Inquiry Search
Rec-ID | Code | Recommendation |
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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. |
REC258-2556 | 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. |
REC258-2539 | 35 - Business and Industry in relation to industry | The Civil Aviation Safety Authority changes its regulatory philosophy and, together with industry, builds an effective collaborative relationship on a foundation of mutual understanding and respect. |
REC258-2560 | 29 - Operational Health and Safety | The Civil Aviation Safety Authority devolve to Designated Aviation Medical Examiners the ability to renew aviation medical certificates (for Classes 1, 2, and 3) where the applicant meets the required standard at the time of the medical examination. |
Rec-ID | Code | Recommendation |
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REC256-1560 | 37 - Funding | The Australian Government should: |
REC256-1559 | 37 - Funding | The Australian Government should gradually increase the amount of annual mitigation funding it provides to state and territory governments to $200 million. Initially, this funding should be distributed to state and territory governments in accordance with the allocation under the National Partnership Agreement on Natural Disaster Resilience. |
REC256-1558 | 37 - Funding | Funding to state and territory governments for community recovery should be provided as untied grants, with a transition period pending the development of a framework to assess community recovery costs. During the transition period, the Australian Government should continue to provide funding for community recovery through a reimbursement model. |
REC256-1557 | 37 - Funding | Where asset management plans at the local, state or territory level pre-identify and cost betterment of assets (improving asset resilience to natural disasters), the Australian Government should share 50 per cent of the betterment component of reconstruction costs following damage from a (eligible) natural disaster. |
REC256-1577 | 37 - Funding | The Australian Government should develop a formula for allocating mitigation funding to state and territory governments on the basis of where such funding is likely to achieve the greatest net benefits, taking into account the future risks of natural disasters. This should be completed within five years and in consultation with state and territory governments. |
REC256-1556 | 37 - Funding | The Australian Government should fund natural disaster recovery by: |
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. |
REC244-2601 | 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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REC239-2724 | 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. |
REC239-2758 | 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. |
REC239-2779 | 37 - Funding | That a new business case for Westgate project should be prepared by an independent party. |
REC239-2683 | 37 - Funding | That the Office of Portfolio Business follows the same budget processes as other agencies. |
REC239-2753 | 37 - Funding | That the proposed Chief Executive Officer Portfolio Business be responsible for developing a cost attribution model for portfolio agencies, including the Queensland Police Service, as a priority. |
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. |
REC239-2682 | 37 - Funding | That a budget based on the desired functional accountabilities should be appropriated to the Portfolio Business as part of the Government budget process. |
REC239-2737 | 29 - Operational Health and Safety | That the workplace health and safety reporting system be reviewed to facilitate ease of reporting. |
REC239-2776 | 25 - Inquiry, audit, lessons management and after action review | That the proposed efficiency review of the Queensland Police Service examine whether: |
REC239-2681 | 37 - Funding | That the funding model for the Portfolio Business is not based on fee- for-service arrangements or notional contributions from the operational services. |
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. |
REC239-2675 | 35 - Business and Industry in relation to industry | That social benefit bonds and other opportunities with the business and not-for-profit sectors be developed to reduce reoffending and to provide rehabilitation programs. Such an instrument should be available to the market within two years. |
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. |
REC239-2780 | 37 - Funding | That should the Westgate project proceed, that consideration must be given to opportunities to partner the investment with the private and public sectors. The business case should also consider alternative facilities such as Australian Defence Force sites. |
Rec-ID | Code | Recommendation |
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REC237-0834 | 37 - Funding | That the NSW Rural Fire Service apply for funding from the NSW Treasury for the development of a multi-agency business case for a BRIMS replacement that includes internal management, risk communication, community engagement capability and publishing activities on websites. |
REC237-0833 | 37 - Funding | That the NSW Rural Fire Service and the NSW Treasury explore ways to ensure that unspent hazard reduction funds be carried over to the next financial year in a timely manner and to ensure that hazard reduction funding has a seamless transition from one financial year to the next. |
Rec-ID | Code | Recommendation |
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REC207-2890 | 37 - Funding | Review and rebalance relative investment in long term climate modelling and medium-term seasonal outlook. |
REC207-2889 | 37 - Funding | Review level of investment in research activities to free up budget and reduce pressure on computing capacity |
REC207-2888 | 35 - Business and Industry in relation to industry | Foster private sector service providers who can offer tailored services or broadcast high quality presentation of general purpose weather information |
REC207-2879 | 37 - Funding | Firm up approval processes and funding for any departures from provision of the basic product set |
REC207-2893 | 37 - Funding | Explore options to obtain revenue from advertising on the Bureau’s website |
REC207-2877 | 37 - Funding | Explore opportunities to re-phase investments in large scale projects and programs such as the Strategic Radar Enhancement Program, the NexGen Forecast and Warning System Products and the Improving Water Information Program. |
REC207-2892 | 37 - Funding | Apply a consistent cost-recovery model to all services delivered to state/territory fire agencies. |
Rec-ID | Code | Recommendation |
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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: |
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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REC189-2912 | 29 - Operational Health and Safety | The review team recommend that the safety case system be strengthened by including provisions for a design notification scheme along the lines of that under the British Offshore Safety Case Regulations. |
REC189-2911 | 29 - Operational Health and Safety | The review team recommend that: |
REC189-2907 | 29 - Operational Health and Safety | a) For the purposes of designing and implementing its regulatory activities, National Offshore Petroleum Safety Authority (NOPSA) should continue to identify priority hazards and risks and their underlying causes, in consultation with the NOPSA Advisory Board and stakeholders (see Theme 9, Stakeholder engagement). |
Rec-ID | Code | Recommendation |
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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. |
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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REC149-3133 | 35 - Business and Industry in relation to industry | Because some issues related to emergency response are beyond any single operator and usually occur outside the title area, there is a need for the representatives of the offshore industry to work together with other governments, interested and involved parties to develop the strategies to be utilised and the emergency planning model that will satisfy the requirements of all parties. |
REC149-3147 | 29 - Operational Health and Safety | As all stakeholders have responsibility for safe outcomes, decisions regarding target subjects for safety promotion need to have the support of all stakeholders including NOPSA and the workforce. Industry, which ultimately has the responsibility for managing risk as well as funding the promotion, should take a leadership role in implementation. |
REC149-3132 | 35 - Business and Industry in relation to industry | Coverage of the regime should be increased to cover the complete hydrocarbons production system from wells through to custody transfer point or reasonable physical/technical system boundary. If NOPSA is also to be responsible for Carbon Capture and Storage it needs to be resourced to ensure that this does not detract from NOPSA's current responsibilities. |
REC149-3146 | 35 - Business and Industry in relation to industry | NOPSA should consider establishing a small forum for consultation consisting of representatives of relevant stakeholders. The representatives should have standing, with authority to participate in decision making and take on commitment on behalf of their stakeholder group. |
REC149-3131 | 35 - Business and Industry in relation to industry | The exploration/production operator making all major decisions related to petroleum activities (i.e. selection of rig, well design and selection of service companies) should be made responsible for demonstrating to the regulator that drilling operations can be conducted safely. Where the drilling contractor owns the rig and conducts the day-to-day management of safety on the rig, this duty can be described in a rig specific Safety Case that is owned by the drilling contractor. This rig specific Safety Case does not have to be submitted for every well/well operation. |
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. |
REC149-3128 | 29 - Operational Health and Safety | National Offshore Petroleum Safety Authority (NOPSA) should develop guidelines in consultation with stakeholders to provide clarity and consistency to the process which ultimately will result in better safety outcomes. |
REC149-3144 | 29 - Operational Health and Safety | The Safety Case proponent should be allowed some flexibility to involve appropriate experience matched with the proposed workforce competencies to enable the Safety Case to be developed with value adding processes. Subsequent to the hiring of the workforce Final Government Response Offshore Petroleum Safety Regulation Inquiry and 2008 Review of NOPSA Operational Activities and preferably before the commencement of operations a review of the Safety Case should take place with the new workforce to ensure they understand the accepted Safety Case, its risks and Safety Management Plan. |
REC149-3135 | 29 - Operational Health and Safety | The initial acceptance of a new facility Safety Case should be in conjunction with inspection of a facility upon commencement of operations. |
Rec-ID | Code | Recommendation |
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REC140-3568 | 37 - Funding | The State Medical Retrieval Cost Centre (TMRS and NETS) be formed and be supported by the appropriate administrative and resource accountant expertise. This cost centre should be placed with those responsible for its management. |
REC140-3567 | 37 - Funding | A uniform retrieval charge to the region of referral should be considered. This should be independent of the mode of transport used. |
REC140-3554 | 37 - Funding | DHHS fund the equivalent of 2 FTE Consultant positions for retrieval duties (1.5 FTE existing, 0.5 FTE new) |
REC140-3553 | 37 - Funding | RHH Neonatal Emergency Transport Service receive DHHS funding for a Senior Registrar to assume the responsibilities of retrieval staffing, quality assurance, data collection and reporting demands. |
REC140-3552 | 37 - Funding | Department of Health and Human Services (DHHS) to fund 3 Full-Time Equivalent (FTE) Senior Registrar positions at the Royal Hobart Hospital (RHH) for the Tasmanian Medical Retrieval Service (TMRS). One registrar in the Anaesthesia Department, one in the Intensive Care Unit and one in Emergency Department is proposed. |
Rec-ID | Code | Recommendation |
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REC121-3748 | 29 - Operational Health and Safety | All new rail cars must have appropriate signage and lighting identifying escape routes in the case of emergency. |
REC121-3709 | 29 - Operational Health and Safety | RailCorp should provide access to electronic versions of safety documentation for all operational staff at their workplace. |
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. |
REC121-3732 | 29 - Operational Health and Safety | If ITSRR accepts such a plan as an appropriate response to the existing weak safety culture, ITSRR should approve it and monitor the effectiveness of the plan. |
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. |
REC121-3691 | 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. |
REC121-3738 | 29 - Operational Health and Safety | All passenger trains must be fitted with an internal passenger emergency door release. |
REC121-3747 | 29 - Operational Health and Safety | All trains should have windows available through which passengers can escape. |
REC121-3707 | 29 - Operational Health and Safety | The safety document management system should provide for the distribution of electronic versions of safety documentation to relevant staff. |
REC121-3755 | 29 - Operational Health and Safety | The RailCorp Board should require a full review of the safety competence of RailCorp managers to ensure that each has the ability to bring about those safety reforms recommended in this report which are applicable to his or her position. |
REC121-3731 | 29 - Operational Health and Safety | RailCorp should develop a plan to be submitted to ITSRR to address the deficiencies in the safety culture of RailCorp, including: |
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. |
REC121-3682 | 29 - Operational Health and Safety | All new rolling stock should be designed to be compatible with at least level 2 automatic train protection discussed in chapter 7 of this report. |
REC121-3737 | 29 - Operational Health and Safety | There must be a minimum of two independent methods of self-initiated emergency escape for passengers from all trains at all times. |
REC121-3706 | 29 - Operational Health and Safety | RailCorp should establish a comprehensive safety document management system. |
REC121-3743 | 29 - Operational Health and Safety | All passenger trains operating in New South Wales must have the external emergency door release clearly marked with the words “Emergency Door Release”. |
REC121-3754 | 29 - Operational Health and Safety | The RailCorp Board should ensure that RailCorp has an adequate and integrated safety management system, including adequate systems for risk assessment, clearly defined safety responsibilities and accountabilities for persons holding management positions, and specific performance criteria against which evaluations can be made of safety performance and accountability for safety performance of all managers. |
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. |
REC121-3764 | 29 - Operational Health and Safety | The ITSRR should not grant accreditation to any rail organisation unless it has an integrated safety management system in accordance with any safety management system regulation and the guidelines published from time to time by ITSRR. |
REC121-3681 | 29 - Operational Health and Safety | RailCorp should progressively implement, within a reasonable time, level 2 automatic train protection with the features identified in chapter 8 of this report. |
REC121-3735 | 29 - Operational Health and Safety | Risk assessments of occupational health and safety issues by RailCorp should include an analysis of broader public safety risks and not be confined to narrow occupational health and safety issues. |
REC121-3702 | 29 - Operational Health and Safety | Random alcohol testing should be continued. |
REC121-3741 | 29 - Operational Health and Safety | The operation of the train doors should have an override facility whereby the train driver or the guard can override an internal passenger emergency door release system if the door release is interfered with when there is no emergency. There should be an alarm, together with an intercom, in the train guard’s compartment so that, if a passenger attempts to initiate an emergency door release, there is an appropriate delay during which time an alarm sounds in the train guard’s compartment and the guard can then, after first attempting to speak via the intercom to the person concerned, if necessary, override the door release, and make an appropriate announcement over the intercom system in the train. |
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. |
REC121-3713 | 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. |
REC121-3759 | 29 - Operational Health and Safety | A Safety Reform Program Director (hereafter referred to as SRPD), reporting directly to the Chief Executive of RailCorp, should be retained to manage, as head of a Safety Reform Program Office, any safety reform program being undertaken by RailCorp. The SRPD should work with the Chief Executive and senior management to ensure the implementation of an integrated safety management system and the cultural change required. The SRPD must have qualifications suitable for recognition by the Australian Institute of Project Management as a master program director. He or she should report to and be under the control of the Chief Executive, to ensure that the accountability of the Chief Executive is not reduced. The SRPD should co-ordinate and integrate any existing rail safety reform programs and, in consultation with and with the authority of the Chief Executive he or she should: |
REC121-3680 | 29 - Operational Health and Safety | All trains must be fitted with a minimum of two independent engineering defences to minimise the risk of derailment or collision in the event of train driver incapacitation. |
REC121-3734 | 29 - Operational Health and Safety | RailCorp should integrate its management of occupational health and safety into its overall safety management. |
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. |
REC121-3740 | 29 - Operational Health and Safety | The internal passenger emergency door release should be fitted with a facility which prevents it from operating unless the train is stationary. |
REC121-3749 | 29 - Operational Health and Safety | All new rolling stock must be designed with an area of the roof through which emergency services personnel can access a rail car without encountering wiring or other equipment. That access point must be clearly marked with words such as “emergency services cut here”. |
REC121-3711 | 29 - Operational Health and Safety | The ITSRR should establish an electronic document control system to enable effective and reliable information to be gathered for monitoring the safety of the New South Wales rail system. |
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. |
REC121-3678 | 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. |
REC121-3733 | 29 - Operational Health and Safety | RailCorp’s approach to occupational health and safety should be proactive and involve the systematic analysis of all current hazards, risks and controls and an assessment of their adequacy to reduce the risk of injury to, or death of, employees to an acceptable level. |
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. |
REC121-3739 | 29 - Operational Health and Safety | All passenger trains operating in New South Wales must be fitted with external emergency door releases which do not require any special key or other equipment to operate. |