Inquiry Search
Rec-ID | Code | Recommendation |
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REC324-4295 | 11 - Evacuation and shelters | Roads: That, to improve the planning and protection of road infrastructure and to ensure communities, freight movers, combat agencies and emergency services have appropriate access and egress during and following a flood event, Government, through TfNSW and NSWRA and working with combat agencies and local and federal governments as needed, should: |
REC324-4313 | 8 - Communications and warnings | NSW disaster app: That, to improve community confidence in government messaging and warnings, the SEOCON and DCS develop a single ‘NSW disaster app’. This: |
REC324-4314 | 8 - Communications and warnings | PIFAC function: That, to ensure the community can better understand the threat of flood, storm and tsunami activity, the Department of Customer Service (DCS) be made accountable for PIFAC in all emergencies. This will improve access to clear, reliable and consistent messaging prior to and during emergencies. This transfers the PIFAC role from NSW Police Force to Service NSW. Under this PIFAC function, DCS would be responsible for: |
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). |
REC314-3271 | 8 - Communications and warnings | Better coordinate public information and warnings including evacuation plans and provide a single source of information about, the location and direction of fires, how and when to use Safer Places, Places of Last Resort, relief and recovery centres and directed evacuations. |
REC314-3262 | 10 - Infrastructure | Invest in upgrading and integrating ICT platforms to eliminate manual data transfers, and ensure IT and radio communication interoperability across the agencies, together with a dedicated focus on the development of a coordinated risk intelligence capability to provide all stakeholders with a common operating picture and rapid damage assessments. |
Rec-ID | Code | Recommendation |
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REC302-2404 | 8 - Communications and warnings | Review the effectiveness of emergency public information arrangements, and give consideration to embedding an ABC Manager (not a journalist) into the RFS headquarters during emergencies to broadcast warnings to the community that can be pooled to commercial media outlets |
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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REC297-1264 | 25 - Inquiry, audit, lessons management and after action review | That the Flood Warning Consultative Committee reviews flood classification levels in the Service Level Specifications with BoM specifically relating to flood level triggers on gauges. |
REC297-1259 | 25 - Inquiry, audit, lessons management and after action review | That DPIPWE examines the Forest Practice Code 2015 for relevance of its concepts to farming and other business activities near rivers, streams and naturally occurring dams and makes recommendations to Government accordingly. |
REC297-1258 | 25 - Inquiry, audit, lessons management and after action review | That DPIPWE examines the WMAwater report along with its own, analyses the differences, consults with the Forest Practices Authority and Environment Protection Authority, and proposes an appropriate course of action to Government. |
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. |
REC297-1267 | 8 - Communications and warnings | That emergency management authorities react with heightened awareness and action when BoM issues flood watches and related warnings. |
REC297-1266 | 8 - Communications and warnings | That Government supports the anticipated SES State Flood Warning proposals aimed at improving public warnings and communication, and that the proposed warning system is consistent with the National Frameworks. |
Rec-ID | Code | Recommendation |
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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. |
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. |
Rec-ID | Code | Recommendation |
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REC295-1279 | 10 - Infrastructure | Install UPS on traffic lights on main Central Business District (CBD) and arterial roads to allow an effective movement of traffic during a loss of power. |
REC295-1317 | 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. |
REC295-1276 | 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 |
REC295-1315 | 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. |
REC295-1297 | 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. |
REC295-1329 | 8 - Communications and warnings | Review and update Part 3, Annex C, of the SEMP ‘Public Information and Warnings’ to: a) clarify the role and responsibilities of the Public Information Functional Support Group and control agencies in relation to public information b) define requirements and processes for liaising with the community, including holding community meetings |
REC295-1296 | 8 - Communications and warnings | That the SES in collaboration with MFS Communications Centre (Comcen) investigate and implement options to reduce the number of calls coming into the Comcen, (particularly on 132500). Options could include better utilisation of the available options on the Interactive Voice Recording and community education to increase community resilience. |
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. |
REC295-1286 | 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. |
REC295-1327 | 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. |
Rec-ID | Code | Recommendation |
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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. |
REC291-1249 | 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. |
REC291-1244 | 11 - Evacuation and shelters | The Department of Fire and Emergency Services to work with the Department of Planning and Local Governments to adopt a policy which enables Local Governments to identify, register and communicate, ‘Places of Bushfire Last Resort’ in settlements and townsites where the life risk from bushfire is very high or greater. |
REC291-1243 | 8 - Communications and warnings | The Department of Fire and Emergency Services to investigate and adopt a system that will allow the public to opt in, monitor and receive, through a ‘push mechanism’, bushfire and other emergency warnings, maps and information using a wide variety of devices including personal hand held smart devices. |
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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REC284-1368 | 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. |
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. |
Rec-ID | Code | Recommendation |
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REC273-1140 | 8 - Communications and warnings | Review the current practise of issuing an ‘emergency alert’ telephone message or an emergency warning and/or watch and act alert to ensure that it is consistent, relevant and necessary. Prior to issuing an emergency alert message, consider state level involvement so that other agencies are made aware of message and intent. |
REC273-1134 | 8 - Communications and warnings | That future declarations be undertaken to ensure that the areas affected by the declaration are clear and concise. |
Rec-ID | Code | Recommendation |
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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. |
REC264-1089 | 8 - Communications and warnings | GDF Suez improve its crisis management communication strategy for the Hazelwood mine in line with international best practice. |
REC264-1087 | 25 - Inquiry, audit, lessons management and after action review | GDF Suez: • practice and ensures that, by taking a risk management approach, it is suitable for fire prevention, mitigation and suppression in all parts of the Hazelwood mine; and review its ‘Mine Fire Service Policy and Code of Practice’ so that it refects industry best • work plan for the Hazelwood mine. incorporate the revised ‘Mine Fire Service Policy and Code of Practice’ into the approved |
REC264-1086 | 25 - Inquiry, audit, lessons management and after action review | GDF Suez: • consequences of fire in the worked out areas of the Hazelwood mine, and an assessment of the most effective fre protection for the exposed coal surfaces; conduct, assisted by an independent consultant, a risk assessment of the likelihood and • controls are in place to eliminate or reduce the risk of fre; and prepare an implementation plan that ensures the most effective and reasonably practicable • implement the plan |
REC264-1085 | 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. |
REC264-1082 | 8 - Communications and warnings | The State review and revise its communication strategy, to: • needed for effective and rapid public communications during an emergency; and ensure all emergency response agencies have, or have access to, the capability and resources • ensure, where appropriate, that private operators of essential infrastructure are included in the coordination of public communications during an emergency concerning that infrastructure. |
Rec-ID | Code | Recommendation |
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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. |
REC258-2549 | 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. |
Rec-ID | Code | Recommendation |
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REC257-1548 | 25 - Inquiry, audit, lessons management and after action review | The Regional Director-Defence Support-Northern NSW, make contact with Deputy Commissioner ~~~~~ Director of Operational Services Rural Fire Service, to arrange a headquarters driven bipartite review of the events of 16 October 2013 with a review to mitigation of future fire events generally, and with specific reference to: |
REC257-1546 | 25 - Inquiry, audit, lessons management and after action review | Defence undertake a review of its ability to respond to a fire within Marrangaroo Training Area, whether bushfire or structural. The underlying assumption should be that the only response available to fight a fire within Marrangaroo Training Area will be provided by Defence. Further, such response must occur while a fire is in its initial stages. A review must either acknowledge the risk of fire occurring in th future, or upgrade Defence's firefighting capability at Marrangaroo Training Area. |
REC257-1539 | 25 - Inquiry, audit, lessons management and after action review | Defence Security Authority conduct an investigation into the whereabouts of items of anaccounted explosive ordnance issued to Defence Explosive Ordnance Training School Exercise Marrangaroo. |
Rec-ID | Code | Recommendation |
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REC256-1573 | 25 - Inquiry, audit, lessons management and after action review | The Australian Government should schedule an independent and public review of the progress of reforms to natural disaster funding arrangements five years after implementation has commenced. This review should examine the operation and efficacy of the arrangements, including the: |
Rec-ID | Code | Recommendation |
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REC247-0903 | 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. |
REC247-0916 | 8 - Communications and warnings | That Tasmania Fire Service ensures that the priority on warning communities at risk of active bushfires is not confined to when bushfires are burning out of control. |
REC247-0887 | 11 - Evacuation and shelters | That qualifying the evacuation authority in section 47 of the Fire Service Act 1979 be considered — by exempting those people with a pecuniary interest in a property from a directed evacuation where it is reasonable for them to remain. |
REC247-0922 | 8 - Communications and warnings | That Tasmania Fire Service develops a research base from which to inform the design of communication campaigns for communities threatened by bushfire. |
REC247-0901 | 11 - Evacuation and shelters | That evacuation centres and other centres have plans and arrangements for electrical power redundancy. |
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. |
REC247-0915 | 8 - Communications and warnings | That Tasmania Fire Service actively uses predictive modelling to design emergency communications for communities threatened by bushfire, unless there is a compelling reason for not doing so. |
REC247-0886 | 11 - Evacuation and shelters | That a state-level policy on evacuations be developed in the emergency management plans, including specific requirements for vulnerable people and guidelines for its implementation. |
REC247-0920 | 8 - Communications and warnings | That Tasmania Fire Service reviews its approach to communicating with communities threatened by bushfire and consider the matters referred to in this Report. |
REC247-0900 | 8 - Communications and warnings | That a public information plan be developed as a part of the State Special Emergency Plan–Recovery, for implementation in the immediate recovery phase. |
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. |
REC247-0909 | 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. |
REC247-0873 | 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. |
REC247-0919 | 8 - Communications and warnings | That Tasmania Fire Service and Tasmania Police review their use of modern forms of communication with the community, including social media, and commit resources to fully use this capability where appropriate. |
REC247-0890 | 11 - Evacuation and shelters | That decisions to open Community Fire Refuges and evacuation centres be coordinated with Tasmania Police. |
REC247-0927 | 25 - Inquiry, audit, lessons management and after action review | That an accountability process be established for managing improvement in the emergency management arrangements, including annual State of Readiness Reports by relevant departments and agencies and on the overall emergency management arrangements. |
REC247-0905 | 8 - Communications and warnings | That the Government consider whether it should discuss options for greater mobile phone coverage and redundancy in areas of high risk in emergency situations where there are presently telecommunications limits. |
REC247-0918 | 8 - Communications and warnings | That the State Emergency Management Committee makes arrangements to actively manage the use of social media in the community during an emergency, to avoid negative consequences for emergency operations. |
REC247-0889 | 11 - Evacuation and shelters | That Tasmania Police be identified as the lead agency on evacuations. |
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. |
REC247-0904 | 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. |
REC247-0917 | 8 - Communications and warnings | That the State Emergency Management Committee makes timely decisions and resource commitments on the appropriate use of social media in emergency management. |
REC247-0888 | 11 - Evacuation and shelters | That arrangements are made and appropriate pre-planning occurs to effectively implement the policy on evacuation. |
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. |
Rec-ID | Code | Recommendation |
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REC244-2617 | 25 - Inquiry, audit, lessons management and after action review | When judging major incidents in the future, consideration be given to Eburn and Dover’s proposal to establish processes with a statutory basis that sufficiently balance the community’s interests in ensuring that true lessons, including lessons of error or neglect, are identified, whilst also protecting members of the emergency services. Processes need to be developed for emergency services such as those used in aviation and medicine, to facilitate open and honest disclosure of errors. |
REC244-2604 | 8 - Communications and warnings | Notification of a total fire ban should be broadcast to the public via any means reasonably available. Section 80, parts (2), (5) and (6) be amended so that broadcast fire ban warnings include, but not be limited to, radio stations, internet sites, social media outlets etc. |
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. |
Rec-ID | Code | Recommendation |
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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: |
REC239-2684 | 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. |
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. |
REC239-2772 | 38 - Agency/Department Reporting | That the roll-out of the mobile service program business case mentioned earlier |
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. |
REC239-2727 | 25 - Inquiry, audit, lessons management and after action review | That as part of its efficiency review, the Queensland Fire and Rescue Service instigate an independent review of commercial operations in terms of statutory obligations and current ‘full cost pricing’ methodology to ensure: |
REC239-2771 | 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. |
REC239-2673 | 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. |
REC239-2725 | 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. |
REC239-2767 | 38 - Agency/Department Reporting | Recommendation: That the CEO Portfolio Business collaborates with the two portfolio Commissioners to: |
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. |
REC239-2724 | 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. |
REC239-2776 | 25 - Inquiry, audit, lessons management and after action review | That the proposed efficiency review of the Queensland Police Service examine whether: |
REC239-2690 | 8 - Communications and warnings | That the Chief Executive Officer Portfolio Business and Commissioners establish a high level working group with the ABC and commercial media to identify and implement an improved information flow to the community on disasters. |
REC239-2763 | 25 - Inquiry, audit, lessons management and after action review | That the proposed efficiency review includes a focus on the rank structure of both the Queensland Police Service and the proposed Fire and Emergency Services. |
Rec-ID | Code | Recommendation |
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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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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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REC201-0259 | 11 - Evacuation and shelters | FESA seek legal and policing advice regarding the policy to leave residents who chose not to evacuate in a declared ‗dangerous area‘ after a bushfire. |
REC201-0250 | 8 - Communications and warnings | Initial StateAlert messages should provide timely broad advice to a wide audience authorised by the SDD, while subsequent messages may provide more detail. |
Rec-ID | Code | Recommendation |
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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. |
REC200-0384 | 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. |
REC200-1711 | 8 - Communications and warnings | FESA develop in partnership with other emergency service agencies develop a 'one source: one message' multi layered system similar to that recommended by the Victoria Bushfire royal Commission. |
REC200-0374 | 11 - Evacuation and shelters | Hazard Management Agencies overseeing the response to incidents on the urban fringe select evacuation centres that are well within the urban environment and unlikely to be impacted by the incident. |
REC200-1710 | 8 - Communications and warnings | The Fire and Emergency Services Authority and the ABC commence a thorough review of emergency warning messages. This review should give consideration to: |
REC200-0371 | 8 - Communications and warnings | FESA develop in partnership with other emergency service agencies a ‘one source: one message’ multi layered system similar to that recommended by the Victoria Bushfire royal Commission. |
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. |
REC200-1732 | 25 - Inquiry, audit, lessons management and after action review | The State Government review implementation of the Special Inquiry's recommendations in two years. |
REC200-0370 | 8 - Communications and warnings | The Fire and Emergency Services Authority and the ABC commence a thorough review of emergency warning messages. This review should give consideration to: The content, structure and presentation of emergency warning messages Media access to the Incident Management Team and State Operations Centre. This review should be expanded to include other media organisations should they demonstrate a willingness and capacity to contribute. 20 |
REC200-1690 | 8 - Communications and warnings | The Fire and Emergency Services Authority work in partnership with Main Roads Western Australia and local governments to develop and implement a comprehensive strategy for the use of mobile variable message boards to alert the community to the declaration of a total fire ban and what it means. |
REC200-1714 | 11 - Evacuation and shelters | Hazard Management Agencies overseeing the response to incidents on the urban fringe select evacuation centres that are well within the urban environment and unlikely to be impacted by the incident. |
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. |
REC200-0392 | 25 - Inquiry, audit, lessons management and after action review | The State Government review implementation of the Special Inquiry’s Recommendations in two years. |
REC200-1689 | 8 - Communications and warnings | The Fire and Emergency Services Authority consider alternative wording to Total Fire Ban that ensures people gain a more complete understanding of what actions are prohibited. |
Rec-ID | Code | Recommendation |
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REC199-0432 | 8 - Communications and warnings | the state develop and implement a single web portal as a means of providing emergency information to communities and local government on an ‘all hazards’ basis, including the information referred to in recommendations 74, 89 and 92. |
REC199-0437 | 8 - Communications and warnings | the state engage with local government to ensure emergency services’ public information and warnings reflect the community demographic. |
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 |
REC199-0428 | 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. |
REC199-0436 | 8 - Communications and warnings | the state develop a standard approach to the provision of emergency warnings and information in formats – spoken and written – that recognise diverse community needs, including language and disability |
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. |
REC199-0407 | 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. |
REC199-0435 | 8 - Communications and warnings | the state put in place appropriate measures to inform the community of the intended purpose of the Emergency Alert warning system. |
REC199-0440 | 8 - Communications and warnings | the state actively pursue the use of social media as part of its emergency warning and public information system. |
REC199-0402 | 8 - Communications and warnings | the state develop a flood warning system for each basin and location with community input and make relevant documents publicly available. Each warning system should include key performance indicators. |
REC199-0434 | 8 - Communications and warnings | the state require that agencies operate in compliance with the guidelines of the Victorian Warning Protocol to ensure efficacy of warning messages. |
REC199-0439 | 8 - Communications and warnings | the state review its Memoranda of Understanding with official emergency broadcasters to take account of increased usage of internet based information, including social media and the ability to broadcast community meetings |
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. |
REC199-0482 | 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. |
REC199-0433 | 8 - Communications and warnings | the state develop and implement standards for Emergency Alert to ensure consistent use, training and application by accredited operators within agencies across ‘all hazards’. |
REC199-0438 | 8 - Communications and warnings | the state investigate the ability to refine the Flood and Storm Information Line to enable it to receive as well as provide information. |
REC199-0471 | 8 - Communications and warnings | the state and the commonwealth, during a flood event, make information available on providers who have capacity to accommodate patients and residents who require evacuation. |
Rec-ID | Code | Recommendation |
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REC197-1733 | 25 - Inquiry, audit, lessons management and after action review | That a review of the Country Fire Authority Act 1958 and the Country Fire Authority Regulations 2004 be undertaken. |
Rec-ID | Code | Recommendation |
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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. |
REC177-3287 | 38 - Agency/Department Reporting | Licensees should be subject to an express obligation to inform regulators of problems which arise in the course of installing barriers, even if they consider that well integrity is not thereby compromised. The information should be provided by way of special report, rather than included in a standard reporting document (such as a DDR). The information provided should include risk assessment details. |
REC177-3374 | 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. |
REC177-3360 | 42 - Culture and Heritage | DEWHA should participate in training programs and exercises relevant to an oil spill in the marine environment. |
REC177-3344 | 25 - Inquiry, audit, lessons management and after action review | There should be a review to determine whether it is appropriate to introduce a rigorous civil penalty regime and/or substantially increase some or all of the penalties that can be imposed for breaches of legislative requirements relating to well integrity and safety. |
REC177-3290 | 38 - Agency/Department Reporting | The successful installation of every barrier should be the subject of written verification within and between licensees and rig operators; and should be the subject of explicit reporting to the relevant regulator(s). |
Rec-ID | Code | Recommendation |
---|---|---|
REC165-0095 | 11 - Evacuation and shelters | Planning and consultation be undertaken by EMQ with all levels of the Disaster Management system to ensure that necessary risk-based disaster evacuation plans are prepared at Local, District and State levels, supported by necessary community education and preparedness programs. |
REC165-0087 | 8 - Communications and warnings | The SDMG commission the Department of Community Safety and seek the necessary funding to develop and enhance the Statewide Disaster Management information and communications system building on alternatives already in place and in consultation with all levels of Government. |
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 |
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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. |
REC149-3138 | 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 |
---|---|---|
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 |
---|---|---|
REC136-3527 | 8 - Communications and warnings | In any future large-scale disaster or event, consideration be given to a centrally located Media Operations Centre. |
REC136-3526 | 8 - Communications and warnings | That consideration be given to additional ways and means to improve broadcast capability into disaster-affected regions, particularly for the early aftermath of any disaster when a loss of power characterises the event. |
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. |
REC136-3528 | 8 - Communications and warnings | An early and high priority task in recovery from a natural disaster should be the development of a coordinated, succinct, practical and flexible public communications plan. |
Rec-ID | Code | Recommendation |
---|---|---|
REC132-3594 | 8 - Communications and warnings | Need for scripting of messages by fire agency representatives when promoting VBIL services via radio, TV and newspapers. |
REC132-3590 | 8 - Communications and warnings | Investigate procedures for updating the Victoria Bushfire Information Line (VBIL) Integrated Voice Response recorded message system to allow recording of permanent bushfire safety, and incident-specific, messages, accessible when the VBIL is experiencing high call volumes during large and/or numerous significant incidents |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC121-3694 | 25 - Inquiry, audit, lessons management and after action review | The ITSRR should conduct random audits of accredited rail organisations for compliance with communications protocols. |
REC121-3722 | 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. |
REC121-3651 | 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. |
REC121-3757 | 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. |
REC121-3775 | 38 - Agency/Department Reporting | The Minister for Transport Services must table in Parliament, each such quarterly report by ITSRR. |
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. |
REC121-3713 | 25 - Inquiry, audit, lessons management and after action review | Recommendations one to seven of the final report of the Special Commission of Inquiry into the Glenbrook Rail Accident should be fully implemented, save that the random auditing referred to in recommendations five and seven should be carried out by ITSRR. |
REC121-3753 | 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. |
REC121-3774 | 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: |
REC121-3691 | 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. |
REC121-3712 | 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. |
REC121-3729 | 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. |
REC121-3768 | 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. |
REC121-3697 | 38 - Agency/Department Reporting | All train drivers’ defects reports should be entered by RailCorp into a computerised record and tracked to finalisation. |
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. |
REC121-3657 | 10 - Infrastructure | All signal telephones must be maintained by RailCorp in proper working order. |
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. |
REC121-3695 | 10 - Infrastructure | There should be interoperability of communications equipment between all trains operating on the New South Wales rail network. |
REC121-3723 | 38 - Agency/Department Reporting | All ATSB accident investigation reports should be made public. |
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. |
REC121-3758 | 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. |