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

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

The State develop and implement, in consultation with local government, a mechanism for sign-off by municipal councils of any permit conditions imposed under the Bushfire-prone Overlay and the regular assessment of landowners’ compliance with conditions.

The Australian Building Codes Board do the following: ■ amend the performance requirements in the Building Code of Australia to ensure that they incorporate reducing the risk of ignition from ember attack; ■ work with Standards Australia to effect expeditious continuing review and development of

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 reclose

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.

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

Councils should strengthen governance arrangements for business continuity by:

Councils should improve assessments of business continuity risks by:
• strengthening risk management practices to assure they identify and consider the full range of specific business continuity risks

Councils should improve the structure, format and content of their business continuity plans to provide greater clarity on roles and responsibilities for emergencies, more specificity on continuity and recovery responses, and better integration with other council disaster recovery and emergency p

Councils should strengthen their continuous improvement frameworks by:
• systematically reviewing the effectiveness of their business continuity activities
• regularly testing business continuity plans to assure they are up-to-date and effective

Local Government Victoria should, further to its work on strengthening the oversight role of audit committees, assist councils to develop good practice approaches to implementing, overseeing and continuously improving business continuity management.

The Department of Human Services should regularly test recovery plans with partner agencies. 

The Department of Human Services should communicate strategic priorities to achieve state and regional level alignment in building recovery capacity and capability. 

The Department of Human Services should work with regions and partner agencies at the state level to create consistent, streamlined impact assessment processes and systems. 

The Department of Human Services should make sure relevant senior staff complete recovery training. 

The Department of Human Services should work with the State Emergency Recovery Planning Committee, regions, and other partners to facilitate understanding and ownership of roles and responsibilities for common recovery services. 

The Department of Human Services should develop practical, operational guidelines for implementing recovery at the state level. 

The Department of Human Services should improve regional recovery plans through:
• developing a consistent format that meets Emergency Management Manual Victoria content requirements
• revising plans biennially with recovery partners 

The Department of Human Services should create evaluation guidelines for recovery operations, including links to planning. 

The Department of Human Services should complete work on emergency communication and information management issues. 

The Department of Human Services should base targets for staff in emergency roles on regional needs and develop a staff deployment strategy. 

Pre‐drilling assessments should include a risk assessment of the worst‐case blowout scenario.

The Government should examine the scope for a single environment plan to meet the regulatory requirements of both the OPGGS Act and the EPBC Act. This could possibly be achieved by way of bilateral agreements and accreditation arrangements and/or legislative amendment.

As soon as a risk of barrier failure arises, no other activities should take place in the well other than those directed to removal of the risk.

A minimum of two barriers should be in place at all times (including during batched operations) whenever it is reasonably practicable to do so.

Any equipment (including PCCCs) used as, or to install, a barrier should be manufactured for that purpose and be generally recognised as fit for purpose.

Written (rather than verbal) approval from the DA (or new regulator) should be obtained before the commencement of well activities that lead to a physical change of a wellbore, other than in a true emergency situation (requiring amendment to regulation 17 of the Management of Well Operations Regu

The Minister consider legislative amendments to the OPGGS Act which make clear that

Problems which arise in the course of installing barriers must be the subject of consultation between licensees, rig operators, and contractors (if used).

OSCPs should be endorsed by AMSA prior to regulatory approval to ensure that they align with the National Plan. Once field operations commence, the capability of operators should be assessed against their plans, and exercises conducted to ensure the plans remain effective.

Achievement and maintenance of well control should be written into the job responsibilities of key personnel, at every level up to and including CEOs. That is, a functional line of accountability for well control must exist up to, and including, CEOs.

If a dispute arises between a licensee and a rig operator in relation to a well control issue, and is not resolved between them, the matter must be raised with the relevant regulator before discretionary operations proceed.

Reliance upon one barrier against a blowout must not take place except with the prior written approval of the relevant regulator and then only in a true emergency situation (see below).

Manufacturers should be consulted about how to address non‐routine operational problems affecting their well control equipment.

The OPGGS Act should be amended to allow for a power to suspend a petroleum production licence (in addition to the current power to cancel a licence or suspend its conditions).

The use/type of barriers (including any change requests relating thereto) must be the subject of consultation between licensees and rig operators prior to installation. A proper risk assessment should be carried out, agreed upon, and documented in writing before installation.

For the purposes of that review, the Minister should issue a ‘show cause’ notice to PTTEPAA under s 276 of the OPGGS Act.

Achievement and maintenance of well control should be written into the job responsibilities of key personnel, at every level up to and including CEOs. That is, a functional line of accountability for well control must exist up to, and including, CEOs.

Perceived time and cost savings relating to any matters impacting upon well control should be subjected to rigorous safety assessment.

Licensees and rig operators should install an additional barrier whenever (i) there is any real doubt as to the integrity of any barrier; (ii) whenever the risk of flow from a reservoir increases materially in the course of operations; and (iii) where the consequences of a blowout are grave (for

Drilling programs dealing with barrier installation should incorporate relevant aspects of manufacturer’s instructions.

The recommendations of the Inquiry in relation to suitable ways of achieving well integrity contained in Chapter 3 be included in a guidance manual that is issued for the assistance of industry and regulators.

Removal of a barrier must be the subject of consultation between licensees and rig operators prior to removal. A proper risk assessment should be carried out and agreed upon, and documented in writing before removal.

In carrying out a review of PTTEPAA’s permit and licence, the Minister should have regard to this Report, particularly (i) the adverse findings set out in this Chapter; and (ii) the extent to which PTTEPAA has implemented the Action Plan submitted to the Inquiry, or otherwise addressed the matter

Supervision/oversight of well control operations (within licensees, rig operators and by regulators) must occur without assuming adherence to good oilfield practice.

Wells drilled into hydrocarbon zones should be treated as live wells, with the potential to blowout unless a documented risk assessment establishes otherwise.

The industry standard of two barriers should be replaced with the concept of ‘two or more barriers’ as a minimum standard. A minimum standard when operations proceed normally should never be regarded as a sufficient standard in other circumstances.

Any pro‐formas used by licensees, rig operators and contractors for recording information about installation of barriers should explicitly provide for ‘exception reporting’, that is, the form should include provision for recording any unforseen or untoward events which occur in the course of inst

The regulator, rather than the responsible Minister, should be given the power to direct an operator to use a particular rig for the purpose of well control operations, if appropriate in the circumstances, and the power should be used in the future if that rig is the best option available.

Decision‐making about well control issues should be professionalised. Industry participants must recognise that decision‐makers owe independent duties to the public, not just their employer or principal, in relation to well control.

Licensees and rig operators should be astute in ensuring that corporate systems and culture encourage rather than discourage raising of well control issues. For instance, do performance bonuses or rewards actually encourage or discourage reporting of issues?

Regulatory approval to rely on only one barrier should not be given unless (i) a proper risk assessment is carried out; (ii) exceptional circumstances exist; and (iii) risks involved are reduced to ‘as low as reasonably practicable’.

Industry, regulators, and training/research institutions should develop standards that address best practices for cementing operations (including liaising, as appropriate, with overseas regulators) with a view to overcoming problems which can effect the integrity of cemented casing shoes, annulus

Batched drilling operations should only be undertaken after careful assessment of the special risks which such operations give rise to; well control must be maintained during the course of batched drilling operations.

The regulatory regime should also impose an obligation on an operator to ascertain the availability, and provide details to the regulator, of any potential relief well rigs, prior to the commencement of drilling operations (including prior to each phase of a drilling operation where applicable).<

Logistics management of well control equipment should be conducted in such a way as to operate as a check against deficient well control practices, for example, use of serial numbers to track availability, testing, and deployment of well control equipment.

It is recommended that industry, regulators, and training/research institutions liaise with one another with a view to developing better techniques for testing and verifying the integrity of cemented casing shoes as barriers (particularly in atypical situations such as where the casing shoe is lo

The regulator should pre‐assess and review in a generic sense, and in conjunction with the offshore petroleum industry, available options for well control in the event of a blowout.

Consideration should be given to ways to ensure that contractors who are involved in barrier installation (such as cementing companies) have a direct interest in the performance of works to a proper standard.

Tracking and analysis of cementing problems/failures should occur to assess industry trends, principal causes, remedial techniques and so on.

Cement integrity should be evaluated wherever practicable by way of cement evaluation tests, rather than relying on pre‐operational calculations of cement and displacement fluid volumes.

Where multiple wells are drilled, operations and occurrences at one well must be carefully assessed for any implications with respect to well control at other wells.

NOPSA develop a policy of engagement with operators so as to enable experts (including safety experts) to canvas all available options for well control in the event of a blowout.

The National Plan should specify that the cost of responding to an oil spill, or other damage to the offshore marine environment, will be totally met by the owner/operator.

Careful consideration must be given to equipment compatibility as part of well construction design.

It should be standard industry practice to re‐test a cemented casing shoe (that is, after WOC) whenever the plugs do not bump or the float valves apparently fail. Standard industry practice should require consideration of other tests in addition to a repeat pressure test.

The mere fact that the rig is over the platform should not be regarded by licensees or regulators as sufficient justification for reliance on only one barrier.

The Inquiry also supports Bills and Agostini’s recommendation: ‘…in relation to safety case development and compliance overall, that NOPSA revise its approach to interacting with operators prior to the safety case assessment process and subsequently direct more resources into its advisory functio

NOPSA’s prohibition powers should be extended such that a prohibition notice can be issued where a NOPSA Occupational Health and Safety Inspector believes, on reasonable grounds, that an activity is occurring or may occur at a facility involving an immediate threat to the health or safety of a pe

The obligation of companies involved in an incident to meet the full costs of monitoring and remediation should be made a condition of approval of proposals under the EPBC Act and OPGGS Act.

Any indication of a compromised cemented shoe which cannot be resolved with a high measure of confidence should result in the installation of additional well control barrier(s).

Relevant personnel from licensees and rig operators should meet face to face to agree on, and document, well control issues/arrangements prior to commencement of drilling operations.

The National Plan should be reviewed to clarify the arrangements to apply in Commonwealth waters regarding key roles and responsibilities, including in relation to the ESC, in the event of an oil spill. This should also address any necessary training required.

The Minister should appoint a senior policy adviser to investigate and report on the best means to implement the recommendations contained in this Chapter 3 of this report.

Well Operations Management Plan (WOMPs) submitted by licensees to the regulator(s) should continue to be the primary framework document for achieving well integrity.

Volumes of cement used in connection with barrier installation should be calculated with the assistance of a pro‐forma which records all relevant baseline data, which should be verified by onshore personnel.

Prior to commencement of drilling operations, senior representatives of the licensee and rig operator should exchange certificates to the effect that their respective key personnel and contractors have been informed in writing of agreed well control arrangements.

The National Plan should be revised to ensure that it fully comprehends environmental matters and that it recognises the importance of the prompt implementation of Scientific Monitoring to facilitate the assessment of the environmental impacts of an incident.

A single, independent regulatory body should be created, looking after safety as a primary objective, well integrity and environmental approvals. Industry policy and resource development and promotion activities should reside in government departments and not with the regulatory agency.

WOMPs should be comprehensive and freestanding, rather than an overarching document cross‐referencing many other documents (although the Inquiry also recommends a freestanding well control manual; this should be a guide to rig and onshore personnel on good oilfield practice).

If performance of barrier installation is outsourced by a licensee, the contractor (for example, the cementing company) should be engaged on terms which clearly require the provision of expert advisory services by the contractor with respect to barrier integrity.

Information relevant to well control must be captured and communicated within and between licensees and rig operators (and relevant third party contractors), in a manner which ensures it comes to the attention of relevant personnel.

Procedures for the approval of development projects should ensure that conditions of approval are comprehensive and clearly set out the obligations of their proponents in relation to environmental matters (including expected monitoring and remediation obligations).

The proposal of the Productivity Commission’s Research Report (Review of Regulatory Burden on the Upstream Petroleum (Oil and Gas) Sector, April 2009) to establish a NOPR should be pursued at a minimum.

There should be a review to determine whether it is appropriate to introduce a rigorous civil penalty regime and/or substantially increase some or all of the penalties that can be imposed for breaches of legislative requirements relating to well integrity and safety.

The concept of ‘good oilfield practice’ should be supplemented by the requirement to incorporate into WOMPs non‐exhaustive minimum compliance standards in relation to well control: for example, stipulations as to when BOPs and/or well control systems must be in place and when they can be removed

Horizontal or high angle penetration of a reservoir should be avoided wherever practicable until such time as the apparent problems associated with the cementing of a casing shoe in these situations are satisfactorily overcome.

All communications between on‐rig and onshore personnel relating to well control should be documented in a timely manner.

DEWHA, in concert with AMSA and with expert input, should develop ‘off the shelf’ monitoring programs that can be speedily implemented following incidents in Commonwealth waters.

Responsibility for well integrity should be moved to NOPSA (as also proposed by the Productivity Commission).

The Minister should, as the JA for the offshore area of the Territory of Ashmore and Cartier Islands, undertake a review of PTTEPAA’s permit and licence to operate at the Montara Oilfield.

Existing well control training programs should be reviewed by the industry, regulators and training providers, with a focus on well control accidents that have occurred (in Australia and overseas).

Well construction and management plans should include provision for an independent compliance review of well integrity (i) in the event of stipulated triggers; and (ii) at least once in the period between perceived achievement of well integrity and production.

The BOP and rig should not move from a well until barrier integrity has been verified.

Licensees, rig operators, and relevant third party contractors should develop well control competency standards for their key personnel. Wherever possible, the competencies of key personnel should be benchmarked against their roles and responsibilities.

The National Plan should be reviewed:
a. to ensure that it adequately addresses the risks associated with offshore oil and gas exploration;
b. to revisit the underlying risk assessment undertaken to inform capacity and preparedness under the National Plan;

DEWHA should participate in training programs and exercises relevant to an oil spill in the marine environment.

In the meantime, the Minister should:

In view of the numerous well integrity problems in all of the Montara Oilfield wells, the Minister should commission a detailed audit of all the other offshore wells operated by PTTEPAA to determine whether they too may suffer from well integrity problems.