Inquiry Search
Rec-ID | Code | Recommendation |
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REC323-4290 | 20 - Role of police | That the NSW Government embed into its emergency plans the appointment of a senior police officer with combat experience to lead recovery efforts following natural disasters. |
Rec-ID | Code | Recommendation |
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REC317-4102 | 25 - Inquiry, audit, lessons management and after action review | Australian, state and territory governments should review Australian Medical Assistance Team capabilities and procedures and develop necessary training, exercising and other arrangements to build capacity for domestic deployments. |
REC317-4074 | 25 - Inquiry, audit, lessons management and after action review | The Australian Government should review the content of the Defence Assistance to the Civil Community manual to ensure consistency of language and application with a revised COMDISPLAN. |
Rec-ID | Code | Recommendation |
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REC002-4012 | 38 - Agency/Department Reporting | Complete sets of daily-report books should be provided, and kept in the mine or office, to be overlooked by the Inspector during his periodical visits. |
Rec-ID | Code | Recommendation |
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REC299-1344 | 25 - Inquiry, audit, lessons management and after action review | That a review of the cross‑tenure approach be undertaken to determine its effectiveness and to address issues that arise in fire prevention on private and public land. |
REC299-1343 | 25 - Inquiry, audit, lessons management and after action review | That the Government conduct a review of fire prevention |
Rec-ID | Code | Recommendation |
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REC280-1396 | 25 - Inquiry, audit, lessons management and after action review | That the Minister for Police and Emergency Services review the communications technologies used by the NSW Rural Fire Service, Fire and Rescue NSW, the NSW National Parks and Wildlife Service and Forestry NSW during fire fighting operations, to ensure that systems are standardised and effective. Within this context, the potential value of satellite phone technology should be investigated. |
REC280-1388 | 25 - Inquiry, audit, lessons management and after action review | That the NSW Rural Fire Service: |
Rec-ID | Code | Recommendation |
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REC261-1505 | 25 - Inquiry, audit, lessons management and after action review | That the NSW Rural Fire Service: |
REC261-1508 | 25 - Inquiry, audit, lessons management and after action review | That the NSW Rural Fire Service review its procedures, systems and infrastructure for notifying community members of bush fires, both when a fire has broken out and as it proceeds, to ensure the provision of timely and adequate information. |
Rec-ID | Code | Recommendation |
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REC242-2643 | 25 - Inquiry, audit, lessons management and after action review | That the Government consult broadly upon and review impediments to volunteering in the community and establish a taskforce to assist in removing barriers to volunteering, particularly with respect to: |
Rec-ID | Code | Recommendation |
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REC236-2799 | 38 - Agency/Department Reporting | The committee recommends that the ATSB prepare and release publicly a list of all its identified safety issues and the actions which are being taken or have been taken to address them. The ATSB should indicate its progress in monitoring the actions every 6 months and report every 12 months to Parliament. |
REC236-2792 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that the investigation be re-opened by the ATSB with a focus on organisational, oversight and broader systemic issues. |
REC236-2806 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that the relevant agencies investigate appropriate methods to ensure that information about the incidence of, and variable weather conditions at, Norfolk Island is available to assist flight crews and operators managing risk that may result from unforseen weather events. |
REC236-2805 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that the relevant agencies review whether any equipment or other changes can be made to improve the weather forecasting at Norfolk Island. The review would include whether the Unicom operator should be an approved meteorological observer. |
REC236-2801 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that the ATSB review its process to track the implementation of recommendations or safety actions to ensure it is an effective closed loop system. This should be made public, and provided to the Senate Regional and Rural Affairs and Transport Committee prior to each Budget Estimates. |
REC236-2808 | 38 - Agency/Department Reporting | The committee recommends that in relation to mandatory and confidential reporting, the default position should be that no identifying details should be provided or disclosed. However, if there is a clear risk to safety then the ATSB, CASA and industry representatives should develop a process that contains appropriate checks and balances. |
REC236-2795 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that a short inquiry be conducted by the Senate Standing Committee on Rural and Regional Affairs and Transport into the current status of aviation regulatory reform to assess the direction, progress and resources expended to date to ensure greater visibility of the processes. |
REC236-2800 | 38 - Agency/Department Reporting | The committee recommends that where a safety action has not been completed before a report being issued that a recommendation should be made. If it has been completed the report should include details of the action, who was involved and how it was resolved. |
REC236-2793 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that CASA processes in relation to matters highlighted by this investigation be reviewed. This could involve an evaluation benchmarked against a credible peer (such as FAA or CAA) of regulation and audits with respect to: non-RPT passenger carrying operations; approach to audits; and training and standardisation of FOI across regional offices. |
Rec-ID | Code | Recommendation |
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REC232-2815 | 25 - Inquiry, audit, lessons management and after action review | The Department of Health and Ageing review the existing evidence base to evaluate the cost-effectiveness of its policy to use heat scanners at ports of entry as a measure to mitigate the risk of infectious disease importation. |
REC232-2828 | 25 - Inquiry, audit, lessons management and after action review | The Australian Government, in consultation with state and territory governments, commission an independent review to assess the case for establishing a national centre for communicable disease control in Australia. The review should outline the role of a national centre and how it might be structured to build on and enhance existing systems. It should examine different models, considering a range of options for location, governance and staffing. The review should incorporate a cost-benefit analysis for each of the models presented. |
REC232-2827 | 25 - Inquiry, audit, lessons management and after action review | The Australian Government, in consultation with state and territory governments, conduct a comprehensive national audit and mapping exercise to: |
Rec-ID | Code | Recommendation |
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REC222-1869 | 25 - Inquiry, audit, lessons management and after action review | The Ministers for Emergency Services, Environment and Police ensure their departments include provisions for regular external audits of invoices for payment in their next round of Employee Assistance Program contract negotiations. |
REC222-1862 | 25 - Inquiry, audit, lessons management and after action review | The Minister for Emergency Services request the State Emergency Management Committee to review by June 2013 the sharing of data between the State’s emergency response agencies using the WebEOC software and any further enhancements that can be made to this process. |
REC222-1847 | 25 - Inquiry, audit, lessons management and after action review | The Ministers for Emergency Services, Environment and Police ensure their departments undertake a formal review by 30 June 2013 of the welfare services addressing stress and trauma provided to both their career and volunteer members. |
REC222-1853 | 38 - Agency/Department Reporting | The Ministers for Emergency Services, Environment and Police ensure their departments include in their annual reports the expenditure they have incurred on preparing their staff for critical incidents, and for managing their response to these incidents. |
Rec-ID | Code | Recommendation |
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REC217-1840 | 25 - Inquiry, audit, lessons management and after action review | The state government implement the Victorian Floods Review recommendation 8, to review the flood gauging network. As part of the review, consideration should also be given to the use of portable telemetered river gauges, and to the replacement of manual gauges with telemetered gauges over time and where appropriate. |
Rec-ID | Code | Recommendation |
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REC210-0736 | 25 - Inquiry, audit, lessons management and after action review | Seqwater should ensure that proper support and oversight mechanisms are put in place around both the substantive and procedural aspects of drafting flood event reports. Seqwater should consider engaging consultants with expertise in the production of reports following significant events to advise on these mechanisms. Measures to be considered should include: • ensuring appropriate systems are in place to ensure the recollections of flood engineers and other parties are recorded immediately after the event, perhaps by engaging an external party to interview the flood engineers and other parties • ensuring that a methodology for writing the report is set out clearly in advance, in writing, and that the final report includes a statement of that methodology • putting in place systems to ensure that members of senior management have sufficient understanding of both the methodology and process by which the report is prepared to allow themselves to be satisfied that these are appropriate. |
REC210-0772 | 25 - Inquiry, audit, lessons management and after action review | Prior to each wet season, the Department of Environment and Resource Management should audit the compliance of each owner of a referable dam with the obligation to have an emergency action plan approved by the Queensland Government. |
REC210-0726 | 25 - Inquiry, audit, lessons management and after action review | The Queensland Fire and Rescue Service should require that each region records in writing the results of its risk assessment undertaken as part of its annual review of its special operations functional plan. |
REC210-0762 | 25 - Inquiry, audit, lessons management and after action review | Seqwater should consider commissioning an investigation into the extent of cracking below the level of the upper gallery of Somerset Dam and the impact of any such cracking on the dam’s stability and, in turn, its operation. |
REC210-0743 | 25 - Inquiry, audit, lessons management and after action review | Seqwater should, in creating the new Wivenhoe and North Pine flood mitigation manuals, comprehensively consider: • the amount of discretion that is able to be exercised by the flood engineers and the senior flood engineers, and the description of the circumstances in which such discretion may be exercised • the circumstances in which it might be appropriate to release water in advance of an impending flood on the basis of forecasts from the Bureau of Meteorology • if strategies of the form of strategy W2 and W3 in Revision 7 are included in the revised manual, or any strategy defined as a ‘transition strategy’, when and how those strategies should be implemented • if the concept of ‘urban inundation’ is relevant to the operation of the dam, how it should be defined, and if the definition involves diverse concepts, how those concepts can be related back to the strategies, so that flood engineers can reach a clear understanding of their objectives and primary considerations • if the concept of ‘natural peak flow’ is relevant, how it should be defined. |
REC210-0738 | 25 - Inquiry, audit, lessons management and after action review | Seqwater should ensure that any future peer review process: • is co-ordinated by someone independent of those who wrote the report • entails the provision of all relevant information to the peer reviewers • permits sufficient time for the review • documents all contact between those whose actions are under review and the reviewers. |
REC210-0737 | 25 - Inquiry, audit, lessons management and after action review | The Department of Environment and Resource Management should ensure that an independent and appropriately qualified person immediately starts the task of reviewing the March flood event report to ensure that the review is completed before the start of the 2012/2013 wet season. |
REC210-0773 | 25 - Inquiry, audit, lessons management and after action review | The Department of Environment and Resource Management should prioritise dam safety audits according to risk. The risk assessment should be informed by criteria including: • structure and materials used in construction • age of the dam • time since last inspection • occurrence of a flood event since last audit and the size of that flood event • population at risk if the dam were to fail • experience and capability of dam owner • dam owner compliance history • time since last audit. |
Rec-ID | Code | Recommendation |
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REC208-0526 | 25 - Inquiry, audit, lessons management and after action review | That OEH’s testing procedures for determining the impact of pollution incidents incorporate additional requirements for the checking and verification of results before those results are released. |
Rec-ID | Code | Recommendation |
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REC204-1912 | 38 - Agency/Department Reporting | The Board of Tourism WA should take action to ensure that it reviews the quality of Board papers that are submitted to it by the executive of Tourism WA. |
REC204-1916 | 25 - Inquiry, audit, lessons management and after action review | Local Emergency Management Committee (LEMC) processes should be reviewed to ensure that: |
REC204-1913 | 25 - Inquiry, audit, lessons management and after action review | The Department of the Attorney General consider conducting a review of the Civil Liability Act 2002 (WA) in light of the 2011 Kimberley Ultramarathon. Such a review should consider issues such as the effectiveness given to competitor waivers under the Act and the potential difficulties of establishing proceedings and enforcing a judgement against foreign‐based providers of recreational activities. |
Rec-ID | Code | Recommendation |
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REC202-0497 | 25 - Inquiry, audit, lessons management and after action review | The Minister for Local Government have urgent discussions with the Western Australian Local Government Association (WALGA) as to why they are not supporting the full Recommendations addressed to local government in the Keelty Report. The Minister ensure that by May 2012 WALGA and its member councils have the resources to fully implement theimplementation of the Recommendations. |
REC202-0495 | 25 - Inquiry, audit, lessons management and after action review | At the conclusion to the 2011-12 bushfire season, the Minister for Emergency Services institute a thorough review of the operations of FESA, the Police and DEC in protecting the State from bushfires and other natural disasters, with a primary focus on: · staffing levels; · equipment levels and coordination; and · training needs. The Minister report to Parliament by June 2012 on any changes that need to be made to the current departmental structures to optimise the State’s preparedness for the 2012-13 bushfire season. |
REC202-0493 | 25 - Inquiry, audit, lessons management and after action review | The Minister for Emergency Services report to Parliament every six months on the progress made in completing all of the outstanding Recommendations of the Keelty Report. |
Rec-ID | Code | Recommendation |
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REC181-0216 | 25 - Inquiry, audit, lessons management and after action review | The State appoint an independent monitor or the Victorian Auditor-General to assess progress with implementing the Commission’s recommendations and report to the Parliament and the people of Victoria by 31 July 2012. |
REC181-0160 | 20 - Role of police | The State clarify whether, during major fires, Victoria Police should discharge its coordination functions from the State Emergency Response Coordination Centre or from the State Control Centre. |
REC181-0168 | 14 - Incident Mgt Teams | The Country Fire Authority and the Department of Sustainability and Environment amend their procedures to require that a suitably experienced, qualified and competent person be appointed as Incident Controller, regardless of the control agency for the fire. |
REC181-0167 | 14 - Incident Mgt Teams | The Country Fire Authority and the Department of Sustainability and Environment establish before the 2010–11 fire season: ■ a uniform, objective and transparent process based on the current DSE approach for the accreditation of level 3 Incident Controllers; ■ a performance review system for level 3 Incident Controllers; ■ a traineeship program for progression from level 2 to level 3 incident management team positions. |
REC181-0165 | 14 - Incident Mgt Teams | The Country Fire Authority and the Department of Sustainability and Environment: ■ amend their procedures to require that an incident action plan summary be completed within the first four hours of an incident being reported and be provided to the State Control Centre and, where established, to the relevant Area of Operations Control Centre; ■ adopt DSE’s incident action plan summary as the template to be used by all incident management teams and ensure that the template is included in the online IMT Tool Box; ■ provide regular training to IMT staff, highlighting the importance of information and reinforcing the support available from specialists within the State Control Centre. |
REC181-0185 | 20 - Role of police | Victoria Police continue to pursue a coordinated statewide approach to arson prevention and regularly review its approach to ensure that it contains the following elements: ■ high-level commitment from senior police; ■ a research program aimed at refining arson prevention and detection strategies; ■ centralised coordination that includes comprehensive training, periodic evaluation of arson prevention strategies and programs, and promotion of best-practice prevention approaches; ■ a requirement that all fire-prone police service areas have arson prevention plans and programs, according to their level of risk. |
REC181-0217 | 25 - Inquiry, audit, lessons management and after action review | The State consider the development of legislation for the conduct of inquiries in Victoria —in particular, the conduct of royal commissions. |
REC181-0159 | 14 - Incident Mgt Teams | The Country Fire Authority and the Department of Sustainability and Environment prescribe and audit the minimum number and nature of level 3 joint training exercises in which incident management team staff (including volunteers) are required to participate. |
Rec-ID | Code | Recommendation |
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REC155-3478 | 38 - Agency/Department Reporting | That all information pertaining to current and planned prescribed burns be published more prominently on the Department of Sustainability and Environment’s website, with a single prominent link to this material on the website homepage. |
REC155-3477 | 38 - Agency/Department Reporting | That the details of any variation or amendment of a Fire Operations Plan, including: the carrying forward or postponement of burns within the three-year period covered by a Fire Operations Plan; the carry over, removal or rescheduling of burns between past, present and future Fire Operations Plans; and the alteration of burn boundaries (including alterations of less than 25 per cent); should appear on the Department of Sustainability and Environment’s website at the time of the change and be included in the Fire Operations Plan for the following year. |
REC155-3476 | 38 - Agency/Department Reporting | That finalised Fire Operations Plans be made publicly available in their entirety (with the exception of any private information) on the Department of Sustainability and Environment’s website and in hard-copy, and that this requirement be clearly stated in future Codes of Practice. This should include the “district burns list”, or its future equivalents, and a map which shows the corresponding burns for each Fire District. Each map should be provided in a format which can be downloaded directly from the Department’s website without the need for further data manipulation by the user. An identical hardcopy version of the map for each Fire District should be also be available to members of the public on request and free of charge. |
REC155-3468 | 38 - Agency/Department Reporting | That the Department of Sustainability and Environment, Department of Primary Industries, Parks Victoria & VicForests separately cost, and report, annual expenditure on fuel reduction burning, ecological burning and regeneration burning in their Annual Reports. |
REC155-3466 | 25 - Inquiry, audit, lessons management and after action review | A comprehensive review of the effectiveness of the increased prescribed burning target in meeting ecological and bushfire suppression needs should be conducted every three years. |
REC155-3467 | 38 - Agency/Department Reporting | The Department of Sustainability and Environment should report its performance against the increased prescribed burning target in its annual report, which should also include the following details: |
Rec-ID | Code | Recommendation |
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REC148-3170 | 25 - Inquiry, audit, lessons management and after action review | That the officer responsible for the importation of horses arrange for Biosecurity Australia to conduct within six months, an inspection and review of the process of horse importation from the time horses arrive in Australia until the completion of their post-arrival quarantine in order to: |
REC148-3178 | 38 - Agency/Department Reporting | That the officer responsible for the importation of horses prepare a report to the Executive Director of AQIS that: |
REC148-3167 | 25 - Inquiry, audit, lessons management and after action review | That the facilities at Eastern Creek and Spotswood Quarantine Stations be reviewed by AQIS in consultation with experts in biosecurity and interested parties including state and territory governments, import agents, veterinarians, farriers, operators of private quarantine stations, and representatives of horse owners, horse racing organisations and equestrian organisations. There should in any event be constructed without delay, an adequate supply of hygienic, modern showering facilities and places of entry and exit to the stations and the horse sections of them that can be supervised and monitored continually. There should also be provided at those stations as soon as is practicable suitable means of electronic surveillance, including closed-circuit television; a secure place to store chemicals, drugs, instruments and equipment for use by people attending the quarantined horses, and a set of horse stalls and yards separate from the main stalls and yards to enable isolation of horses suffering from contagious or infectious diseases. These reviews should also consider the desirability of separate areas in quarantine stations to hold horses forming part of a single quarantine intake but that have been imported from different regions or have undergone pre-export quarantine in different places. The reviews should be carried out without delay, and the two quarantine stations should be upgraded in accordance with the recommendations of the reviews. |
REC148-3149 | 38 - Agency/Department Reporting | That there be established the position of Inspector General of Horse Importation, the duties of that position being: |
REC148-3154 | 25 - Inquiry, audit, lessons management and after action review | That the officer responsible for the importation of horses arrange for Biosecurity Australia or another qualified body to inspect and review the activities and events that occur from the time horses enter pre-export quarantine until the time they arrive at an airport in Australia, in order to identify any biosecurity risks and recommend any necessary changes to import conditions or other requirements. This inspection and review shall be performed without delay for each country or region from which horses are imported to Australia, and it should take account of my other recommendations and comments in this report. |
REC148-3182 | 25 - Inquiry, audit, lessons management and after action review | That Biosecurity Australia review that formal import risk analysis at least once every two years to take into account any relevant developments in scientific knowledge—specifically testing methods, vaccines, vaccination procedures and other matters that affect biosecurity. Reports on the reviews should be provided to the officer responsible for the importation of horses and should contain recommendations for any necessary changes to policies for importation. |
REC148-3175 | 25 - Inquiry, audit, lessons management and after action review | That the officer responsible for the importation of horses arrange for Biosecurity Australia to review, at least once every two years, the operating procedures to ensure that they adequately identify and manage the risk of entry and spread of equine influenza associated with the importation of horses into Australia. The outcome of each such review should be the subject of a written report and recommendations to the person responsible for the importation of horses and the Executive Director of AQIS. A determination should then be made as to whether any, and if so what, changes should be made to the operating procedures. |
Rec-ID | Code | Recommendation |
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REC146-3193 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that the Australian National Audit Office audit CASA's implementation and administration of its Safety Management Systems approach. |
Rec-ID | Code | Recommendation |
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REC144-3379 | 25 - Inquiry, audit, lessons management and after action review | The Committee recommends that a thorough review be undertaken of the communications and coordination between the separate agencies which make up the Emergency Services Agency, to assess the extent to which cultural factors are detrimental to the effective operation of the ESA. |
Rec-ID | Code | Recommendation |
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REC128-3619 | 38 - Agency/Department Reporting | That the Department of Primary Industries should ensure the roles and capacities of Rural Lands Protection Boards and industry are effectively monitored to enable assessment of the effectiveness of animal health programs. |
REC128-3605 | 38 - Agency/Department Reporting | That the Department of Primary Industries make every effort to meet its targets for the TSE program and encourage public and private sector veterinarians across the State to submit samples. The Department should include reports on its performance against these targets in annual reports. |
REC128-3598 | 25 - Inquiry, audit, lessons management and after action review | That the Department of Primary Industries incorporates reviews of plans and operating procedures as a result of emergency incidents and exercises and ensures that there is adequate commitment from all participants in the review process. |
REC128-3602 | 38 - Agency/Department Reporting | That the Department’s performance against tactical and strategic benchmarks be regularly reported in annual reports or animal and plant health emergency evaluation reports and compared to other jurisdictions where possible. |
REC128-3601 | 38 - Agency/Department Reporting | That, as a matter of principle, the NSW Government provide public reports on the lessons learned from emergency exercises which it manages or in which it participates. If necessary, such reports should exclude material which might jeopardise security. |
Rec-ID | Code | Recommendation |
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REC098-2186 | 38 - Agency/Department Reporting | The Committee recommends that the Department of Transport and Regional Services review its record keeping practices to show the type of emergency for which assistance is provided through the Natural Disaster |
REC098-2155 | 25 - Inquiry, audit, lessons management and after action review | The Committee recommends that Emergency Management Australia initiate a process involving Australasian Fire Authorities Council and the Australian Assembly of Volunteer Fire Brigades Association to review |
Rec-ID | Code | Recommendation |
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REC061-3246 | 38 - Agency/Department Reporting | The Committee recommends that performance monitoring standards be established, reviewed and maintained through a common reporting system by the Minister for Police and Emergency Services. |
REC061-3258 | 25 - Inquiry, audit, lessons management and after action review | The Committee recommends that the Metropolitan Fire Brigades Board be reviewed five years from the tabling of this report in Parliament. |
REC061-3423 | 25 - Inquiry, audit, lessons management and after action review | The Committee recommends that the Metropolitan Fire Brigades Board be reviewed five years from the tabling of this report in Parliament. |