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. |
REC258-2549 | 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. |
REC258-2558 | 12 - EM agency and authority | The Civil Aviation Safety Authority applies a project management approach to the completion of all Civil Aviation Safety Regulation Parts not yet in force, with drafting to be completed within one year and consultation completed one year later, with: |
REC258-2547 | 12 - EM agency and authority | The Civil Aviation Safety Authority establishes small offices at specific industry centres to improve monitoring, service quality, communications and collaborative relationships. |
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. |
REC258-2546 | 12 - EM agency and authority | The Civil Aviation Safety Authority changes its organisational structure to a client-oriented output model. |
REC258-2553 | 12 - EM agency and authority | The Civil Aviation Safety Authority establishes a safety oversight risk management hierarchy based on a categorisation of operations. Rule making and surveillance priorities should be proportionate to the safety risk. |
REC258-2545 | 12 - EM agency and authority | The Australian Transport Safety Bureau transfers its safety education function to the Civil Aviation Safety Authority. |
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. |
REC258-2532 | 12 - EM agency and authority | The next Director of Aviation Safety has leadership and management experience and capabilities in cultural change of large organisations. Aviation or other safety industry experience is highly desirable. |
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. |
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: |
REC256-1570 | 1 - Land-use and building regs | All governments should put in place best-practice institutional and governance arrangements for the provision of public infrastructure, including road infrastructure. These should include: |
Rec-ID | Code | Recommendation |
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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. |
REC244-2618 | 12 - EM agency and authority | SES be given a power ‘to register, subject to any conditions the Chief Officer SES considers appropriate, suitable organisations (such as Volunteer Marine Rescue Associations) as affiliated organisations of the State Emergency Service’. |
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. |
REC244-2617 | 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. |
REC244-2627 | 4 - Fire season preparation | Government in conjunction with the CFS identify the ownership of disused railway corridors which may pose a significant fire risk and ensure the agency or individual responsible for the land complies with legislative requirements. |
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. |
REC244-2621 | 36 - Volunteers | Greater attention needs to be given to the recruitment and retention of volunteers in alignment with the National Emergency Management Volunteer Action Plan. |
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. |
REC244-2620 | 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. |
REC244-2601 | 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. |
REC244-2619 | 12 - EM agency and authority | Should the SES be given the power ‘to register suitable organisations’, then the ‘other person’ in Section 127 – Protection from liability, could be defined to include members of organisations affiliated to emergency service organisations. |
REC244-2634 | 12 - EM agency and authority | If possible the terms of election for CFS Health and Safety Representatives be aligned with group elections. |
Rec-ID | Code | Recommendation |
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REC239-2669 | 12 - EM agency and authority | That specific business cases should be developed for contestability of correctional services in Queensland, including: |
REC239-2719 | 12 - EM agency and authority | That the current Queensland Fire and Rescue Service model of functional management be expanded, shifting line management responsibility for community safety operations and professional development from Regional Assistant Commissioners to the State Commanders. Regional Assistant Commissioners become responsible for operations and coordination of departmental support within geographic locations and report to the Deputy Commissioner operations. |
REC239-2744 | 12 - EM agency and authority | That the revitalised PCYC Emergency Service Cadet Program continue to be supported by government. |
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. |
REC239-2725 | 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. |
REC239-2758 | 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. |
REC239-2707 | 12 - EM agency and authority | That the Inspector General Emergency Management ensures that improvement strategies identified are acted upon and improvement strategies embedded within agencies as standard practice. |
REC239-2734 | 12 - EM agency and authority | That a new Deputy Commissioner position be created to manage volunteer emergency services including the Rural Fire Service and the State Emergency Service. |
REC239-2766 | 12 - EM agency and authority | Recommendation: |
REC239-2665 | 12 - EM agency and authority | That planning, especially for infrastructure, must take into account the service delivery model (e.g. the fact that prisoners have high level health needs). |
REC239-2716 | 12 - EM agency and authority | That the remainder of the current Emergency Management structure transition to the Commissioner, Fire and Emergency Services for further consideration regarding the most appropriate reporting alignment giving due consideration to existing capacity. This should be done in consultation with the Commissioner, the Queensland Police Service to ensure proper collaboration with the Queensland Police Service Disaster Management Unit staff. |
REC239-2743 | 12 - EM agency and authority | That where practicable, the consideration for new or enhanced facilities include an assessment of the viability of creating a Rural Fire Service /SES common user facility. |
REC239-2680 | 12 - EM agency and authority | That the fire service takes a broader view of its role as an emergency management organisation. |
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. |
REC239-2754 | 12 - EM agency and authority | That the Chief Executive Officer Portfolio Business should overhaul portfolio information and communication technology and appoint a Chief Information Officer with appropriate qualifications and significant industry experience as a first priority. |
REC239-2706 | 12 - EM agency and authority | The establishment, management, support and education of the State Emergency Service (SES) become the responsibility of a Deputy Commissioner, Fire and Emergency Services and this person should also be responsible for Rural Fire Service Queensland. |
REC239-2733 | 12 - EM agency and authority | That the Queensland Fire and Rescue Service reduce the number of communication centres to two, with one being a primary site and the other site providing redundancy and business continuity functionality. |
REC239-2765 | 12 - EM agency and authority | That the Chief Executive Officer Portfolio Business promote innovation and drive cultural change in terms of business practice. |
REC239-2663 | 12 - EM agency and authority | That the Commissioner of Queensland Corrective Service report directly to the Director-General the Department of Justice and Attorney-General. |
REC239-2715 | 12 - EM agency and authority | That the Disaster Management Standards Branch element of Standards Improvement, transition to the Inspector General Emergency Management. |
REC239-2742 | 12 - EM agency and authority | That the recommendations of The Malone Review in relation to Criminal History checks, so far as supported, by the Review team in this report be progressed inclusive of SES issues. |
REC239-2677 | 12 - EM agency and authority | That biometric tools be leveraged for other demands (e.g. bail reporting). |
REC239-2723 | 1 - Land-use and building regs | That the Queensland Fire and Rescue Service examine alternative contractual arrangements with building owners which would reduce the need for physical attendance at alarm activations. |
REC239-2751 | 12 - EM agency and authority | That collaboration on new initiatives such as the co-responder model in Cairns continue and if successful, initiatives should be considered for state wide or service wide adoption. |
REC239-2698 | 12 - EM agency and authority | That the Deputy Commissioner, Operations (of the proposed new Department of Fire and Emergency Services) should be responsible for ensuring the readiness of the disaster operations system, including the State Disaster Coordination Centre, enabling seamless transition to police control when required. |
REC239-2731 | 12 - EM agency and authority | That the CEO Portfolio Business and the Commissioner Queensland Fire and Rescue Service find a more appropriate method of accounting for part time and volunteer staff when considering the support required to raise, train and sustain this very large part of the workforce. |
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. |
REC239-2658 | 12 - EM agency and authority | That the Queensland Ambulance Service maintains its own identity to: |
REC239-2714 | 12 - EM agency and authority | That the following units of Emergency Management Queensland transition to the control of the position of Deputy Commissioner Rural Fire Service Queensland and State Emergency Services: |
REC239-2739 | 36 - Volunteers | That the Queensland Police Service and the Department of Community Safety develop intuitive, easily accessible systems that reduce the administrative burden on volunteers and their time. Greater exploitation of technology to deliver intuitive, simple and practical systems is required. |
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. |
REC239-2672 | 12 - EM agency and authority | That Queensland Corrective Service conduct business analysis and planning to clearly identify its customers and its contribution to the Government’s priorities |
REC239-2722 | 12 - EM agency and authority | That the Queensland Fire and Rescue Service should introduce alternative means of response to automatic alarms such as small first response investigative crews e.g. two fire–fighters in a sedan (not responding under lights and siren). |
REC239-2746 | 36 - Volunteers | That volunteers should be engaged to assist in determining what constitutes ‘fit for task’ and how that should be implemented. |
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. |
REC239-2730 | 12 - EM agency and authority | That the Queensland Fire and Rescue Service actively progress initiatives for flexible employment including: |
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. |
REC239-2656 | 12 - EM agency and authority | That the Queensland Ambulance Service is maintained as a state-wide service into the future. |
REC239-2713 | 12 - EM agency and authority | That the following units of Emergency Management Queensland transition to the control of the Deputy Commissioner of Regional Operations (Department of Fire and Emergency Services): |
REC239-2738 | 36 - Volunteers | That the current employer and family recognition practices be reviewed with a view to meet the needs of volunteers, their families and their employers. |
REC239-2776 | 25 - Inquiry, audit, lessons management and after action review | That the proposed efficiency review of the Queensland Police Service examine whether: |
REC239-2670 | 12 - EM agency and authority | That prisoner transport and non-managerial roles within watch-houses should be a priority for contestability. |
REC239-2720 | 12 - EM agency and authority | That a reduced regional model for fire and emergency services be generally aligned to that of the Queensland Police Service with a district structure that accords with disaster districts. |
REC239-2745 | 12 - EM agency and authority | That the Emergency Service Cadet Program take a full spectrum approach to emergency services |
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. |
REC239-2727 | 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: |
REC239-2760 | 12 - EM agency and authority | That a suitably qualified Chief Information Officer with whole of portfolio responsibility is appointed to oversight corporate support and capability development |
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. |
REC239-2736 | 36 - Volunteers | That training for volunteers be reviewed to determine which courses require national standardisation. Organisational training should then address the remaining training needs. The review should take into account the risk exposure to government agencies if changes are to be made. |
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. |
Rec-ID | Code | Recommendation |
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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. |
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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REC205-1903 | 25 - Inquiry, audit, lessons management and after action review | The Australian Government should commission an independent public review of disaster prevention and recovery arrangements. This should be broader than the review currently being conducted by the Attorney-General’s Department. The review should cover the Natural Disaster Relief and Recovery Arrangements, as well as the funding mechanisms for disaster mitigation, including the National Partnership Agreement on Natural Disaster Resilience. This review should: |
REC205-1902 | 25 - Inquiry, audit, lessons management and after action review | The Council of Australian Governments should commission an independent public inquiry to develop an appropriate response to managing the risks of climate change to existing settlements. The inquiry should: |
REC205-1901 | 1 - Land-use and building regs | The Council of Australian Governments’ Building Ministers’ Forum should provide formal direction to the Australian Building Codes Board to: |
REC205-1900 | 1 - Land-use and building regs | As a priority, state and territory governments should ensure that land-use planning systems are sufficiently flexible to enable a risk management approach to incorporating climate change risks into planning decisions at the state, territory, regional and local government levels. Consideration should be given to: |
Rec-ID | Code | Recommendation |
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REC197-1738 | 12 - EM agency and authority | A. The CFA, in consultation with its volunteers and employees, determine and adopt a statement of Vision, Mission and Values. |
REC197-1773 | 12 - EM agency and authority | The CFA continue, in consultation with volunteers, paid personnel and their representatives, its review of disciplinary arrangements and as part of that review consider the concept of the establishment of a Volunteer Ombudsman. |
REC197-1744 | 12 - EM agency and authority | The CFA revisit with the UFU the arrangements relating to lateral entry and secondment. |
REC197-1760 | 12 - EM agency and authority | The CFA continue with its initiatives to implement the Garnock Report, keeping volunteers and paid personnel fully informed of progress and consulting with them in relation to the implementation. This implementation should be given priority, having regard to its importance. |
REC197-1737 | 12 - EM agency and authority | A. The CFA, in consultation with employers and volunteers, explore the establishment of employer consultation and support mechanisms along the lines of those developed by the Australian Defence Force. |
REC197-1772 | 12 - EM agency and authority | The CFA, in relation to developing any process for brigade support or career structure or position description for Brigade Administrative Support Officers, as referred to in Clause 8 of the 2010 Deed, consult with the VFBV and volunteers before reaching any decision on those matters. |
REC197-1743 | 12 - EM agency and authority | The CFA revisit with the UFU the arrangement relating to the recruitment of volunteer firefighters as an employee. |
REC197-1759 | 12 - EM agency and authority | The CFA continue its consultations with the UFU to establish a satisfactory and workable process for the use of sessional instructors. |
REC197-1736 | 12 - EM agency and authority | The CFA and the Chief Officer continue to develop the initiatives outlined in relation to service delivery and standards, decision‐making and allocation of resources. |
REC197-1771 | 12 - EM agency and authority | The CFA, in consultation with the VFBV and volunteers, develop a comprehensive strategy for the administrative support of volunteer brigades to ensure that such brigades can operate efficiently and effectively. |
REC197-1742 | 36 - Volunteers | The CFA, in consultation with the VFBV and volunteers, develop initiatives and strategies that will maximise the involvement of young people as volunteers and their retention as volunteers. |
REC197-1758 | 12 - EM agency and authority | The CFA revisit with the UFU the arrangements contained in industrial agreements relating to the engagement of instructors with a view to increasing the ability and flexibility of the CFA to fill instructor positions and thereby ensure maximum training capacity to the benefit of CFA members, both volunteer and paid. |
REC197-1735 | 36 - Volunteers | A. The CFA continue to explore and develop initiatives with modern information and communication technologies to maximise the benefits that they may bring to volunteer involvement in the CFA. |
REC197-1770 | 36 - Volunteers | The CFA, in consultation with the VFBV and volunteers, review the arrangements for the reimbursement of volunteer expenses. This review could be done in conjunction with the review of possible reimbursement of employers of CFA volunteers as recommended in Recommendation 5. |
REC197-1740 | 36 - Volunteers | The CFA, in consultation with the VFBV and volunteers, develop and introduce an arrangement whereby a volunteer can transfer from one brigade to another and still remain a member of the CFA, without the need to resign. |
REC197-1746 | 12 - EM agency and authority | The CFA revisit with the UFU the arrangements relating to the employment of part‐time and casual employees. |
REC197-1734 | 36 - Volunteers | A. Consideration be given to the VFBV being funded directly by Government rather than by the CFA. |
REC197-1769 | 12 - EM agency and authority | The CFA, in consultation with the VFBV and volunteers, explore and develop initiatives whereby qualified volunteers may be more utilised in Incident Management Teams. |
REC197-1739 | 36 - Volunteers | The CFA, in consultation with the VFBV and volunteers, develop a systemic exit strategy, which ensures that relevant information is captured consistently across all brigades. |
REC197-1745 | 36 - Volunteers | The CFA revisit with the UFU the arrangements relating to Community Education Firefighters/Fire Officers and the use of volunteers in this role. |
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. |
REC197-1766 | 12 - EM agency and authority | The CFA as part of any examination of the utilisation of the NBN give priority to the establishment of internet access for brigades. |
Rec-ID | Code | Recommendation |
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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. |
Rec-ID | Code | Recommendation |
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REC161-3034 | 12 - EM agency and authority | That National Offshore Petroleum Safety Authority critically review its regulatory manning levels based on its current workload and the recommendations for additional areas of focus and increased auditing presented in this Report. To meet these requirements, we estimate that National Offshore Petroleum Safety Authority requires up to 50 inspectors in total plus associated support staff to bring overall staffing from about 55 to 75. RET should help facilitate the necessary ongoing levy funding in consultation with industry. |
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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REC151-3080 | 12 - EM agency and authority | The United Firefighters Union of Australia – SA Branch (UFU) be given full voting rights on the Advisory Board. |
REC151-3109 | 36 - Volunteers | As a matter of priority, SAFECOM examine what further measures can be taken to provide support and protection for volunteers as potential witnesses in public enquiries. |
REC151-3078 | 12 - EM agency and authority | All members of the proposed reconstituted SAFECOM Board be given full voting rights. |
REC151-3108 | 36 - Volunteers | Liability and immunity as these provisions apply in Section 127 be reassessed in terms of burden of proof so as to ensure the best protection for volunteers. |
REC151-3077 | 12 - EM agency and authority | The presiding member of the Advisory Board appointed under Section 18(4) be also appointed as a member of the SAFECOM Board. |
REC151-3099 | 12 - EM agency and authority | The selection procedures in the Regulations for SACFS officer positions be reviewed in terms of ensuring that appropriate skills and experience are considered. |
REC151-3067 | 12 - EM agency and authority | Fresh consideration be given to the title of Commissioner of Fire and Emergencies so as to ensure it does not give the impression that it is operationally superior to the Chief Officers of the emergency service agencies. |
REC151-3098 | 12 - EM agency and authority | Nominations for candidates for SACFS group elections be received both by written nomination and by oral nomination. |
REC151-3066 | 12 - EM agency and authority | Accountability for matters of policy, strategy and resource allocation for the emergency services sector, currently the province of the Board, be given to the position created in Recommendation 3 above. |
REC151-3083 | 12 - EM agency and authority | Provisions remain in the FES Act relating to the emergency service organisations being separate legal entities. |
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. |
Rec-ID | Code | Recommendation |
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REC140-3566 | 12 - EM agency and authority | Launceston General and Burnie Hospital’s Emergency Departments require sufficient equipment, monitors and human resources to provide occasional safe local retrieval in their region. |
REC140-3562 | 12 - EM agency and authority | A rapidly responsive helicopter and road retrieval capability to be developed out of RHH. |
REC140-3557 | 12 - EM agency and authority | Royal Flying Doctor Service fixed wing to remain in Launceston for the duration of the current contract. |
REC140-3571 | 12 - EM agency and authority | A senior, experienced, clinically trained ambulance officer to be based in TAS Communications in Hobart for at least 14 hours a day. |
REC140-3570 | 12 - EM agency and authority | The fragmentation and duplication of fixed wing and helicopter clinical coordination should be eliminated through centralisation to TAS Communications. |
REC140-3569 | 12 - EM agency and authority | A senior Tasmanian NETS representative be confirmed on the Tasmanian Medical Retrieval Services Committee. |
Rec-ID | Code | Recommendation |
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REC121-3695 | 10 - Infrastructure | There should be interoperability of communications equipment between all trains operating on the New South Wales rail network. |
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. |
REC121-3713 | 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. |
REC121-3684 | 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. |
REC121-3758 | 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. |
REC121-3694 | 25 - Inquiry, audit, lessons management and after action review | The ITSRR should conduct random audits of accredited rail organisations for compliance with communications protocols. |
REC121-3710 | 39 - Disaster Risk Management | The ITSRR should have permanent access to the RailCorp intranet. |
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. |
REC121-3683 | 39 - Disaster Risk Management | RailCorp should undertake risk assessments of each of its activities as follows: |
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. |
REC121-3693 | 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. |
REC121-3708 | 12 - EM agency and authority | RailCorp should employ a Chief Safety Information Officer to manage the collection, collation, and dissemination of safety information within RailCorp. |
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. |
REC121-3753 | 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. |
REC121-3691 | 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. |
REC121-3700 | 39 - Disaster Risk Management | Maintenance plans on all trains should be revised annually. |
REC121-3658 | 12 - EM agency and authority | All emergency services stations should be provided with access keys to, and maps showing, all gates providing access to RailCorp tracks within their geographic area of responsibility. |
REC121-3752 | 12 - EM agency and authority | RailCorp should establish clear safety accountability statements and reporting lines for all management positions. |
REC121-3689 | 12 - EM agency and authority | All RMC communications related staff should be selected upon the basis of the ability to convey information clearly, accurately and concisely and to follow strict communications protocols. |
REC121-3766 | 12 - EM agency and authority | Staffing arrangements for ITSRR should be reviewed by it to ensure that adequate staff are employed in field positions, actively monitoring the safety of rail operations and compliance with conditions of accreditation. |
REC121-3700 | 12 - EM agency and authority | The RailCorp defects unit should be combined with the passenger fleet maintenance division of RailCorp. |
REC121-3657 | 10 - Infrastructure | All signal telephones must be maintained by RailCorp in proper working order. |
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. |
REC121-3687 | 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. |
REC121-3765 | 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. |