Inquiry Search
Rec-ID | Code | Recommendation |
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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. |
REC258-2552 | 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. |
REC258-2551 | 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. |
REC258-2549 | 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. |
REC258-2528 | 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. |
REC258-2559 | 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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REC256-1573 | 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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REC244-2605 | 39 - Disaster Risk Management | A thorough consultative process be developed and implemented between the CFS and local government. This will determine how bushfire management planning can enable improved process and practice to mitigate bushfire risk, and ensure that fire permits are issued and complied with. |
REC244-2604 | 8 - Communications and warnings | Notification of a total fire ban should be broadcast to the public via any means reasonably available. Section 80, parts (2), (5) and (6) be amended so that broadcast fire ban warnings include, but not be limited to, radio stations, internet sites, social media outlets etc. |
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. |
REC244-2631 | 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. |
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. |
REC244-2620 | 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. |
Rec-ID | Code | Recommendation |
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REC239-2692 | 39 - Disaster Risk Management | That the Queensland Police Service Disaster Management Unit is to be permanently located at the State Disaster Coordination Centre to work on a day to day basis with the proposed new Department of Fire and Emergency Services. |
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. |
REC239-2725 | 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. |
REC239-2773 | 38 - Agency/Department Reporting | That should the Mobile Strategy in its current form be approved by government the CEO Portfolio Business and the Deputy Commissioner Operations: |
REC239-2673 | 38 - Agency/Department Reporting | That Queensland Corrective Service, in consultation with key partners in the criminal justice and social services sectors, develops specific performance indicators focused on efficiencies and customer/stakeholder outcomes across the criminal justice system. |
REC239-2750 | 20 - Role of police | That the Queensland Police Service: |
REC239-2691 | 39 - Disaster Risk Management | That the Commissioners of Police and the Queensland Fire and Rescue Service review the current district disaster boundaries as a matter of urgency in-line with the findings and recommendations of the Auditor–General’s report into the Queensland disaster management system. |
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. |
REC239-2724 | 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. |
REC239-2772 | 38 - Agency/Department Reporting | That the roll-out of the mobile service program business case mentioned earlier |
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. |
REC239-2748 | 20 - Role of police | That the Queensland Police Service considers adopting the broader use of ANPR in line with other Australian jurisdictions in consultation with the Privacy Commissioner. |
REC239-2781 | 34 - Local knowledge | That the current provisions enabling there to be a Ministerial Direction be maintained and actioned as the Minister sees fit. |
REC239-2690 | 8 - Communications and warnings | That the Chief Executive Officer Portfolio Business and Commissioners establish a high level working group with the ABC and commercial media to identify and implement an improved information flow to the community on disasters. |
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. |
REC239-2711 | 39 - Disaster Risk Management | That the Inspector General Emergency Management be empowered to provide an assurance to Government that the disaster management system is both appropriate and capable of dealing with complex events. |
REC239-2771 | 38 - Agency/Department Reporting | That the Queensland Police Service Commissioner addresses the situation regarding statistical reporting. The Commissioner, in collaboration with the Chief Executive Officer Portfolio Business and the Queensland Fire and Rescue Service Commissioner should also examine the opportunity to acquire the services of a qualified and experienced Chief Information Officer or Chief Digital Officer in line with other Queensland and Australian government agencies. |
REC239-2747 | 20 - Role of police | That as the Queensland Police Service moves to a digital platform the strategy around effective targeting and alternative automated number plate recognition models should form part of the design architecture. |
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. |
REC239-2689 | 20 - Role of police | That, where appropriate, the Commissioner of Police appoints appropriately trained and experienced public service officers to appropriate roles in the disaster management system to support District Disaster Coordinators in their vital roles. |
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. |
REC239-2703 | 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. |
REC239-2767 | 38 - Agency/Department Reporting | Recommendation: That the CEO Portfolio Business collaborates with the two portfolio Commissioners to: |
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: |
REC239-2776 | 25 - Inquiry, audit, lessons management and after action review | That the proposed efficiency review of the Queensland Police Service examine whether: |
REC239-2684 | 38 - Agency/Department Reporting | The Chief Executive Officer Portfolio Business establishes a set of performance indicators to provide a transparent process for government to monitor its performance. |
REC239-2757 | 20 - Role of police | That the Queensland Police Service executive team reassesses its preparedness to collaborate with other agencies to deliver a whole of Government approach to delivering community safety. |
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. |
REC239-2764 | 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. |
REC239-2726 | 20 - Role of police | That the Queensland Fire and Rescue Service enters into discussion with the Queensland Police Service regarding the possibility for the Queensland Police Service to assist with prosecutions that may arise out of fire safety matters. |
REC239-2774 | 39 - Disaster Risk Management | Those final determinations of disaster management districts include consultation with the Local Government Association Queensland, the Queensland Fire and Rescue Service and other Government departments. |
REC239-2674 | 38 - Agency/Department Reporting | That Queensland Corrective Service continues to develop its proposed recidivism index as a priority, including place and program based measures. |
REC239-2752 | 20 - Role of police | That the roll-out of the Queensland Police Service digital technology should take into consideration adopting and facilitating new processes including the police response to domestic violence. |
Rec-ID | Code | Recommendation |
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REC207-2882 | 39 - Disaster Risk Management | Review disaster recovery and business continuity plans. |
Rec-ID | Code | Recommendation |
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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: |
REC205-1903 | 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: |
Rec-ID | Code | Recommendation |
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REC197-1733 | 25 - Inquiry, audit, lessons management and after action review | That a review of the Country Fire Authority Act 1958 and the Country Fire Authority Regulations 2004 be undertaken. |
Rec-ID | Code | Recommendation |
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REC177-3290 | 38 - Agency/Department Reporting | The successful installation of every barrier should be the subject of written verification within and between licensees and rig operators; and should be the subject of explicit reporting to the relevant regulator(s). |
REC177-3356 | 39 - Disaster Risk Management | 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. Being ‘match fit’ in this sense will enable a quicker and more effective response in terms of safety assessment, and will ensure that expectations of both operator and regulator are more readily aligned. |
REC177-3289 | 39 - Disaster Risk Management | 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. Joint written certification as to the appropriateness of the use of particular barriers should take place before installation. Senior onshore representatives of stakeholder entities should be involved in that certification process. |
REC177-3345 | 2 - Emergency powers | 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 person. |
REC144-3387 | 25 - Inquiry, audit, lessons management and after action review | In order that the ACT public can be reassured about the project management and financial planning in relation to the Fairbairn site as a proposed centralised accommodation facility for emergency services, the Auditor-General undertake a review of the project from a financial probity and project management perspective. |
REC177-3287 | 38 - Agency/Department Reporting | Licensees should be subject to an express obligation to inform regulators of problems which arise in the course of installing barriers, even if they consider that well integrity is not thereby compromised. The information should be provided by way of special report, rather than included in a standard reporting document (such as a DDR). The information provided should include risk assessment details. |
REC177-3344 | 25 - Inquiry, audit, lessons management and after action review | 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. |
REC177-3378 | 25 - Inquiry, audit, lessons management and after action review | 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. |
REC177-3286 | 39 - Disaster Risk Management | Problems which arise in the course of installing barriers must be the subject of consultation between licensees, rig operators, and contractors (if used). A proper risk assessment should then be carried out and remedial steps (including further testing/verification) should be agreed upon, and documented in writing before the performance of remedial work whenever practicable. Joint written certification as to resolution of the problem should take place before resumption of drilling operations. Senior onshore representatives of stakeholder entities should be involved in that certification process. |
REC177-3330 | 39 - Disaster Risk Management | 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. Risk management in the context of well control needs to be understood as an ethical/professional duty. Self‐regulation contemplates self‐regulation by the industry, not just by individual licensees and operators. |
REC177-3374 | 25 - Inquiry, audit, lessons management and after action review | 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. |
REC177-3285 | 39 - Disaster Risk Management | Pre‐drilling assessments should include a risk assessment of the worst‐case blowout scenario. |
REC177-3291 | 39 - Disaster Risk Management | 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. Joint written certification as to the appropriateness of removal should take place before removal. Senior onshore representatives of stakeholder entities should be involved in that certification process. |
Rec-ID | Code | Recommendation |
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REC165-0086 | 2 - Emergency powers | Suggested escalation trigger points be discussed with District Disaster Coordinators and Local Disaster Coordinators, and if considered practical and useful, be incorporated in Local, District and State Disaster Management Plans. |
REC165-0085 | 20 - Role of police | The Commissioner of Police, through a dedicated Assistant Commissioner (supported by a cohort of Assistant Commissioners to ensure adequate coverage), be assigned responsibility for overall control of each natural Disaster Management event in Queensland as the preferred arrangement. |
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. |
REC165-0095 | 11 - Evacuation and shelters | Planning and consultation be undertaken by EMQ with all levels of the Disaster Management system to ensure that necessary risk-based disaster evacuation plans are prepared at Local, District and State levels, supported by necessary community education and preparedness programs. |
REC165-0090 | 7 - Inter-agency communication | The SDMG lead an initiative to integrate and/or inter-connect all of the control centres involved at all levels of the Disaster Management system in Queensland as part of the project to integrate State communications. |
REC165-0087 | 8 - Communications and warnings | The SDMG commission the Department of Community Safety and seek the necessary funding to develop and enhance the Statewide Disaster Management information and communications system building on alternatives already in place and in consultation with all levels of Government. |
REC165-0081 | 2 - Emergency powers | District and State levels utilise the current Act to make pre-emptive declarations of a disaster event (likely disasters) so as to be proactive in leading and controlling disaster events. All levels of the system should immediately notify other levels if they activate the Disaster Management arrangements. The Public Safety Preservation Act 1986 be amended to provide powers for Police Officers to provide an immediate response in the event of a rapid onset disaster event such as a landslide. |
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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REC151-3107 | 2 - Emergency powers | Immunity be prescribed for persons (including volunteers) using force in the exercise of a power or function under the FES Act or carrying out any direction or requirement given or imposed at the scene of a fire or other emergency. |
REC151-3079 | 2 - Emergency powers | Crown Law opinion be obtained to determine whether the FES Act gives the Minister power to direct and control individual Chief Officers and if that provision does not exist then the FES Act be amended to include that power. |
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. |
REC149-3139 | 39 - Disaster Risk Management | The industry should develop in conjunction with the Regulator a process for addressing the need to maintain the risk profile of a facility moving into extended life operation at the same risk profile as when it was within design life. |
REC149-3138 | 38 - Agency/Department Reporting | The current KPI measures used by the Regulator and industry need to be reassessed and the performance indicators need to be related to the risk profiles of the industry. The industry needs to develop the indicators, which need to be agreed and measured by the industry in discussion with other stakeholders. The KPI's selected should be published in comparison with the worldwide offshore industry and with other industries. NOPSA should continue discussions with Australian Safety and Compensation Council (ASCC) with a view to adopting their goals. |
Rec-ID | Code | Recommendation |
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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. |
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. |
REC121-3775 | 38 - Agency/Department Reporting | The Minister for Transport Services must table in Parliament, each such quarterly report by ITSRR. |
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. |
REC121-3666 | 14 - Incident Mgt Teams | The rail commander should have complete authority to direct and control any rail employees attending the site of a rail accident, in accordance with directions given or arrangements put in place by the site controller, until the rescue phase of the emergency response to the rail accident has been completed. |
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. |
REC121-3693 | 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. |
REC121-3774 | 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: |
REC121-3712 | 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. |
REC121-3665 | 14 - Incident Mgt Teams | The role of the rail commander should be to provide support and assistance to the site controller and emergency services personnel until the rescue phase of the emergency response to any rail accident is completed. |
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. |
REC121-3691 | 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. |
REC121-3768 | 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. |
REC121-3710 | 39 - Disaster Risk Management | The ITSRR should have permanent access to the RailCorp intranet. |
REC121-3664 | 20 - Role of police | The location of the command post for site control at the scene of any rail accident should be identified by NSW Police by a distinctive flashing light. |
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. |
REC121-3684 | 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. |
REC121-3765 | 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. |
REC121-3700 | 39 - Disaster Risk Management | Maintenance plans on all trains should be revised annually. |
REC121-3663 | 14 - Incident Mgt Teams | The incident command system should clearly identify the roles of the rail commander, site controller, police commander and commanders of the other emergency services, and the way in which each is to work together during the recovery phase of any rail accident. |
REC121-3723 | 38 - Agency/Department Reporting | All ATSB accident investigation reports should be made public. |
REC121-3683 | 39 - Disaster Risk Management | RailCorp should undertake risk assessments of each of its activities as follows: |
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. |
REC121-3697 | 38 - Agency/Department Reporting | All train drivers’ defects reports should be entered by RailCorp into a computerised record and tracked to finalisation. |
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. |
REC121-3652 | 14 - Incident Mgt Teams | A designated staff member at the RMC should act as the rail emergency management co-ordinator. He or she should be the sole point of contact at the RMC with other rail personnel involved in the rail accident and emergency services personnel during the rescue phase of the emergency response. |
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. |
REC121-3676 | 14 - Incident Mgt Teams | A direct line of communication should be established between the RMC and Emergency Services Operations Control Centre by a “tie line” or otherwise, so as to ensure that in the case of a serious rail accident there is an open line of communication between the officer in charge of the management of the incident at the RMC and the various emergency response services. |
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. |