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. |
REC210-0773 | 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. |
REC210-0737 | 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. |
REC210-0772 | 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. |
REC210-0736 | 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. |
REC210-0766 | 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. |
REC210-0734 | 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. |
REC210-0762 | 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. |
REC210-0726 | 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. |
REC210-0775 | 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. |
Rec-ID | Code | Recommendation |
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REC181-0174 | 29 - Operational Health and Safety | The Country Fire Authority and the Department of Sustainability and Environment amend their procedures for investigating safety incidents and ‘near-misses’ to ensure that all dangerous incidents, including back-burns, are fully investigated and that all relevant people are consulted and informed of the results. |
REC181-0155 | 11 - Evacuation and shelters | The State introduce a comprehensive approach to evacuation, so that this option is planned, considered and implemented when it is likely to offer a higher level of protection than other contingency options. The approach should: ■ encourage individuals—especially vulnerable people—to relocate early; ■ include consideration of plans for assisted evacuation of vulnerable people; ■ include consideration of plans for assisted evacuation of vulnerable people. |
REC181-0171 | 17 - Assets and technology | The State, in conjunction with Emergency Management Australia and the Department of Defence, develop an agreement that allows Commonwealth aerial resources that are suitable for firefighting and support activities to be incorporated in preparedness plans and used on days of high fire 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. |
REC181-0154 | 11 - Evacuation and shelters | The State introduce a comprehensive approach to shelter options that includes the following: ■ developing standards for community refuges as a matter of priority and replacing the 2005 Fire Refuges in Victoria: Policy and Practice; ■ designating community refuges—particularly in areas of very high risk—where other bushfire safety options are limited; ■ working with municipal councils to ensure that appropriate criteria are used for bushfire shelters, so that people are not discouraged from using a bushfire shelter if there is no better option available; ■ acknowledging personal shelters around their homes as a fallback option for individuals. |
REC181-0170 | 17 - Assets and technology | The Country Fire Authority and the Department of Sustainability and Environment amend their policies on aerial preparedness and standby arrangements, their dispatch protocols and the management of aircraft in order to do the following: ■ require that at locations that attract the risk assessment or preparedness level A on code red days all personnel needed for air operations must be on standby by 10.00 am; ■ establish a system that enables the dispatch of aircraft to fires in high-risk areas without requiring a request from an Incident Controller or the State Duty Officer. |
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. |
REC181-0151 | 11 - Evacuation and shelters | The State revise its bushfire safety policy. While adopting the national Prepare. Act. Survive. framework in Victoria, the policy should do the following: ■ enhance the role of warnings—including providing for timely and informative advice about the predicted passage of a fire and the actions to be taken by people in areas potentially in its path; ■ emphasise that all fires are different in ways that require an awareness of fire conditions, local circumstances and personal capacity; ■ recognise that the heightened risk on the worst days demands a different response; ■ retain those elements of the existing bushfire policy that have proved effective; ■ strengthen the range of options available in the face of fire, including community refuges, bushfire shelters and evacuation; ■ ensure that local solutions are tailored and known to communities through local bushfire planning; ■ improve advice on the nature of fire and house defendability, taking account of broader landscape risks. |
REC181-0176 | 29 - Operational Health and Safety | The Country Fire Authority and the Department of Sustainability and Environment adopt the title ‘safety officer’ (as opposed to ‘safety adviser’) and require without exception that a safety officer be appointed to every level 3 incident management team. |
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. |
Rec-ID | Code | Recommendation |
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REC019-4144 | 16 - Training and behaviour | No opportunity be lost of encouraging the formation of bush fire brigades and the maintenance of enthusiasm and that the Bush Fires Board assist the brigades in any way possible to obtain adequate training and equipment. |
REC019-4158 | 16 - Training and behaviour | That needs in the direction of a fire emergency service be met as far as practicable by the Bush Fires Board in its training programme and in the tactical organisation of existing brigades for use as reserves in districts other than their own. |
REC019-4153 | 17 - Assets and technology | No opportunity be lost by the Forests Department to improve the efficiency of their fire fighting gangs, radio and other equipment in the light of the latest practical and scientific developments. |
Rec-ID | Code | Recommendation |
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REC016_3949 | 17 - Assets and technology | It is recommended that the A.R.P. dams or earth tanks be kept filled during possible danger periods. |
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. |
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. |
Rec-ID | Code | Recommendation |
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REC004-3992 | 17 - Assets and technology | That the use of a spark-arrester and cinder-arrester by the Railway Department shall not constitute a defence to an action for damage caused by fire escaping from a locomotive, unless the Department proves that such spark-arrester and cinder-arrester were in a thoroughly efficient condition when the fire took place. |
REC004-3996 | 17 - Assets and technology | That the standard pattern of cinder arrester be affixed to the ash-pans in all locomotives during the summer months. |
REC004-3994 | 17 - Assets and technology | That the Railway Department, while gradually reducing the number of different types of locomotives, should steadily keep in view the adoption of English and American railway practice, by providing engines with larger boilers, fire boxers, and smoke-boxes, and with wide blast-pipes, in order to insure ample steaming power with a minimum of forced draught. |