Inquiry Search
Rec-ID | Code | Recommendation |
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REC258-2549 | 25 - Inquiry, audit, lessons management and after action review | The Civil Aviation Safety Authority provides full disclosure of audit findings at audit exit briefings in accordance with international best practice. |
REC258-2557 | 6 - Insurance and legal liability | The Civil Aviation Safety Authority reassesses the penalties in the Civil Aviation Safety Regulations. |
REC258-2544 | 6 - Insurance and legal liability | The Australian Transport Safety Bureau transfers information from Mandatory Occurrence Reports to the Civil Aviation Safety Authority, without redaction or de-identification. |
REC258-2556 | 25 - Inquiry, audit, lessons management and after action review | The Civil Aviation Safety Authority structures all regulations not yet made with the three-tier approach, and subsequently reviews all other Civil Aviation Safety Regulation Parts (in consultation with industry) to determine if they should be remade using the three-tier structure. |
REC258-2543 | 6 - Insurance and legal liability | The Civil Aviation Safety Authority reintroduces a ‘use of discretion’ procedure that gives operators or individuals the opportunity to discuss and, if necessary, remedy a perceived breach prior to CASA taking any formal action. This procedure is to be followed in all cases, except where CASA identifies a Serious and Imminent Risk to Air Safety. |
REC258-2552 | 25 - Inquiry, audit, lessons management and after action review | The Civil Aviation Safety Authority implements a system of using third-party commercial audits as a supplementary tool to its surveillance system. |
REC258-2540 | 6 - Insurance and legal liability | The Civil Aviation Safety Authority continues to provide appropriate indemnity to all industry personnel with delegations of authority. |
REC258-2551 | 25 - Inquiry, audit, lessons management and after action review | The Civil Aviation Safety Authority assures consistency of audits across all regions, and delivers audit reports within an agreed timeframe. |
REC258-2528 | 25 - Inquiry, audit, lessons management and after action review | The Australian Transport Safety Bureau investigates as many fatal accidents in the sport and recreational aviation sector as its resources will allow. |
REC258-2550 | 6 - Insurance and legal liability | The Civil Aviation Safety Authority introduces grading of Non-Compliance Notices on a scale of seriousness. |
REC258-2559 | 15 - Inter-service cooperation | The Civil Aviation Safety Authority’s Director of Aviation Safety meet with industry sector leaders to jointly develop a plan for renewing a collaborative and effective Standards Consultative Committee. |
Rec-ID | Code | Recommendation |
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REC256-1572 | 6 - Insurance and legal liability | Insurers should provide additional standardised information to households regarding their insurance policies, the natural hazards they face and indicative costs of rebuilding after a natural disaster. This work should be led by the Insurance Council of Australia developing guidelines, within one year, to ensure consistency in the provision and presentation of this information across insurers. |
REC256-1565 | 13 - Mapping and data quality | Governments should task the Australia–New Zealand Emergency Management Committee with leading the development of guidelines for the collection and dissemination of natural hazard mapping, modelling and metadata. Guidelines should be developed for all hazards that need to be modelled and mapped at the local/regional level and where consistency across regions is desirable. |
REC256-1564 | 6 - Insurance and legal liability | State and territory governments, local governments and insurers should explore opportunities for collaboration and partnerships. Partnerships, for example, could be formed through the Insurance Council of Australia and state-based local government associations (or regional organisations of councils). Consideration could be given to the Trusted Information Sharing Network model. Partnerships could involve: |
REC256-1563 | 13 - Mapping and data quality | Governments at all levels should make new and currently held natural hazard data publicly available in accordance with open public sector information principles. When collecting new natural hazard data or undertaking modelling, all levels of government should: |
REC256-1573 | 25 - Inquiry, audit, lessons management and after action review | The Australian Government should schedule an independent and public review of the progress of reforms to natural disaster funding arrangements five years after implementation has commenced. This review should examine the operation and efficacy of the arrangements, including the: |
Rec-ID | Code | Recommendation |
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REC244-2620 | 25 - Inquiry, audit, lessons management and after action review | Review employment conditions under the F&ES Act to align with those under the Public Sector Act unless there is a compelling reason to the contrary. |
REC244-2617 | 25 - Inquiry, audit, lessons management and after action review | When judging major incidents in the future, consideration be given to Eburn and Dover’s proposal to establish processes with a statutory basis that sufficiently balance the community’s interests in ensuring that true lessons, including lessons of error or neglect, are identified, whilst also protecting members of the emergency services. Processes need to be developed for emergency services such as those used in aviation and medicine, to facilitate open and honest disclosure of errors. |
REC244-2616 | 6 - Insurance and legal liability | That once the review of the Emergency Management Act has been finalised, any reference to the liability of councils should be mirrored in both the EM Act and the F&ES Act. |
REC244-2601 | 25 - Inquiry, audit, lessons management and after action review | That an independent review of the operational and geographic boundaries of the ESOs be conducted recognising the limitations of the current governance structures to adequately address such issues. Such a review needs to be performed periodically, but not less than every 8 years. |
REC244-2600 | 25 - Inquiry, audit, lessons management and after action review | An external audit of shared services performed by SAFECOM and services now provided by the three ESOs which have the potential to be shared, be undertaken to determine the most efficient and cost effective way such services can be delivered to the sector. The three ESO Chiefs need to have input into this process. |
REC244-2631 | 25 - Inquiry, audit, lessons management and after action review | Review Section 134 to ensure that it is not a deterrent to a group of farm fire units operating at an incident. |
Rec-ID | Code | Recommendation |
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REC239-2769 | 9 - Community education | That the Chief Executive Officer portfolio business and Commissioner of Police in line with the government’s open data policy consider introducing an improved social media style forum for interaction with the community and stakeholders across the portfolio. |
REC239-2703 | 15 - Inter-service cooperation | That the protocols developed by the Queensland Police Service and SES for operations define the respective roles and responsibilities as well as recognise the varying capabilities of SES units across the State. |
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. |
REC239-2768 | 9 - Community education | Recommendation: That: |
REC239-2694 | 15 - Inter-service cooperation | That Queensland enters into a similar arrangement with Bureau of Meteorology to have an experienced forecaster seconded to Kedron State Disaster Coordination Centre for at least the duration of fire and storm seasons. |
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: |
REC239-2764 | 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. |
REC239-2667 | 15 - Inter-service cooperation | That Queensland Corrective Service, the Queensland Police Service and Queensland Health should work together to develop a position that enables prisoners to have timely access to their prescribed medication despite travel between facilities and without the need for costly re-prescription. |
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. |
REC239-2763 | 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. |
REC239-2659 | 9 - Community education | That Queensland Health continues to recognise and foster the important contributions of Local Ambulance Committees to supporting effective community focused ambulance services across the State. |
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. |
REC239-2762 | 15 - Inter-service cooperation | That the Chief Executive Officer Portfolio Business in consultation with the Police Commissioner and the Commissioner Fire & Emergency Services should provide the direction for future information and communication technology strategies and acquisitions. |
REC239-2770 | 9 - Community education | That the efficiency review of the Queensland Police Service develop options for better management of community expectations and divesting the organisation of historical practices. |
REC239-2710 | 13 - Mapping and data quality | That all agencies participating in these activities should, as far as legally possible, share data sets whether or not the relevance is immediately obvious. |
REC239-2761 | 15 - Inter-service cooperation | That systems development in the Queensland Police Service capitalises on the advances made by the Queensland Fire and Rescue Service in recent years. |
Rec-ID | Code | Recommendation |
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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. |
REC237-0830 | 9 - Community education | That Bush Fire Risk Management Plans be tabled at Local Emergency Management Committees for comment. |
Rec-ID | Code | Recommendation |
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REC207-2885 | 13 - Mapping and data quality | Increased automation and outsourcing of observations |
Rec-ID | Code | Recommendation |
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REC205-1906 | 6 - Insurance and legal liability | Governments should not subsidise household or business property insurance, whether directly or by underwriting risks. |
REC205-1905 | 6 - Insurance and legal liability | The Australian Government should only proceed with reforms that require all household insurers to offer flood cover if it can be demonstrated that the benefits to the wider community would exceed the costs. |
REC205-1903 | 25 - Inquiry, audit, lessons management and after action review | The Australian Government should commission an independent public review of disaster prevention and recovery arrangements. This should be broader than the review currently being conducted by the Attorney-General’s Department. The review should cover the Natural Disaster Relief and Recovery Arrangements, as well as the funding mechanisms for disaster mitigation, including the National Partnership Agreement on Natural Disaster Resilience. This review should: |
REC205-1902 | 25 - Inquiry, audit, lessons management and after action review | The Council of Australian Governments should commission an independent public inquiry to develop an appropriate response to managing the risks of climate change to existing settlements. The inquiry should: |
REC205-1897 | 9 - Community education | The Australian Government initiative to improve the coordination and dissemination of flood-risk information should proceed in the most cost-effective way, be regularly updated and be expanded over time to encompass other natural hazards. Guidelines to improve the quality and consistency of risk information should also be regularly updated and take climate change into account where feasible. |
Rec-ID | Code | Recommendation |
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REC165-0096 | 15 - Inter-service cooperation | The Department of Community Safety and Councils develop MOUs to reflect the genuine partnership that exists in present arrangements including an emphasis on the use of the agreed State disaster arrangements to task and deploy SES units following State/Local consultation. |
Rec-ID | Code | Recommendation |
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REC161-3030 | 25 - Inquiry, audit, lessons management and after action review | That National Offshore Petroleum Safety Authority review the risk assessment of pipelines. National Offshore Petroleum Safety Authority should focus, in particular, on the efficacy of anti-corrosion systems, and recognise potential interference effects and MAE escalation risks associated with adjacent pipelines and unlicenced pipes even if they fall outside its direct regulatory responsibilities. |
Rec-ID | Code | Recommendation |
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REC151-3092 | 19 - Offences | Expiation fees be reviewed so as to be consistent with the seriousness of the offences. |
Rec-ID | Code | Recommendation |
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REC149-3145 | 25 - Inquiry, audit, lessons management and after action review | NOPSA should consider an audit regime that targets Greenfields operations at commencement of operations. |
REC149-3142 | 19 - Offences | NOPSA should use encouragement as the primary tool of enforcing compliance provided willingness to improve is exhibited by the players. |
Rec-ID | Code | Recommendation |
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REC140-3558 | 6 - Insurance and legal liability | DHHS need to confirm adequate accident insurance coverage for staff working in retrieval medicine. Coverage specific to helicopter and fixed wing duties is required. |
REC140-3573 | 13 - Mapping and data quality | Databases with a common minimum data set complete with incident monitoring should be established for TAS Air Ambulance, TMRS and NETS missions. |
Rec-ID | Code | Recommendation |
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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. |
REC121-3753 | 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. |
REC121-3742 | 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. |
REC121-3768 | 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. |
REC121-3694 | 25 - Inquiry, audit, lessons management and after action review | The ITSRR should conduct random audits of accredited rail organisations for compliance with communications protocols. |
REC121-3726 | 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. |
REC121-3765 | 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. |
REC121-3693 | 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. |
REC121-3725 | 13 - Mapping and data quality | The data and information management system should be compatible with any data and information management system established by the ATSB for the designated interstate rail network, provided that the establishment of a compatible system does not reduce the amount or quality of the information obtained by ITSRR below the optimum levels which it needs to conduct trend analysis, and otherwise properly manage the safety of rail operations in New South Wales. |
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. |
REC121-3691 | 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. |
REC121-3724 | 13 - Mapping and data quality | The ITSRR should establish a data and information management system, containing all data and information that it requires, to continually monitor the safety of the New South Wales rail system. |
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. |