At the height of the flood on February 28, 3000 calls for help went unanswered, an independent flood inquiry has found.
Compounding the tragedy, across the state only 200 people were trained in flood rescue, servicing a population of 8 million people.
These are just some of the failings revealed in the 2022 Flood Inquiry Report, authored by Professor Mary O'Kane and former NSW Police Commissioner Mick Fuller.
They found there were significant failings in the preparation, response, and recovery surrounding the flood, and made 28 recommendations to fill those gaps.
In the lead up to the flood, the report found an inability to predict floods and how severe they might be, with the current rain and river gauge network found to be "not fit for purpose", and radar coverage inadequate.
Transferring ownership and maintenance responsibility for as many of the river and rain gauges as possible in NSW to the Bureau of Meteorology was recommended.
During the flood, the Inquiry found the SES did not have the operational ability to coordinate multiple flood rescues, and found not enough people had training to conduct those rescues.
Mr Fuller said in NSW there were "around 200 people who are trained for flood rescue, and in a state of 8 million people when we see catastrophic weather events, it's just not enough".
The Inquiry found in NSW, flood rescues were approached differently to other types of rescue which were coordinated by NSW Police. It found "no compelling reasoning for this type of rescue to operate differently to other forms of rescue".
An overloaded communication network also placed lives in danger, the report found.
The Inquiry heard evidence that Beacon, the SES deployment system, was purportedly turned off or ignored by overwhelmed local SES because of the extraordinary number of calls for service, and that in one location up to 3,000 calls for service were never actioned by the SES.
It also heard calls directed from Triple Zero (000) to SES were not taken and often went through to a recorded voice message.
Mr Fuller acknowledged the work of the emergency services and the challenges faced by the SES during the weather events in February and March, but said structural changes were needed to improve flood response.
He said appointing a permanent State Emergency Management Operations Coordinator (SEOCON), establishing a training centre, creating a Government "flood" committee, and merging the back office operations of the RFS and SES were steps towards providing a better response to floods and emergencies overall.
Mr Fuller said while some members of the SES may be disappointed in the decision to merge the back office with the RFS, they saw it as a way to capitalise on the knowledge and organisational structure already well established within the fire service, and allow members to focus on operational needs.
Amongst the other findings, the Inquiry found Resilience NSW "did not perform as intended".
The main criticisms were directed at Resilience NSW's "slowness and unresponsiveness in respect of evacuation and recovery centres, clean up, restoring essential services and issuing of grant funding to affected communities and businesses, all of which exacerbated the stresses resulting from the disaster".
Resilience NSW will be reshaped to 'Recovery NSW', and the new agency will be "more streamlined and agile to drive recovery in the first 100 days post disaster", the report says.
Responsibility for public messaging will be transferred to Service NSW to "improve access to clear, reliable and consistent messaging prior to and during emergencies.
To further simplify messaging, a new NSW Disaster App will be created.
The loss of power during the flood events was "significant in terms of scale, duration and its compounding effect on other services including telecommunication, sewerage system plants and water supply systems".
To avoid issues in a future event, it was recommended all levels of government work with relevant power and telecommunications regulatory, policy and market bodies to ensure services are not lost during an emergency.
The Inquiry found some of these failings were not new to this flood event. It looked at a number of previous reviews, and "noted many common themes, most of which strongly resonated with 2022 flood experiences and key findings in this report.".
The inquiry report said it found it difficult to determine what recommendations had been implemented in the past, noting an April 2021 NSW Audit Office Performance Audit report on Addressing public inquiry recommendations found that "two-thirds of recommendations reviewed in the audit could not be verified as being implemented as intended, and in line with the outcomes sought. The audit also found that agencies did not always nominate milestone dates or priority rankings for accepted recommendations, and so could not demonstrate if they were managing or monitoring them effectively"
The Inquiry heard a deep sense of frustration from many flood-affected residents and community members over a lack of implementation and change over time, despite multiple previous reviews.
"Many were sceptical that this Inquiry would succeed in effecting significant change", the report says.
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