Inquiry Search
Rec-ID | Code | Recommendation |
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REC002-4003 | 35 - Business and Industry in relation to industry | Where gas exists, and no provisions are made for its constant removal, no shots should be fired, and, where permitted in a gassy mine, shots should be fired only by a man specially appointed, and at such hours when the miners are not within the mine. All shots should be tamped by stone well damped, and only copper or wooden tools should be employed. As far as possible the use of explosives should be discouraged, and skilful mining encouraged. Danger-boards should be placed further from the faces whence gas issues (say), where practicable, 50 yards. |
REC002-4013 | 19 - Offences | Infringement of the regulations by either party should be followed by a summary form of justice, instituted before two Magistrates. |
REC002-4002 | 19 - Offences | Where safety-lamps are necessary - gas being present for (say) one month after being found in dangerous quantity - they should be securely locked by a man duly appointed, and tampering with them must be punishable by a simple and inexpensive process of law. |
REC002-4012 | 38 - Agency/Department Reporting | Complete sets of daily-report books should be provided, and kept in the mine or office, to be overlooked by the Inspector during his periodical visits. |
REC002-4001 | 35 - Business and Industry in relation to industry | The Commission consider that in all mines where gas exists the course of the air should be directed to sweep along the working-faces; in mines worked by Pillar and Stall, bratticing must be resorted to to carry the gas from the face as it issues, and so prevent any accumulation of explosive gases or of gases inimical to life. In cases where gas exists it would be better that no bords should be broken off the back or return heading or supplied with air fouled by dangerous gases. The panel system of working by confining and localising districts, or some modification thereof, might be pursued with advantage. |
REC002-4010 | 35 - Business and Industry in relation to industry | The Commission do not approve of removing any responsibility from the management by increasing the power or number of the Inspectors. The visits of these officials should, so far as possible, be visits of surprise. |
REC002-4008 | 35 - Business and Industry in relation to industry | Where dust exists in quantity, and under conditions favourable for ignition, it should be periodically and sufficiently dampened by water |
REC002-4004 | 35 - Business and Industry in relation to industry | Where safety-lamps are used, and the obligation is laid upon the men to cleanse the same, all examinations, tests, and repairs to these should be done by the owners. |
Rec-ID | Code | Recommendation |
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REC274-1408 | 7 - Inter-agency communication | That the Department of Health & Human Services uses Emergency Services Telecommunications Authority Computer Aided Dispatch data to report ambulance emergency response time performance. |
REC274-1405 | 37 - Funding | That the Department of Justice & Regulation broadens Budget Paper 3 response time measures to more comprehensively cover emergency responses to fires, rescues and other emergencies. |
Rec-ID | Code | Recommendation |
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REC262-1485 | 7 - Inter-agency communication | That Victoria Police implements the recommendations relating to protective services officers in the Service Demand and Dispatcher Capacity Analysis dated September 2013 and: |
REC262-1484 | 7 - Inter-agency communication | That Ambulance Victoria: |
REC262-1483 | 7 - Inter-agency communication | That the Emergency Services Telecommunications Authority includes Victoria State Emergency Service vehicle capability details in the Computer Aided Dispatch database. |
REC262-1491 | 7 - Inter-agency communication | That Emergency Management Victoria expedites the expansion of the Rural Mobile Radio network to all emergency services organisations. |
REC262-1487 | 7 - Inter-agency communication | That the Emergency Services Telecommunications Authority, assisted by the Inspector-General for Emergency Management and responder agencies, improves the process for changing call-taking and dispatch procedures by comprehensively appraising the costs, benefits and operational impacts of these changes and agreeing a plan for their implementation with all affected agencies. |
REC262-1486 | 7 - Inter-agency communication | That Emergency Management Victoria novates the head contract for the StateNet Mobile Radio network to the Emergency Services Telecommunications Authority. |
Rec-ID | Code | Recommendation |
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REC237-0834 | 37 - Funding | That the NSW Rural Fire Service apply for funding from the NSW Treasury for the development of a multi-agency business case for a BRIMS replacement that includes internal management, risk communication, community engagement capability and publishing activities on websites. |
REC237-0833 | 37 - Funding | That the NSW Rural Fire Service and the NSW Treasury explore ways to ensure that unspent hazard reduction funds be carried over to the next financial year in a timely manner and to ensure that hazard reduction funding has a seamless transition from one financial year to the next. |
REC237-0830 | 9 - Community education | That Bush Fire Risk Management Plans be tabled at Local Emergency Management Committees for comment. |
REC237-0829 | 9 - Community education | That Bush Fire Risk Management Plans be posted on the NSW Rural Fire Service website. |
REC237-0828 | 9 - Community education | That the NSW Rural Fire Service develop a strategy to better inform the community and NSW Rural Fire Service members about the NSW bush fire management system and its components. |
Rec-ID | Code | Recommendation |
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REC208-0525 | 7 - Inter-agency communication | That the Office of Environment and Heritage amend its operating procedures for the Environment Line to ensure that there are clear obligations to pass on information relevant to other agencies, to those agencies in a timely manner. |
REC208-0527 | 35 - Business and Industry in relation to industry | That the Office of Environment and Heritage require Orica to engage and fund appropriate independent experts to oversee any modifications to the plant in the next major maintenance overhaul of the plant in 2016 and in any upgrades to the plant prior to that date. |
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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REC180-2970 | 22 - Role of local Gvt | Councils should improve assessments of business continuity risks by: |
REC180-2969 | 22 - Role of local Gvt | Councils should strengthen governance arrangements for business continuity by: |
REC180-2973 | 22 - Role of local Gvt | 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. |
REC180-2972 | 22 - Role of local Gvt | Councils should strengthen their continuous improvement frameworks by: |
REC180-2971 | 22 - Role of local Gvt | 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 plans. |
Rec-ID | Code | Recommendation |
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REC179-2980 | 24 - Govt responsibility | 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. |
REC179-2979 | 24 - Govt responsibility | The Department of Human Services should communicate strategic priorities to achieve state and regional level alignment in building recovery capacity and capability. |
REC179-2977 | 38 - Agency/Department Reporting | The Department of Human Services should create evaluation guidelines for recovery operations, including links to planning. |
REC179-2983 | 24 - Govt responsibility | 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. |
Rec-ID | Code | Recommendation |
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REC158-3448 | 24 - Govt responsibility | That the Director of Marine Safety works with the Australian Maritime Safety Authority to ensure that State and port emergency arrangements interface appropriately with the National Maritime Emergency Response Arrangements. |
REC158-3454 | 24 - Govt responsibility | That the Department of Transport ensures that key stakeholders are engaged during the implementation of the approved Review recommendations. |
REC158-3433 | 24 - Govt responsibility | That Harbour Masters are employed by a government body and remain geographically located at the port. |
REC158-3452 | 25 - Inquiry, audit, lessons management and after action review | That the nominated marine safety authority undertakes a further assessment to determine the recommendations from this Review that may also be applicable to State waters outside commercial port waters. |
REC158-3429 | 38 - Agency/Department Reporting | That the nominated marine safety authority is required to ensure that incident notification and data recording requirements for Victorian commercial ports are consistent and adhered to. |
REC158-3451 | 37 - Funding | That port/channel managers should be able, within the general context of the pricing/cost recovery arrangements established under the Port Services Act 1995 and pricing determinations made by the Essential Services Commission, to recover the reasonable costs of meeting their statutory obligations (as per recommendation 26) through charges for prescribed service applied to port users. |
REC158-3428 | 38 - Agency/Department Reporting | That the nominated marine safety authority, in consultation with the Emergency Services Commissioner and senior emergency services personnel, is responsible for monitoring the implementation and auditing against appropriate performance standards, risk management guidelines and good practice guidelines. |
REC158-3450 | 37 - Funding | That emergency services are responsible for funding the development of the emergency services marine emergency response capacity/capability to meet their statutory obligations. |
REC158-3449 | 37 - Funding | That port/channel managers are responsible for funding the preparation of marine emergency risk assessments and marine emergency response arrangements and ensuring the availability of identified marine resources in support of response to a marine emergency, to meet their statutory obligations. |
Rec-ID | Code | Recommendation |
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REC123-3877 | 25 - Inquiry, audit, lessons management and after action review | All agencies review formal and informal incident notification processes to ensure they support the earliest possible reporting of emergencies to all stakeholders involved in the Airport Emergency Plan and in so doing, ensure early access to specialist advice and support. |
Rec-ID | Code | Recommendation |
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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. |
REC121-3765 | 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. |
REC121-3713 | 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. |
REC121-3776 | 38 - Agency/Department Reporting | The Minister for Transport Services should retain, independently of ITSRR, safety auditors to provide a report to the Minister confirming or qualifying the contents of each such ITSRR quarterly report. |
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. |
REC121-3693 | 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. |
REC121-3758 | 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. |
REC121-3712 | 38 - Agency/Department Reporting | RailCorp and ITSRR should co-operate with national programs for the collection, collation, trend analysis and dissemination of safety critical information. |
REC121-3775 | 38 - Agency/Department Reporting | The Minister for Transport Services must table in Parliament, each such quarterly report by ITSRR. |
REC121-3723 | 38 - Agency/Department Reporting | All ATSB accident investigation reports should be made public. |
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. |
REC121-3757 | 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. |
REC121-3704 | 28 - Personal responsibility | RailCorp should continue its system of voluntary self-identification and rehabilitation of employees with alcohol or drug related problems. |
REC121-3774 | 38 - Agency/Department Reporting | The ITSRR must provide a quarterly report to the Minister for Transport Services on the progress made by RailCorp in implementing these recommendations, including: |
REC121-3722 | 38 - Agency/Department Reporting | The ATSB should deliver any report of any such rail accident which it investigates to the Board of any rail organisation involved in the accident, ITSRR and the Minister for Transport Services. |
REC121-3678 | 35 - Business and Industry in relation to industry | All railway owners and operators should have a quality assurance program for the design and construction of rolling stock and regular review of construction to ensure that the rolling stock satisfies the original functional performance specifications. |
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. |
REC121-3703 | 6 - Insurance and legal liability | Alcohol and drug testing should be mandatory for any train driver or guard involved in any accident or incident. |
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. |
REC121-3721 | 24 - Govt responsibility | The ITSRR should ensure that OTSI, as a division of ITSRR, co-operates and assists the ATSB in the conduct of any independent investigation by the ATSB of any rail accident or incident in New South Wales. |
REC121-3742 | 19 - Offences | The risk of abuse of internal passenger emergency door releases should be further reduced by introducing significant penalties for any improper use of such an emergency facility. It should be a criminal offence for anyone to use or tamper improperly with an emergency escape facility in a train. |
REC121-3697 | 38 - Agency/Department Reporting | All train drivers’ defects reports should be entered by RailCorp into a computerised record and tracked to finalisation. |
REC121-3767 | 24 - Govt responsibility | All accredited rail organisations should be required to re-apply every three years to ITSRR for accreditation. |
REC121-3720 | 24 - Govt responsibility | The New South Wales Government should make the necessary arrangements with the Australian Government, including any necessary legislation, for the Australian Transport Safety Bureau (ATSB) to have the power to investigate all rail accidents occurring on the New South Wales rail network the investigation of which may advance the knowledge of the causes of rail accidents in Australia. |
REC121-3729 | 38 - Agency/Department Reporting | All reports of the Chief Investigator of OTSI should be delivered, upon completion and without being reviewed, to ITSRR and the Minister for Transport Services. |
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: |
REC119-3648 | 38 - Agency/Department Reporting | It is recommended that providers supply data to the Board: |
Rec-ID | Code | Recommendation |
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REC004-3998 | 19 - Offences | That a by-law be made forbidding, under a heavy penalty, any persons travelling in such trains to throw lighted tobacco, cigars, cigarettes, pipe ashes, matches, or other inflammable matter on the railway line or right-of-way, or in any part of a railway carriage except the receptacles duly provided for the purpose. |