Inquiry Search
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC002-4008 | 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 |
REC002-4006 | 17 - Assets and technology | The Commisison would not insist upon a barometer being provided at each mine. Experience has proved that this is a tardy index to atmospheric conditions. Serious changes in the atmospheric pressure occur and are felt before they are indicated by a barometer. |
REC002-4013 | 19 - Offences | Infringement of the regulations by either party should be followed by a summary form of justice, instituted before two Magistrates. |
REC002-4004 | 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. |
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. |
REC002-4003 | 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. |
REC002-4010 | 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. |
REC002-4002 | 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. |
REC002-4009 | 16 - Training and behaviour | In gassy mines the Manager should be specially competent, and one possessing a thorough knowledge of the principles and practice of mining, the properties of gases, and systems of ventilation; and, above all, he must be prudent and cautious, yet resolute, possessing sound judgement. He must have absolute and supreme control over the whole operations, and of the men within the mine, to maintain rigid discipline, and be perfectly free and untrammelled by any outside influences. The competency of a manager should be certified by an examination before a specially-appointed Board. The Commission consider that better results may be obtained if such examinations be oral, and probably assume a more practical form than those hitherto conducted in Great Britain for the same object. |
Rec-ID | Code | Recommendation |
---|---|---|
REC286-1480 | 26 - Research | Deliver Flood Studies. |
REC286-2037 | 1 - Land-use and building regs | Make property level information on landslide hazards publicly available |
REC286-2058 | 24 - Govt responsibility | Clarify the relationship between the DHHS and THS in the establishment of flu services. |
REC286-2081 | 39 - Disaster Risk Management | Engage with industry bodies to explore opportunities to better understand and manage risks. |
REC286-1440 | 9 - Community education | Expand the existing Fire Ready Schools Program with enhanced support and incorporate other sites used by vulnerable groups. |
REC286-1458 | 13 - Mapping and data quality | Make coastal mapping available to public. |
REC286-2023 | 1 - Land-use and building regs | Locate and design new public infrastructure so that it can continue to operate during flood events. |
REC286-2043 | 22 - Role of local Gvt | Assessment of council’s capacity to manage land effectively. |
REC286-2065 | 16 - Training and behaviour | Deliver human influenza pandemic training and exercises in THS and other key organisations. |
REC286-2087 | 41 - Emergency Management exercises | Develop and exercise Severe Storm Emergency Management Plan. |
REC286-1446 | 9 - Community education | Introduce child-centred household level disaster risk reduction strategies in school programs. |
REC286-1464 | 41 - Emergency Management exercises | Exercise time-critical decision making processes within the context of an earthquake scenario. |
REC286-1473 | 13 - Mapping and data quality | Develop a statewide flood hazard map for use within the Tasmanian Planning System. |
REC286-2031 | 10 - Infrastructure | Improve information about electricity demand during heatwaves. |
REC286-2049 | 39 - Disaster Risk Management | Pro-actively manage landslide areas. |
REC286-2070 | 25 - Inquiry, audit, lessons management and after action review | Test the Biosecurity Act 2015. |
REC286-2094 | 13 - Mapping and data quality | Deliver updated inundation mapping. |
REC286-1434 | 16 - Training and behaviour | Improve the strategic resource-to-risk skills mix (recruitment, retention, capacity), including investigating difference models of volunteering within the TFS Brigade Network. |
REC286-1451 | 1 - Land-use and building regs | Include consideration of coastal inundation in land use planning for new developments and uses. |
REC286-1478 | 39 - Disaster Risk Management | Review environmental risks associated with hazardous uses within flood prone areas. |
REC286-2036 | 16 - Training and behaviour | Provide information on landslide hazards and risks to decision makers. |
REC286-2057 | 16 - Training and behaviour | Provide training sessions to GPs to improve their understanding of their roles, options and obligations relating to human influenza pandemic. |
REC286-2079 | 26 - Research | Develop capacity to utilise the new high-resolution satellite products now available. |
REC286-1439 | 9 - Community education | Continue the Community Bushfire Protection Program with a renewed focus on vulnerable groups. |
REC286-1457 | 26 - Research | Improve understanding of how coastal inundation events interact with riverine flood events. |
REC286-2019 | 24 - Govt responsibility | Assess water supply resilience in the case of an interruption. |
REC286-2041 | 22 - Role of local Gvt | Development mechanisms to support small councils to manage treatment across the PPRR spectrum (across all hazards). |
REC286-2064 | 35 - Business and Industry in relation to industry | Encourage businesses to consider human influenza pandemics in business continuity planning. |
REC286-2085 | 9 - Community education | Up-skill isolated communities in emergency PPRR skills. |
REC286-1445 | 41 - Emergency Management exercises | Develop, implement, review and exercise inter-agency community evacuation and recovery plans across the State. |
REC286-1463 | 39 - Disaster Risk Management | Develop enablers and capacity for Tasmanian earthquake risk owners. |
REC286-1471 | 1 - Land-use and building regs | Promote the use of Water Sensitive Urban Design in stormwater systems. |
REC286-2028 | 8 - Communications and warnings | Review community information and warning systems to ensure they cater for heatwave messages |
REC286-2048 | 26 - Research | Conduct research into changes of owners’ and occupiers stated and revealed risk tolerance and preference for treatment measures before and after natural hazard events. |
REC286-2069 | 24 - Govt responsibility | Implement a database management approach for notifiable disease record systems. |
REC286-2092 | 26 - Research | Investigate usefulness of satellite data for PPRR (prevention, preparedness, response, recovery) planning. |
REC286-1450 | 39 - Disaster Risk Management | Improve the understanding of the vulnerability of critical infrastructure. |
REC286-1477 | 16 - Training and behaviour | Develop and deliver flood incident response management training to SES personnel. |
REC286-2035 | 9 - Community education | Include heatwave in existing preparedness programs. |
REC286-2056 | 39 - Disaster Risk Management | Review Ambulance Tasmania surge capacity. |
REC286-2075 | 9 - Community education | Develop and implement a community storm safe awareness program. |
REC286-1438 | 25 - Inquiry, audit, lessons management and after action review | Consider outcomes of national review of warnings and review resilience of warning systems’ infrastructure. |
REC286-1456 | 26 - Research | Improve understanding of the weather systems that cause storm surge events to improve predictability and warnings. |
REC286-2017 | 39 - Disaster Risk Management | Improve maintenance of flood mitigation infrastructure. |
REC286-2040 | 1 - Land-use and building regs | Further development of Landslide Hazard Banding of the State (MRT). |
REC286-2063 | 24 - Govt responsibility | Review Tas Govt interoperability arrangements. |
REC286-2084 | 10 - Infrastructure | Establish emergency services ICT redundancy arrangements for damage loss of communications infrastructure. |
REC286-1444 | 16 - Training and behaviour | Maintain adequate seasonal fire crew resources across the fire agencies. |
REC286-1461 | 39 - Disaster Risk Management | Review all hazards response and recovery plans to ensure they address likely earthquake consequences. |
REC286-1469 | 39 - Disaster Risk Management | Actively manage riparian vegetation to manage flood dynamics. |
REC286-2027 | 8 - Communications and warnings | Develop arrangements to identify and communicate with people vulnerable to heat stress |
REC286-2046 | 1 - Land-use and building regs | Incentivising safer sites (charge people less rates and discounts for defensive actions by land managers). |
REC286-2068 | 24 - Govt responsibility | Develop a disaster client record system. |
REC286-2090 | 26 - Research | Increase understanding of the Puysegur Trench dynamics to improve certainty around the likelihood and magnitude of future Tsunamis. |
REC286-1449 | 9 - Community education | Develop coastal inundation education materials that meet the needs of exposed communities. |
REC286-1476 | 9 - Community education | Develop and implement a targeted community flood awareness program. |
REC286-2034 | 9 - Community education | Improve community educational information. |
REC286-2052 | 22 - Role of local Gvt | Undertake local level emergency management planning for areas at risk of debris flow. |
REC286-2074 | 8 - Communications and warnings | Continue the enhancement of forecast and warning services. |
REC286-1437 | 9 - Community education | Continue the Bushfire Ready Neighbourhoods Program. |
REC286-1455 | 39 - Disaster Risk Management | Assess options for managed coastal retreat. |
REC286-2015 | 1 - Land-use and building regs | Build flood capable infrastructure. |
REC286-2039 | 41 - Emergency Management exercises | Nuance the exercises for flood / dam-break / debris flow to incorporate consideration. |
REC286-2061 | 41 - Emergency Management exercises | Review and exercise the Tasmanian Mass Vaccination Plan. |
REC286-2083 | 9 - Community education | Enhance the community development program. |
REC286-1442 | 25 - Inquiry, audit, lessons management and after action review | Review legislation relating to Fuel Stove only areas, Fire Permit System and Total Fire Bans to ensure appropriate incentives to modify individuals’ behaviour. |
REC286-1460 | 25 - Inquiry, audit, lessons management and after action review | Review seismic monitoring network alert systems to ensure emergency managers are on the contact lists. |
REC286-2025 | 41 - Emergency Management exercises | Exercise heatwave arrangements with a focus on the public administration sector and management of vulnerable people |
REC286-2045 | 26 - Research | Investigate the potential effectiveness of economic and financial mechanisms to manage the risk appetites of land owners. |
REC286-2067 | 24 - Govt responsibility | Improve integration of health information systems. |
REC286-2089 | 39 - Disaster Risk Management | Identify and analyse statewide storm hazard risk. |
REC286-1448 | 39 - Disaster Risk Management | Utilise coastal mapping to assess need for coastal defences. |
REC286-1468 | 39 - Disaster Risk Management | Identify and anlalyse the location of critical infrastructure within defined flood areas. |
REC286-1475 | 8 - Communications and warnings | Integrate existing capabilities into a Total Flood Warning System. |
REC286-2033 | 24 - Govt responsibility | Incorporate heatwave surge response planning into business continuity planning. |
REC286-2051 | 1 - Land-use and building regs | Establish arrangements to enable the buy-back of specified landslip prone land. |
REC286-2073 | 16 - Training and behaviour | Ensure people designing and certifying buildings are appropriately trained and qualified. |
REC286-1436 | 4 - Fire season preparation | Continue the development and implementation of community level Bushfire Mitigation Plans. |
REC286-1453 | 1 - Land-use and building regs | Review building controls to ensure they are adaptive to changing coastal inundation risks. |
REC286-2013 | 16 - Training and behaviour | State to develop a Swift Water rescue capability. |
REC286-2038 | 1 - Land-use and building regs | Monitor effectiveness of new Land Use Planning reforms to evaluate effectiveness of delivering desired outcomes. |
REC286-2059 | 24 - Govt responsibility | Enhance business continuity planning by the Tasmanian Health Service. |
REC286-2082 | 41 - Emergency Management exercises | Undertake inter-agency severe storm exercises. |
REC286-1441 | 5 - Hazard reduction burns | Continue the Fuel Reduction Program. |
REC286-1459 | 13 - Mapping and data quality | Improve beach morphology mapping to understand coastal inundation, including post-event surveys. |
REC286-2024 | 26 - Research | Improve knowledge and understanding of the effect heatwaves coinciding with other hazard events have on the effectiveness and capability of response and recovery capabilities |
REC286-2044 | 1 - Land-use and building regs | Develop linkages between landslide risk assessors and building engineers/structural works. |
REC286-2066 | 39 - Disaster Risk Management | Advocate for an National Notifiable Diseases Database. |
REC286-2088 | 9 - Community education | Develop a community education strategy for when to call 000, 131 444, and 132 500. |
REC286-1447 | 39 - Disaster Risk Management | Assess vulnerability of ecosystems and species to coastal inundation. |
REC286-1466 | 9 - Community education | Develop and deliver earthquake hazard awareness products. |
REC286-1474 | 1 - Land-use and building regs | Raised access routes. |
REC286-2032 | 26 - Research | Quantify the effect of heatwaves on vulnerable people. |
REC286-2050 | 1 - Land-use and building regs | Ensure landuse planning and building systems, including appeal mechanisms, are transparent, equitable and integrated at the municipal, State and national levels. |
REC286-2072 | 35 - Business and Industry in relation to industry | Relax the requirement for medical certificates in the event of an outbreak. |
REC286-2097 | 13 - Mapping and data quality | Extend current tsunami maritime hazard modelling project to deliver coastal inundation modelling. |
REC286-1435 | 1 - Land-use and building regs | Monitor effectiveness of new Land Use Planning and Building System reforms to evaluate effectiveness of delivering desired outcomes. |
REC286-1452 | 39 - Disaster Risk Management | Improve understanding of the allocation of ownership across government, business and individuals. |
Rec-ID | Code | Recommendation |
---|---|---|
REC285-2525 | 38 - Agency/Department Reporting | The report recommends that Ambulance Tasmania outline what KPIs are measured and provide targets or benchmarks to define what is good or poor performance. |
REC285-2524 | 25 - Inquiry, audit, lessons management and after action review | The report recommends that Ambulance Tasmania investigate why the level of multiple responses had increased. |
REC285-2520 | 25 - Inquiry, audit, lessons management and after action review | The report recommends that Ambulance Tasmania investigate whether the additional resources in the North and North West regions were effective in reducing average response times. |
REC285-2518 | 38 - Agency/Department Reporting | The report recommends that regional summary reports of clinical reviews be standardised to facilitate review and comparison across regions. |
REC285-2517 | 38 - Agency/Department Reporting | The report recommends that Ambulance Tasmania collects data to allow regular and meaningful comparison of clinical outcomes at the regional level, to better allocate resources and to rapidly identify problems. |
Rec-ID | Code | Recommendation |
---|---|---|
REC279-1232 | 16 - Training and behaviour | Volunteer Charter: by December 2014, agree a charter with volunteers that clarifies roles and expectations including commitments by: a) SES to support volunteers to prepare for and respond to emergencies b) SES to make the best use of volunteers’ time by introducing user-friendly systems and reducing the administrative burden on them c) volunteers to turn-out when called to respond to emergencies. |
REC279-1231 | 16 - Training and behaviour | Training Strategy: By April 2015, develop a training strategy that identifies volunteer training priorities and provides for ongoing review to ensure operational currency, flexibility of delivery and evaluation |
Rec-ID | Code | Recommendation |
---|---|---|
REC245-2596 | 24 - Govt responsibility | That the Whole of Government project’s objectives should include meeting entity requirements and the consultant be asked to reevaluate the revised set of objectives. |
REC245-2595 | 17 - Assets and technology | That stakeholders involved with the Whole of Government radio project re-engage positively to ensure a solution to the current impasse is achieved in the best interests of the stakeholders and the State as a whole. |
REC245-2594 | 17 - Assets and technology | That the network managers produce business cases for all major upgrades. |
REC245-2593 | 17 - Assets and technology | That network managers develop and document strategic plans for the management of their radio networks. |
REC245-2598 | 24 - Govt responsibility | That government considers the establishment of a separate unit to implement and operate a Whole of Government network if existing stakeholders fail to make significant progress toward an agreed Whole of Government solution. |
REC245-2591 | 17 - Assets and technology | That until the outcome of the Whole of Government project is complete (and interoperability is achieved), emergency services should investigate and implement methods for further improving interoperability. |
REC245-2597 | 17 - Assets and technology | That the project team become independent from any of the entities involved in the Whole of Government network. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC237-0825 | 1 - Land-use and building regs | That the NSW Rural Fire Service hold discussions with the Department of Planning and Infrastructure and Local Government NSW on ways to improve compliance with development consents under section 76A of the Environmental Planning and Assessment Act 1979. |
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. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC208-0524 | 8 - Communications and warnings | That the Premier issue clear and unambiguous guidelines to all Government Ministers specifying the timing of notifications to the public of any matters that may affect public health or safety. |
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. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC140-3559 | 17 - Assets and technology | A service level agreement is negotiated with the Police department that will cover access, tasking, price, equipment and staffing. This will enable a more strategic use of the helicopter. |
REC140-3565 | 17 - Assets and technology | The TMRS medical equipment inventory requires an overhaul. The TMRS medical equipment should be located with the TMRS team. |
REC140-3556 | 17 - Assets and technology | The use of hospital transport vehicles to support retrieval operations be investigated. |
REC140-3564 | 17 - Assets and technology | The medical equipment used in retrieval and air ambulance duties undertaken by helicopter and fixed wing must be standardised. |
REC140-3555 | 16 - Training and behaviour | The Tasmanian Ambulance Service Clinical Advisory Committee review helicopter and fixed wing Flight Paramedic training and consider extending the scope of practice to embrace the role of retrieval paramedic in the Doctor/Paramedic retrieval team setting. |
REC140-3563 | 17 - Assets and technology | An additional secure emergency oxygen supply source to be located in the BK 117 helicopter. An internal supply is preferred. |
REC140-3575 | 24 - Govt responsibility | The preferred model for the Tasmanian Medical Retrieval Services is to have TMRS and NETS staff based in RHH. The fixed wing would remain based in Launceston (for the present) with the helicopter to remain based in Hobart. |
REC140-3561 | 17 - Assets and technology | Development of a helipad at Mersey Hospital. |
REC140-3574 | 38 - Agency/Department Reporting | Formation of a subcommittee of the DHHS Tasmanian Medical Retrieval Services Committee to identify risk exposures, system problems and potential solutions. The subcommittee should review data, problem cases, system issues and generate a risk register. Meetings should occur at least quarterly. |
REC140-3560 | 17 - Assets and technology | RHH requires a helipad. Plans to rebuild RHH must include a helipad at its earliest stage of conception. |
Rec-ID | Code | Recommendation |
---|---|---|
REC129-3623 | 41 - Emergency Management exercises | We recommend that NSW Health continue with its good work and apply the lessons learnt from Exercise Cumpston to further improve preparedness for major infectious disease emergencies. |
REC129-3628 | 41 - Emergency Management exercises | We recommend that NSW Health continue with its good work and continue to develop and test the capability of its contact tracing system to deal with a public health emergency. |
REC129-3622 | 39 - Disaster Risk Management | We recommend that NSW Health continue with its good work and consider building on influenza pandemic preparedness planning to develop broader contingency plans to address the emergence of other new, highly transmissible and/or severe infectious diseases. |
REC129-3627 | 41 - Emergency Management exercises | We recommend that NSW Health continue with its good work and continue to develop and test its surveillance systems for early detection of infectious diseases. |
REC129-3620 | 35 - Business and Industry in relation to industry | We recommend that NSW Health continue with its good work and conclude agreements with private health providers specifying roles, and expectations in the case of an infectious disease pandemic. |
REC129-3626 | 39 - Disaster Risk Management | We recommend that NSW Health continue with its good work and consider a more structured and systematic approach to the planning and risk assessment of major infectious diseases to assist transparency and decision making. |
REC129-3625 | 38 - Agency/Department Reporting | We recommend that NSW Health continue with its good work and establish a performance management framework with targets and indicators to assess progress in preparing for infectious disease emergencies. |
REC129-3624 | 41 - Emergency Management exercises | We recommend that NSW Health continue with its good work and formally establish and oversight a comprehensive program of training, testing and evaluation of plans at the state, area and facility level. |
REC129-3629 | 8 - Communications and warnings | We recommend that NSW Health continue with its good work and continue to improve communication mechanisms with those, such as GPs, likely to be affected in major infectious disease outbreaks. |
Rec-ID | Code | Recommendation |
---|---|---|
REC128-3602 | 38 - Agency/Department Reporting | That the Department’s performance against tactical and strategic benchmarks be regularly reported in annual reports or animal and plant health emergency evaluation reports and compared to other jurisdictions where possible. |
REC128-3609 | 16 - Training and behaviour | That the Department of Primary Industries be conscious of its responsibilities in maintaining the continued enthusiasm of Industry Liaison Officers and offer training and refresher training as required. |
REC128-3601 | 38 - Agency/Department Reporting | That, as a matter of principle, the NSW Government provide public reports on the lessons learned from emergency exercises which it manages or in which it participates. If necessary, such reports should exclude material which might jeopardise security. |
REC128-3608 | 16 - Training and behaviour | That emergency animal health training be included in induction programs for newly recruited District Veterinarians and all District Veterinarians be encouraged to maintain their skills by attending regular refresher training as appropriate. |
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. |
REC128-3607 | 16 - Training and behaviour | That the Department of Primary Industries should continue efforts to develop the skills of private sector veterinarians to increase the level of resources available in emergency responses. |
REC128-3619 | 38 - Agency/Department Reporting | That the Department of Primary Industries should ensure the roles and capacities of Rural Lands Protection Boards and industry are effectively monitored to enable assessment of the effectiveness of animal health programs. |
REC128-3606 | 24 - Govt responsibility | That the Department of Primary Industries address the forthcoming potential shortage of veterinary pathologists and agronomists within its testing facilities by positive recruitment actions over the next five years such as offering scholarships or training existing professional staff to develop skills in pathology. |
REC128-3615 | 9 - Community education | That the Department of Primary Industries should continue to raise awareness among producers of OJD risks and the operation of Sheep Health Statements. |
REC128-3605 | 38 - Agency/Department Reporting | That the Department of Primary Industries make every effort to meet its targets for the TSE program and encourage public and private sector veterinarians across the State to submit samples. The Department should include reports on its performance against these targets in annual reports. |
REC128-3613 | 9 - Community education | That the Department of Primary Industries and Rural Lands Protection Boards employ outreach activities to alert these small producers to their responsibilities and improve their awareness of animal and plant pests and diseases. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC121-3670 | 16 - Training and behaviour | The RailCorp emergency response plan should be provided to all emergency response agencies. The officers of each emergency service should be trained in any rail specific features of the plan, so as to better ensure inter-agency co-ordination in the circumstances of an emergency. |
REC121-3710 | 39 - Disaster Risk Management | The ITSRR should have permanent access to the RailCorp intranet. |
REC121-3716 | 16 - Training and behaviour | Train driver and guard training should encourage teamwork and discourage authority gradients. |
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. |
REC121-3678 | 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. |
REC121-3721 | 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. |
REC121-3767 | 24 - Govt responsibility | All accredited rail organisations should be required to re-apply every three years to ITSRR for accreditation. |
REC121-3651 | 10 - Infrastructure | A dedicated telephone line should be established by RailCorp between the RMC and any Emergency Services Control Centre for use during any emergency. |
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. |
REC121-3726 | 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. |
REC121-3669 | 16 - Training and behaviour | All operational rail staff should be trained by RailCorp in the action check list relevant to each. |
REC121-3704 | 28 - Personal responsibility | RailCorp should continue its system of voluntary self-identification and rehabilitation of employees with alcohol or drug related problems. |
REC121-3751 | 16 - Training and behaviour | RailCorp should make it a condition of employment that all level 2 managers have or obtain a formal qualification in system safety management. |
REC121-3677 | 16 - Training and behaviour | A training centre for emergency services personnel should be established by RailCorp. The emergency services personnel should be required to undertake training at such a centre, which should be equipped with features replicating railway infrastructure and rolling stock. |
REC121-3715 | 16 - Training and behaviour | RailCorp should use its simulators to train drivers and guards in methods of dealing with degraded operations on the rail network. |
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. |
REC121-3765 | 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. |
REC121-3650 | 16 - Training and behaviour | Staff at the Rail Management Centre (RMC) should receive training from RailCorp to enable them to quickly and accurately assess that an emergency has occurred and to provide precise and reliable information to emergency response personnel about the location of the emergency, the available access to the site and the resources necessary. |
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. |
REC121-3725 | 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. |
REC121-3776 | 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. |
REC121-3657 | 10 - Infrastructure | All signal telephones must be maintained by RailCorp in proper working order. |
REC121-3700 | 39 - Disaster Risk Management | Maintenance plans on all trains should be revised annually. |
REC121-3746 | 16 - Training and behaviour | All emergency services personnel should be trained in the location and operation of emergency door release mechanisms on all rail cars. |
REC121-3675 | 16 - Training and behaviour | All rail employees should be trained by their employer to commence any emergency communication with the words “Emergency, emergency, emergency”, thereafter to identify themselves, the train, its location, what has occurred, the approximate passenger load and whether death or injuries have occurred. |
REC121-3714 | 16 - Training and behaviour | RailCorp should use its simulators in an interactive manner. |
REC121-3719 | 16 - Training and behaviour | The position of team leader should be created by RailCorp to be responsible for a group of approximately 30 train drivers, with responsibility to ensure that each train driver’s training needs are being met and that any safety concerns of train drivers are being properly addressed. The team leaders are to have direct access to the Chief Executive of RailCorp if any safety concerns they have are not addressed. |
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. |
REC121-3687 | 10 - Infrastructure | There must be compatibility of communications systems throughout the rail network. It is essential that all train drivers, train controllers, signallers, train guards and supervisors of trackside work gangs in New South Wales be able to communicate using the same technology. |
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. |
REC121-3775 | 38 - Agency/Department Reporting | The Minister for Transport Services must table in Parliament, each such quarterly report by ITSRR. |
REC121-3656 | 17 - Assets and technology | Satellite telephones should be provided by RailCorp to all rail commanders at any emergency. |
REC121-3697 | 38 - Agency/Department Reporting | All train drivers’ defects reports should be entered by RailCorp into a computerised record and tracked to finalisation. |
REC121-3744 | 16 - Training and behaviour | All RailCorp operational personnel should be trained in the location and operation of external emergency door release mechanisms. |
REC121-3673 | 41 - Emergency Management exercises | Regular field training exercises should be conducted by RailCorp with the emergency services to ensure that the incident command system and rail displan are able to be fully implemented as quickly as possible and are reviewed and improved. |
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. |
REC121-3718 | 16 - Training and behaviour | Training should be based upon a needs analysis, to determine what skills a particular person will require to carry out the tasks of any position safely and efficiently, and instruction and practice, to acquire and demonstrate those skills. |
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. |
REC121-3684 | 39 - Disaster Risk Management | The ITSRR should conduct its own risk assessment in relation to the risk of any such high consequence, low probability accident and, if necessary, direct RailCorp to conduct a further risk assessment to reduce the level of residual risk to a level ITSRR regards as acceptable. |
REC121-3723 | 38 - Agency/Department Reporting | All ATSB accident investigation reports should be made public. |
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: |
REC121-3654 | 16 - Training and behaviour | All train guards should be trained by RailCorp in the use of the Metronet radio and instructed to use it in any emergency. |
REC121-3695 | 10 - Infrastructure | There should be interoperability of communications equipment between all trains operating on the New South Wales rail network. |
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. |
REC121-3672 | 16 - Training and behaviour | All emergency response personnel should be specifically trained in the features of railways which are relevant to their work, such as the location and means of operation of all emergency door releases on trains, the location and use of signal telephones, the methods by which electrical power can be isolated and the means by which they can readily identify and obtain information from the on-site rail commander. |
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. |
REC121-3717 | 16 - Training and behaviour | RailCorp must establish a task analysis for particular categories of employees, to identify the specific skills and responsibility of those employees or groups of employees, and thereafter undertake a training needs analysis, to develop the skills required in particular areas. |
REC121-3756 | 16 - Training and behaviour | RailCorp should ensure that where the safety competency of any manager is deficient such manager is required to undertake professional development courses to raise his or her safety competency level to an adequate standard. |
REC121-3683 | 39 - Disaster Risk Management | RailCorp should undertake risk assessments of each of its activities as follows: |
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. |
REC121-3768 | 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. |
REC121-3653 | 10 - Infrastructure | The RMC should be equipped by RailCorp with a transcriber system, or mimic board, or such other system as is necessary to enable identification of the precise location at any time of any train on the RailCorp network. |
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. |
Rec-ID | Code | Recommendation |
---|---|---|
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 |
---|---|---|
REC008-3985 | 17 - Assets and technology | The Commission recommends that conductors carrying currents at medium pressure should not be encased in wood in damp places. |
REC008-3984 | 16 - Training and behaviour | The Commission recommends that the live parts of resistances should be fixed so that no unprotected combustible material is within 6ins of the frames or cases containing them or within 24ins measured vertically above. |
REC008-3990 | 16 - Training and behaviour | The Commission recommends that more than one means of exit should be provided in every mine from every level of it to the surface; and that the miners should be kept informed where they are situated. |
REC008-3989 | 17 - Assets and technology | The Commission recommends that there be continuous supervision of every chamber in which electrical machinery is worked by currents of medium pressure. |
REC008-3987 | 17 - Assets and technology | The Commission recommends that systematic tests be made and recorded of apparatus and circuits as a precaution against fire and so that any gradual deterioration of the system may be detected. |
REC008-3986 | 17 - Assets and technology | The Commission recommends that every precaution be taken to keep water off electrical machinery. |