in particular, on the efficacy of anti-corrosion systems, and recognise potential interference effects and MAE escalation risks associated with adjacent pipelines and unlicenced pipes even if they fall outside its direct regulatory responsibilities. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC149-3131 | 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. |
REC149-3145 | 25 - Inquiry, audit, lessons management and after action review | NOPSA should consider an audit regime that targets Greenfields operations at commencement of operations. |
REC149-3146 | 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. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC121-3704 | 28 - Personal responsibility | RailCorp should continue its system of voluntary self-identification and rehabilitation of employees with alcohol or drug related problems. |
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. |
REC121-3652 | 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. |
REC121-3676 | 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. |
REC121-3694 | 25 - Inquiry, audit, lessons management and after action review | The ITSRR should conduct random audits of accredited rail organisations for compliance with communications protocols. |
REC121-3758 | 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. |
REC121-3657 | 10 - Infrastructure | All signal telephones must be maintained by RailCorp in proper working order. |
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. |
REC121-3757 | 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. |
REC121-3653 | 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. |
REC121-3666 | 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. |
REC121-3691 | 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. |
REC121-3753 | 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. |
REC121-3678 | 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. |
REC121-3651 | 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. |
REC121-3665 | 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. |
REC121-3768 | 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. |
REC121-3695 | 10 - Infrastructure | There should be interoperability of communications equipment between all trains operating on the New South Wales rail network. |
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. |
REC121-3713 | 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. |