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. |
REC210-0755 | 13 - Mapping and data quality | CS Energy should supplement physical monitoring of Splityard Creek Dam with visual monitoring by installing surveillance cameras or similar devices. |
REC210-0717 | 32 - Doctrine, standards, and reform | The Queensland Government should consider amending the Environmental Protection Act 1994 to provide a definition of the term ‘emergency’ for the purposes of section 468 of that Act. |
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. |
REC210-0664 | 13 - Mapping and data quality | Councils should, resources allowing, maintain flood maps and overland flow path maps for use in development assessment. For urban areas these maps should be based on hydraulic modelling; the model should be designed to allow it to be easily updated as new information (such as information about further development) becomes available. |
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. |
REC210-0750 | 32 - Doctrine, standards, and reform | The assessment of flood mitigation manuals should be completed by a person with appropriate expertise who has had no involvement in its development, at any stage, and who can be seen to be independent of all individuals who were so involved. |
REC210-0714 | 32 - Doctrine, standards, and reform | The Queensland Government should consider amending the Environmental Protection Act 1994 so that it allows for the relaxation of environmental authority conditions, by transitional environmental program or otherwise, as to discharge of water: • pre-emptively, in advance of rainfall or flooding events, or • for all mines in a catchment that is flooding. |
REC210-0770 | 32 - Doctrine, standards, and reform | The Queensland Government should legislate to oblige each owner of a referable dam to have an emergency action plan approved by the appropriate Queensland Government agency. Such plans should be reviewed periodically |
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. |
REC210-0749 | 32 - Doctrine, standards, and reform | The Queensland Government should amend the Water Supply (Safety and Reliability) Act 2008 to designate the Minister as the person who must approve a flood mitigation manual. |
REC210-0712 | 32 - Doctrine, standards, and reform | The Queensland Government should legislate to clarify the purposes for which a transitional environmental program can be granted. In particular, if the government considers the transitional environmental program the appropriate regulatory mechanism to deal with the discharge of water from mines during flood, section 330 of the Environmental Protection Act 1994 should be clarified to make it clear that it extends to that use. |
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. |
REC210-0733 | 32 - Doctrine, standards, and reform | Emergency Management Queensland should pursue the execution of the ‘Local Arrangements’ with councils where a Memorandum of Agreement is in place. The contents of the arrangements should be reviewed and updated regularly |
REC210-0746 | 13 - Mapping and data quality | Seqwater should consider engaging a technical writer to develop completely new manuals after the operational strategies for Wivenhoe, Somerset and North Pine dams are set by the Queensland Government. |
REC210-0760 | 32 - Doctrine, standards, and reform | CS Energy should amend its business procedure to remove any ambiguity as to the establishment of communications with Seqwater and to acknowledge the formal communications protocol regarding releases. |
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. |
REC210-0683 | 13 - Mapping and data quality | All councils should, resources allowing, map the overland flow paths of their urban areas. |
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. |
REC210-0759 | 32 - Doctrine, standards, and reform | CS Energy should review its emergency action plan and business procedures to ensure they are wholly consistent and give appropriate consideration to flooding as a possible emergency event. |
REC210-0719 | 32 - Doctrine, standards, and reform | The Queensland Government should amend the Environmental Protection Act 1994 so as to permit an emergency direction to be given orally where it is not practicable to provide the direction in writing, with provision for its subsequent confirmation in writing |
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. |
REC210-0665 | 13 - Mapping and data quality | Councils should make their flood and overland flow maps and models available to applicants for development approvals, and to consultants engaged by applicants. |
Rec-ID | Code | Recommendation |
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REC181-0166 | 13 - Mapping and data quality | The Country Fire Authority and the Department of Sustainability and Environment improve mapping support in the following ways: ■ DSE providing mapping data free of charge to emergency response agencies; ■ greatly increasing the CFA’s ‘write’ access to FireMap for incident management team staff; ■ establishing a joint DSE–CFA training program to ensure that mapping officers in level 2 and 3 incident management teams are fully trained in using FireMap, including in producing fire prediction maps; ■ requiring before the 2010–11 fire season that FireMap be used for joint incidents. |
REC181-0208 | 13 - Mapping and data quality | The Department of Sustainability and Environment significantly upgrade its program of long-term data collection to monitor and model the effects of its prescribed burning programs and of bushfires on biodiversity in Victoria. |
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. |
REC181-0164 | 32 - Doctrine, standards, and reform | The Victorian fire agencies amend the AIIMS framework before the 2010–11 fire season in order to do the following: ■ designate the Information Unit as a separate section reporting directly to the Incident Controller and require that the Information Unit contain a dedicated Public Information Officer whenever a full incident management team is required; ■ specify a set of functions in relation to which the Deputy Incident Controller for a level 3 incident will have oversight, which may be adjustable for a particular incident by agreement between the Incident Controller and the Deputy Incident Controller; ■ ensure that an individual with local knowledge is incorporated in an incident management team |
REC181-0193 | 13 - Mapping and data quality | The Department of Sustainability and Environment conduct biodiversity mapping identifying flora, fauna and any threatened species throughout Victoria and make the results publicly available. The format used should be compatible with that used for Bushfire-prone Area mapping. |
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. |
REC181-0217 | 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. |
REC181-0163 | 32 - Doctrine, standards, and reform | The State consider amending the Emergency Management Act 1986 to introduce a graded scale of emergency declarations short of a state of disaster. |
REC181-0187 | 13 - Mapping and data quality | The State identify a central point of responsibility for and expertise in mapping bushfire risk to: ■ review urgently the mapping criteria at present used by the Country Fire Authority to map the Wildfire Management Overlay, to ensure that the mapping used to determine building and planning controls is based on the best available science and takes account of all relevant aspects of bushfire risk; ■ map and designate Bushfire-prone Areas for the purposes of planning and building controls, in consultation with municipal councils and fire agencies; ■ finalise the alignment of site-assessment methods for planning and building purposes, taking into account bushfire risk to human safety as well as to property. |
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. |
REC181-0216 | 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. |
REC181-0162 | 32 - Doctrine, standards, and reform | The State consider either amending the Emergency Management Act 1986 or adopting a standing practice to require the Minister for Police and Emergency Services or the Chief Commissioner of Police to consult the Premier about the possibility of declaring a state of disaster for all of or any part of Victoria whenever the Minister or the Chief Commissioner of Police becomes aware of circumstances that make it a reasonable possibility that the criteria for making such a declaration will be satisfied. |
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. |
REC181-0213 | 32 - Doctrine, standards, and reform | The State enact legislation designed to achieve two specific ends: ■ appoint a Fire Commissioner as an independent statutory officer responsible to the Minister for Police and Emergency Services and as the senior operational firefighter in Victoria; ■ make the Chief Fire Officer of the Department of Sustainability and Environment a statutory appointment. The Fire Commissioner should have responsibility for the following: ■ promoting and directing reform aimed at increasing the operational capability, interoperability and resilience of Victoria’s fire services; ■ developing and building operational capacity to prepare for the days of highest bushfire risk and exercising control over level 3 fires as the permanent State Controller; ■ providing to government periodic advice on the metropolitan fire district boundary on the basis of triggers, frequency and criteria approved by government; ■ representing Victorian interests on operational matters in national committees. |
REC181-0161 | 32 - Doctrine, standards, and reform | The State consider amending the Emergency Management Act 1986 and the Emergency Management Manual Victoria in order to achieve the following: ■ remove the title of Coordinator in Chief of Emergency Management from the Minister for Police and Emergency Services; ■ clarify the function and powers of the Minister; ■ designate the Chief Commissioner of Police as Coordinator in Chief of Emergency Management, who would have primary responsibility for keeping the Minister informed during an emergency. |
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. |
REC181-0209 | 32 - Doctrine, standards, and reform | The Department of Sustainability and Environment amend the Code of Practice for Fire Management on Public Land in order to achieve the following: ■ provide a clear statement of objectives, expressed as measurable outcomes; ■ include an explicit risk-analysis model for more objective and transparent resolution of competing objectives, where human life is the highest priority; ■ specify the characteristics of fire management zones—including burn size, percentage area burnt within the prescribed burn, and residual fuel loading; ■ adopt the use of the term ‘bushfire’ rather than ‘wildfire’. |
REC181-0158 | 32 - Doctrine, standards, and reform | The Country Fire Authority and the Department of Sustainability and Environment amend their procedures to require the following: ■ that at locations that attract preparedness levels A or B there be a full incident management team under the leadership of an accredited level 3 Incident Controller in position by 10.00 am on days of code red fire danger and a core incident management team (eight personnel) under the leadership of an accredited level 3 Incident Controller in position by 10.00 am on days of extreme fire danger; ■ that at locations that attract preparedness levels A or B there be a full incident management team under the leadership of an accredited level 3 Incident Controller in position by 10.00 am on days of code red fire danger and a core incident management team (eight personnel) under the leadership of an accredited level 3 Incident Controller in position by 10.00 am on days of extreme fire danger. |
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. |
Rec-ID | Code | Recommendation |
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REC008-3989 | 17 - Assets and technology | The Commission recommends that there be continuous supervision of every chamber in which electrical machinery is worked by currents of medium pressure. |
REC008-3987 | 17 - Assets and technology | The Commission recommends that systematic tests be made and recorded of apparatus and circuits as a precaution against fire and so that any gradual deterioration of the system may be detected. |
REC008-3986 | 17 - Assets and technology | The Commission recommends that every precaution be taken to keep water off electrical machinery. |
REC008-3985 | 17 - Assets and technology | The Commission recommends that conductors carrying currents at medium pressure should not be encased in wood in damp places. |
REC008-3991 | 32 - Doctrine, standards, and reform | The Commission recommends that the provisios of section 185 of the "Mining Act 1905" relating to exits from coal mines be extended to metalliferous mines employing more than 20 men in any one shift. |
Rec-ID | Code | Recommendation |
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REC004-3995 | 32 - Doctrine, standards, and reform | That the standard double arrester, fitted to the locomotives during the summer months, be subjected to more careful daily inspection before and after each journey during such months, in addition to the present periodical examination by the locomotive foreman and boiler inspector; and that any omission of this duty on the part of the running staff be severely punished. |
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. |
REC004-3993 | 32 - Doctrine, standards, and reform | That in any case where there is primá facie evidence of a fire, creating damage to the extent of $100 or upwards in value, having been caused by the escape of particles of lighted matter from a locomotive engine, or by the action of railway employes in burning off grass or other inflammable material along any line of railway, a Special Board of Inquiry shall investigate and report on the subject, such Board to consist of a Police Magistrate as Chairman, with a railway officer and a competent person chosen from outside the State service as members. |
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. |
REC004-4000 | 32 - Doctrine, standards, and reform | That section 22 of the Police Offences Act 1890 be amended, to enable the burning of grass and debris along the railway lines in the summer season to be carried out at an earlier hour than two o'clock in the afternoon, when, in the judgement of the railway inspectors, it is safe and necessary to do so. |
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. |