Inquiry Search
Rec-ID | Code | Recommendation |
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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. |
REC210-0772 | 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. |
REC210-0692 | 10 - Infrastructure | The Queensland Government should consider measures to ensure that requirements are included in the designation of land for community infrastructure under the Sustainable Planning Act 2009 to ensure that critical infrastructure for operating works under the Electricity Act is built to remain operational during and immediately after a flood of a particular magnitude. That magnitude should be determined by an appropriate risk assessment. |
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. |
REC210-0766 | 16 - Training and behaviour | Wide Bay Water should, in addition to its usual wet season preparations and maintenance, undertake the following activities in advance of each wet season: Queensland Floods Commission of Inquiry | Final Report 29 Complete list of Final Report recommendations • conduct training for personnel on dam operation, including contingency plans for the situation in which one or more of the gates is inoperable • hold meetings of key personnel of Wide Bay Water involved in the operation of the dam during floods, which: – in addition to any other matters, inform staff about the current status of the gates, dam operation strategies and contingency plans for the situation in which one or more of the gates is inoperable – are recorded in minutes which document the information provided and are made available to all operational staff. |
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. |
REC210-0762 | 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. |
REC210-0734 | 16 - Training and behaviour | Emergency Management Queensland should simplify the process by which SES members gain recognition for prior qualifications so that unnecessary duplication of training can be avoided. |
REC210-0758 | 10 - Infrastructure | CS Energy should put in place contingency measures to ensure email and telephone communications at Wivenhoe Power Station are not entirely dependent on a network located off-site. |
REC210-0775 | 16 - Training and behaviour | The Department of Environment and Resource Management should conduct periodic dam safety information and education sessions with emergency management personnel including those from Emergency Management Queensland, local and district disaster management groups and local councils. Priority should be given to sessions if the Bureau of Meteorology forecasts a wet season with a greater than 50 per cent chance of above median rainfall. |
REC210-0695 | 10 - Infrastructure | The Queensland Government should consider implementing mandatory requirements to ensure that all conduits for the purpose of providing electrical supply below the applicable defined flood level are sealed to prevent floodwaters from entering them or flowing into them. |
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. |
REC210-0743 | 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. |
REC210-0773 | 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. |
REC210-0693 | 10 - Infrastructure | Electricity distributors should consider installing connection points for generators to provide electricity supply to non-flooded areas that have had their supply cut during floods. |
Rec-ID | Code | Recommendation |
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REC181-0175 | 16 - Training and behaviour | The Country Fire Authority and the Department of Sustainability and Environment require without exception that all relevant staff be trained in the need for Incident Controller approval to be obtained before a back-burn is lit. |
REC181-0182 | 10 - Infrastructure | The State (through Energy Safe Victoria) require distribution businesses to do the following: ■ disable the reclose function on the automatic circuit reclosers on all SWER lines for the six weeks of greatest risk in every fire season; ■ adjust the reclose function on the automatic circuit reclosers on all 22-kilovolt feeders on all total fire ban days to permit only one reclose attempt before lockout. |
REC181-0180 | 10 - Infrastructure | The State amend the regulatory framework for electricity safety to require that distribution businesses adopt, as part of their management plans, measures to reduce the risks posed by hazard trees—that is, trees that are outside the clearance zone but that could come into contact with an electric power line having regard to foreseeable local conditions. |
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. |
REC181-0179 | 10 - Infrastructure | The State (through Energy Safe Victoria) require distribution businesses to review and modify their current practices, standards and procedures for the training and auditing of asset inspectors to ensure that registered training organisations provide adequate theoretical and practical training for asset inspectors. |
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. |
REC181-0178 | 10 - Infrastructure | The State (through Energy Safe Victoria) require distribution businesses to change their asset inspection standards and procedures to require that all SWER lines and all 22-kilovolt feeders in areas of high bushfire risk are inspected at least every three years. |
REC181-0184 | 10 - Infrastructure | The State amend the regulatory framework for electricity safety to strengthen Energy Safe Victoria’s mandate in relation to the prevention and mitigation of electricity-caused bushfires and to require it to fulfil that mandate. |
REC181-0177 | 10 - Infrastructure | The State amend the Regulations under Victoria’s Electricity Safety Act 1998 and otherwise take such steps as may be required to give effect to the following: ■ the progressive replacement of all SWER (single-wire earth return) power lines in Victoria with aerial bundled cable, underground cabling or other technology that delivers greatly reduced bushfire risk. The replacement program should be completed in the areas of highest bushfire risk within 10 years and should continue in areas of lower bushfire risk as the lines reach the end of their engineering lives; ■ the progressive replacement of all 22-kilovolt distribution feeders with aerial bundled cable, underground cabling or other technology that delivers greatly reduced bushfire risk as the feeders reach the end of their engineering lives. Priority should be given to distribution feeders in the areas of highest bushfire risk. |
REC181-0183 | 10 - Infrastructure | The State (through Energy Safe Victoria) require distribution businesses to do the following: ■ fit spreaders to any lines with a history of clashing or the potential to do so; ■ fit or retrofit all spans that are more than 300 metres long with vibration dampers as soon as is reasonably practicable. |
Rec-ID | Code | Recommendation |
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REC016_3945 | 16 - Training and behaviour | It is recommended that a large proportion of men employed in and about the open-cut be systematically trained in the use of equipment and in the tactical disposition of it. |
REC016_3944 | 10 - Infrastructure | It is recommended that the water pressure be improved so that a greater volume and jet may be available for the suppression of fires on the faces and also for the purpose of wetting the berms more widely and thoroughly when necessary. It is suggested that there should be variable control of the pressure so that production need not be adversely affected in times of normal danger. |
REC016_3943 | 10 - Infrastructure | It is recommended that a more constant, running revision of the main and sprinkler system be maintained in future so that the service which it is intended to convey shall be closely and efficiently available to all parts of the berms and faces. It is emphasized that the reticulation system in the berms is fixed and stationary, whereas the faces are continually receding as their surfaces are scraped away by the dredges. |
REC016_3951 | 10 - Infrastructure | It is recommended that the State Electricity Commission adopt a policy of conciliation and good will towards its closer neighbours. It is not suggested that its policy has been essentially otherwise. In future that policy can best be assured of success by time conferring of material benefit upon its neighbours at some monetary cost to the Commission. It is suggested, with conviction, that it would prove to be of great advantage to time Commission if it were to take an active part in the clearing and bettering of its neighbours’ scrub and timber country at time cost of the Commission. The settler whose land is fully cleared and in production, or who knows that his land will be cleared for him, has no incentive to burn illegally or carelessly. If this suggestion should he adopted, it would be necessary that it should be carried out in all cases in accordance with the settler’s convenience, that he himself should take an active part in the operations, and that he should be left, not with a financial obligation, but with a definite material advantage. |
REC016_3948 | 16 - Training and behaviour | It is recommended that workers and volunteers generally be instructed in accordance with a pre-arranged plan, as to what they should do in future times of emergency. Since the fighting of fires is for the greater part a matter of voluntary action, some estimate could perhaps be made, after investigation, of the numbers of men in each department who would be willing to volunteer. It would be necessary that each department should become a component part of an over-riding scheme and that it and its members should be fully instructed in the matter of whistle or siren warnings, places of assembly, reception of messages from the director of proceedings, use of equipment, and the various details which would necessarily be parts of an effective scheme. The training need not be onerous. If given once or twice at the beginning of possible danger periods, it would make for some degree of order and efficiency instead of a probable state of confusion. |
Rec-ID | Code | Recommendation |
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REC008-3990 | 16 - Training and behaviour | The Commission recommends that more than one means of exit should be provided in every mine from every level of it to the surface; and that the miners should be kept informed where they are situated. |
REC008-3984 | 16 - Training and behaviour | The Commission recommends that the live parts of resistances should be fixed so that no unprotected combustible material is within 6ins of the frames or cases containing them or within 24ins measured vertically above. |
Rec-ID | Code | Recommendation |
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REC004-3999 | 10 - Infrastructure | That, in view of the fact that along many of the lines, between the road-bed and the fences, there are numbers of dry inflammable stumps, which, when they catch fire, are very difficult to extinguish, and that the surface of the ground surrounding these stumps is usually chipped by the permanent-way men every summer, thus causing considerable expense without removing the risk of fire, the Railway Department should remove this source of danger, by grabbing them out and burning them as early as may be found practicable. |