Inquiry Search
Rec-ID | Code | Recommendation |
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REC325-4321 | 25 - Inquiry, audit, lessons management and after action review | The Inspector-General of Emergency Management recommends this report be returned to the Office of the Inspector-General of Emergency Management to monitor, evaluate, and report on progress and implementation of the recommendations that are accepted in whole or in part by government. |
Rec-ID | Code | Recommendation |
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REC322-4240 | 25 - Inquiry, audit, lessons management and after action review | The Inspector-General Emergency Management recommends the next review of the Queensland State Disaster Management Plan examines and provides guidance in respect to the application of Queensland’s disaster management arrangements to support hazard specific events such as bushfire. |
REC322-4223 | 5 - Hazard reduction burns | The Inspector-General Emergency Management recommends the Department of Environment and Science implements the proposed treatments for fire identified in the Queensland Parks and Wildlife Service K’gari Compliance Strategy. |
REC322-4246 | 25 - Inquiry, audit, lessons management and after action review | The Inspector-General Emergency Management recommends the Interagency Protocol for Fire Management be reviewed by all relevant entities, including representatives of the Butchulla people, and be updated as a matter of priority. Entities responsible for the protocol should implement a process for regular review and evaluation of its effectiveness. This review process should be conducted after a major bushfire event, or to reflect any material change to applicable legislation and policy. It should also consider pre-arranged approvals and a range of agreed fiscal protocols between the agencies. |
REC322-4248 | 5 - Hazard reduction burns | The Inspector-General Emergency Management recommends the prescribed burn program for K’gari be developed by the Department of Environment and Science, in collaboration with the Locality Specific Fire Management Group and the Butchulla people, based on the principles of the National Position on Prescribed Burning. This program should incorporate a process for monitoring and evaluation of outcomes and integration of evolving fire management practices. |
REC322-4252 | 25 - Inquiry, audit, lessons management and after action review | The Inspector-General Emergency Management recommends Queensland Fire and Emergency Services regularly review and evaluate the effectiveness of the Queensland Bushfire Plan with land managers and stakeholders, including disaster management groups. A review should occur in line with any material change to the Queensland State Disaster Management Plan, the Disaster Management Act 2003, the Prevention Preparedness Response and Recovery Guideline, or after major bushfire events, to ensure appropriate alignment and currency. |
REC322-4218 | 25 - Inquiry, audit, lessons management and after action review | The Inspector-General Emergency Management recommends this report be returned to the IGEM to monitor, evaluate and report on progress and implementation of the recommendations that are accepted in whole or in part by government. |
REC322-4219 | 25 - Inquiry, audit, lessons management and after action review | The Inspector-General Emergency Management recommends should a Queensland Government Action Plan be considered, clarity about the intent of the recommendations be sought from the Inspector-General Emergency Management to assist in informing this process. |
REC322-4220 | 25 - Inquiry, audit, lessons management and after action review | The Inspector-General Emergency Management recommends Queensland Fire and Emergency Services and the Department of Environment and Science monitor the progress of relevant improvement activities resulting from the K’gari (Fraser Island) Bushfire Review, through their respective lessons management programs. |
Rec-ID | Code | Recommendation |
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REC315-3798 | 25 - Inquiry, audit, lessons management and after action review | That, in order to ensure recommendations accepted by the Government are implemented in a timely and transparent manner, Government establish a central accountability mechanism to track implementation of recommendations from bush fire-related reviews and inquiries and consider expanding this to other policy areas. |
REC315-3873 | 25 - Inquiry, audit, lessons management and after action review | That Resilience NSW review existing functional area arrangements to ensure they are closely aligned to agencies responsible for direct service delivery. |
REC315-3860 | 25 - Inquiry, audit, lessons management and after action review | That, in order to ensure the guiding principles and approval processes are contemporary, streamlined and more flexible, the NSW and Commonwealth Governments review the Defence Assistance to the Civil Community (DACC) arrangements. This review should include the circumstances in which the State can request Commonwealth assistance, and the level of information provided by the ADF to the State on available resources and capabilities. |
REC315-3859 | 25 - Inquiry, audit, lessons management and after action review | That, in order to ensure State Emergency Operations Centre (SEOC) interoperability during all natural disasters, Resilience NSW review the current SEOC arrangements and location including responsibilities for ongoing resourcing and maintenance. |
REC315-3858 | 25 - Inquiry, audit, lessons management and after action review | That, in order to improve cross-agency communication and coordination during bush fires, the NSW RFS review Fire Control Centres (FCCs) in areas that were heavily affected by fire. The results should be combined with the Emergency Operations Centre (EOC) Facilities Review to identify areas that would benefit from a purpose-built FCC, enabling co-location with the EOC. |
REC315-3817 | 5 - Hazard reduction burns | That Government, noting that hazard reduction targeted in proximity to assets is on balance more likely to provide help than hinder, should: |
REC315-3812 | 25 - Inquiry, audit, lessons management and after action review | That Government commit to: |
REC315-3816 | 5 - Hazard reduction burns | That Government re-commit to the current, regionally based approach to planning and coordinating hazard reduction activities across all tenures through Bush Fire Management Committees but ensure that it is actually being implemented at a high-level of quality across NSW. Getting it to a high-level of quality requires: |
Rec-ID | Code | Recommendation |
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REC311-2505 | 25 - Inquiry, audit, lessons management and after action review | This report be returned to the InspectorGeneral Emergency Management to monitor, evaluate and report on progress and implementation of the recommendation(s) that are accepted in whole or in part by government. |
REC311-2504 | 25 - Inquiry, audit, lessons management and after action review | To enable entities in the sector to proactively work to achieve better results for the community, the recommendations and lessons of this review should be evaluated through the lessons management processes of entities involved in dam safety for their value and relevance. |
Rec-ID | Code | Recommendation |
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REC309-2478 | 25 - Inquiry, audit, lessons management and after action review | The progress of recovery for this event be reviewed incrementally over the next 2 to 3 years, with a formal, independent report provided on the effectiveness of the recovery after 3 years. |
Rec-ID | Code | Recommendation |
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REC308-2449 | 25 - Inquiry, audit, lessons management and after action review | Queensland should implement and maintain a system-wide lesson management program. |
Rec-ID | Code | Recommendation |
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REC292-2370 | 25 - Inquiry, audit, lessons management and after action review | I recommend that the New South Wales Police Force undertake a formal assessment of alternatives to the TOU’s current soft-point ammunition to determine whether a more appropriate form of ammunition is reasonably available. |
Rec-ID | Code | Recommendation |
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REC281-1201 | 25 - Inquiry, audit, lessons management and after action review | Preventing Flood Related Fatalities: The NSW Government consider the recommendations from the Preventing Flood Related Fatalities Report when it is released. |
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. |
REC280-1375 | 5 - Hazard reduction burns | That the NSW Government commit to and fund a long term program of prescribed burning based on the recommendation of the 2009 Victorian Bushfires Royal Commission of an annual rolling target of a minimum of five per cent of public land per year, and that the NSW Government commit to extending the funding for the National Parks and Wildlife Service five year hazard reduction program past 2016. |
REC280-1388 | 25 - Inquiry, audit, lessons management and after action review | That the NSW Rural Fire Service: |
REC280-1378 | 5 - Hazard reduction burns | That the NSW Rural Fire Service: -improve accountability in relation to the implementation of bush fire risk management plans as a means of delivering more hazard reduction. |
REC280-1377 | 5 - Hazard reduction burns | That the NSW Rural Fire Service, in collaboration with the NSW National Parks and Wildlife Service, review and improve the system of bush fire management zones to ensure that greater priority is given to hazard reduction on land classified within land management zones. |
REC280-1376 | 5 - Hazard reduction burns | That the NSW National Parks and Wildlife Service establish a regime of frequent mosaic burning within the Warrumbungle National Park, where conditions permit, to be monitored and evaluated via a formal fully funded research program. This program should then inform the Service’s approach to the wider national park estate. |
Rec-ID | Code | Recommendation |
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REC272-1415 | 25 - Inquiry, audit, lessons management and after action review | An audit of all local government areas vulnerable to storm tide events is completed and opportunities identified to resolve gaps in evacuation zone planning to ensure consistency with the Queensland Evacuation Guidelines for Disaster Management Groups and neighbouring local government areas. |
Rec-ID | Code | Recommendation |
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REC268-1424 | 25 - Inquiry, audit, lessons management and after action review | The Queensland Emergency Alert Guidelines is reviewed to reflect current practice and incorporate evidence-based improvements informed by lessons learned and research. |
REC268-1422 | 25 - Inquiry, audit, lessons management and after action review | The Queensland State Disaster Management Plan is reviewed to: |
Rec-ID | Code | Recommendation |
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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. |
REC261-1495 | 5 - Hazard reduction burns | That the NSW Rural Fire Service: |
REC261-1505 | 25 - Inquiry, audit, lessons management and after action review | That the NSW Rural Fire Service: |
REC261-1493 | 5 - Hazard reduction burns | That the NSW National Parks and Wildlife Service establish a regime of frequent mosaic burning within the Warrumbungle National Park, where conditions permit, to be monitored and evaluated via a formal fully funded research program. This program should then inform the Service’s approach to the wider national park estate. |
Rec-ID | Code | Recommendation |
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REC260-1070 | 5 - Hazard reduction burns | The NPWS conduct a review of its prescribed burns program to ensure, as far as reasonably practicable, that all necessary managerial approvals for a prescribed burn are provided as promptly as possible. |
REC260-1063 | 5 - Hazard reduction burns | That the National Parks and Wildlife Service consider reviewing its guidelines and protocols in respect of hazard reduction planning and burning-off operations in the light of the evidence from experts witnesses in these proceedings that the incidence of, and intensity of, major fires is increasing and in the light of expert evidence given in these proceedings concerning the dangers of vorticity-driven lateral spread. |
REC260-1061 | 18 - Access to fire ground | That the National Parks and Wildlife Service, in consultation with the relevant local Council(s), devise a policy that enables the John Renshaw Parkway to be closed at either end of the Warrumbungle National Park during a bush fire in such a way that its closure would not impede access by emergency services vehicles into the park. |
Rec-ID | Code | Recommendation |
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REC241-0995 | 5 - Hazard reduction burns | At the next reprint of the ‘Permit to Light Fire’ book, the requirement to notify neighbours when applying for a permit is reinstated to properly reflect the requirement under the Fire and Rescue Service Act 1990. |
REC241-0994 | 5 - Hazard reduction burns | That the Rural Fire Service Queensland needs to provide greater emphasis and acknowledgement of the use of fire as a tool in sustainable land management. |
REC241-1030 | 25 - Inquiry, audit, lessons management and after action review | That Rural Fire Brigades only be required to conduct an audit of finances if the Brigades income exceeds $5,000 for a financial year. RFSQ District offices should investigate options for savings on the costs of auditing Brigades in their district through either an in-house or external provider. Legal Status of Brigades |
REC241-0997 | 5 - Hazard reduction burns | That the electronic fire permit system used in the Mackay District be made available across the state for Fire Wardens who wish to use it. |
REC241-0996 | 5 - Hazard reduction burns | That Section 66 (2) of the Fire and Rescue Service Act 1990 relating to the exemption for issuing of permits to burn in State Forests, National Parks and Reserves is withdrawn and Departments must work within the District Fire Management Plan. |
Rec-ID | Code | Recommendation |
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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. |
REC239-2763 | 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. |
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. |
REC239-2727 | 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: |
REC239-2777 | 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. |
REC239-2725 | 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. |
REC239-2776 | 25 - Inquiry, audit, lessons management and after action review | That the proposed efficiency review of the Queensland Police Service examine whether: |
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. |
Rec-ID | Code | Recommendation |
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REC238-0799 | 18 - Access to fire ground | Develop and implement a program of cost-effective road improvement works that can enhance flood evacuation capacity in the short-medium term. |
REC238-0802 | 25 - Inquiry, audit, lessons management and after action review | Review the NSW state-wide governance arrangements for flood risk management so that broader issues identified by this Review can be most effectively addressed. |
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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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 |
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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. |
Rec-ID | Code | Recommendation |
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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. |
REC121-3768 | 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. |
REC121-3713 | 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. |
REC121-3765 | 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. |
REC121-3694 | 25 - Inquiry, audit, lessons management and after action review | The ITSRR should conduct random audits of accredited rail organisations for compliance with communications protocols. |
REC121-3758 | 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. |
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. |
REC121-3757 | 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. |
REC121-3691 | 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. |
REC121-3753 | 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. |
Rec-ID | Code | Recommendation |
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REC119-3649 | 25 - Inquiry, audit, lessons management and after action review | It is recommended that the Board: |
Rec-ID | Code | Recommendation |
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REC111-3939 | 25 - Inquiry, audit, lessons management and after action review | It is recommended that the State Disaster Management Group and the Department of Emergency Services review the current disaster district boundary framework and its relevance to the regional boundaries established by other public sector lead entities to ensure that resources within the Disaster Management System are economically, efficiently and effectively allocated across Queensland. |
Rec-ID | Code | Recommendation |
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REC013_3975 | 5 - Hazard reduction burns | To burn, where necessary, at least 33 feet where there is a risk of fire, on the outside of the railway fence, in conjunction with the railway employees. |