Inquiry Search
Rec-ID | Code | Recommendation |
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REC324-4312 | 17 - Assets and technology | Impact to essential services: That, to minimise disruption to essential services, including outages which compromise basic communication coverage, and to ensure access to safe water supply and power during flood events, Government work directly or together with the Australian and other state governments and/or their relevant power and telecommunications regulatory, policy and market bodies to: |
REC324-4319 | 26 - Research | Climate and weather research: That, to enable effective mitigation and adaptation measures in response to changing climate risks, Government establish NSW as a world centre of disaster research and technology development. This should include: |
REC324-4293 | 17 - Assets and technology | Essential services and floodplain infrastructure: That, to minimise disruption to essential services (power, communications, water, sewerage) and to ensure flood infrastructure is fully serviceable before flooding, Government ensure: |
REC324-4308 | 26 - Research | Compound mental helath studies: That, to inform Government policies and programs for mental health and disasters, Government commission a longitudinal study on the effect of consecutive disasters on community mental health. |
Rec-ID | Code | Recommendation |
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REC297-1265 | 13 - Mapping and data quality | That BoM and the Flood Warning Consultative Committee, in consultation with gauge owners, review flood gauges and develop a program to update data used to support hydrologic modelling. This should include reviewing gauge maintenance before and after floods. |
REC297-1254 | 13 - Mapping and data quality | That Government: |
REC297-1264 | 25 - Inquiry, audit, lessons management and after action review | That the Flood Warning Consultative Committee reviews flood classification levels in the Service Level Specifications with BoM specifically relating to flood level triggers on gauges. |
REC297-1253 | 13 - Mapping and data quality | That agencies undertaking flood studies adopt a standardised approach, based on Australia Handbook 7, maintain public ownership of underlying data sets to support future modelling, and ensure open access to these studies. |
REC297-1263 | 13 - Mapping and data quality | Subject to funding, that the Flood Warning Consultative Committee investigates the hydrological matters and advice received during this Review and detailed in this Report in Sections 4.1.9 and 4.1.11. |
REC297-1252 | 13 - Mapping and data quality | That SES uploads current flood studies and plans to the Common Operating Platform as a flood plan layer and that councils, subject to resolving licence restrictions, arrange to have appropriate access. |
REC297-1262 | 13 - Mapping and data quality | That the Flood Warning Consultative Committee considers the merits of delineating the Ouse River as a separate catchment from the Derwent River Basin. |
REC297-1259 | 25 - Inquiry, audit, lessons management and after action review | That DPIPWE examines the Forest Practice Code 2015 for relevance of its concepts to farming and other business activities near rivers, streams and naturally occurring dams and makes recommendations to Government accordingly. |
REC297-1273 | 25 - Inquiry, audit, lessons management and after action review | That the State Emergency Management Committee allocates resources to reviewing all findings and recommendations in the Productivity Commission Report No. 74 relevant to Tasmania and, for those identified as relevant, actions taken and, if none, why not. |
REC297-1258 | 25 - Inquiry, audit, lessons management and after action review | That DPIPWE examines the WMAwater report along with its own, analyses the differences, consults with the Forest Practices Authority and Environment Protection Authority, and proposes an appropriate course of action to Government. |
Rec-ID | Code | Recommendation |
---|---|---|
REC295-1326 | 14 - Incident Mgt Teams | Establish a State-wide resourcing capability to support incident management teams, regional coordination centres, zone emergency centres, relief centres, recovery centres and State control centres. some of the features of such a capability should include: a) multi-agency, cross-government, State-wide pool of incident management and emergency management personnel building on the State incident management team concept currently facilitated by the Country Fire Service, and expanded to include all hazards, multiagency teams with a roster that provides year-round coverage b) a system that enables staff and volunteers from any agency to identify their availability for upcoming shifts c) a rostering system that enables one or more incident management teams, staging areas, regional coordination centres, State control centres and relief centres to develop, maintain and distribute rosters and structure charts in a more coordinated manner d) identifying areas of expertise for key incident and emergency management functions (e.g. public information, alerts and warning, media liaison, logistics and resource management) that would benefit from a coordinated and resource pooling approach and take steps to implement (consider the Mapping Functional Support Group model as a potential service delivery model). |
REC295-1294 | 13 - Mapping and data quality | That consideration and resources be given to support the implementation of recommendations in the report prepared on behalf of Department of Environment, Water and Natural Resources (Australian Water Environments, 2016), for flood warning classification of stream gauges and other locations. |
REC295-1313 | 16 - Training and behaviour | That regular training and exercising is conducted for all State Emergency Centre participants including Liaison Officers. |
REC295-1324 | 16 - Training and behaviour | Establish a State incident management and emergency management training capability which provides for: a) consistent training across the State b) personal development and endorsement processes for roles c) identification, recruitment and development of personnel from other government agencies; and d) incident management and State emergency centre functional role training and development across all sectors. e) skills maintenance including upskills, refresher training and exercises f)incident and strategic leadership training g) consistent training for inter-agency liaison officers at all levels |
REC295-1293 | 13 - Mapping and data quality | That the Flood Reform Task Group identify an appropriate mechanism for stakeholder agencies (including the State Emergency Service, Department of Environment and Natural Resources, Bureau of Meteorology and SA Water, as a minimum) to share data and information and develop plans and strategies for management of water levels in reservoirs and spill management during floods in South Australian water catchments |
REC295-1303 | 16 - Training and behaviour | That the State Emergency Service be provided with resources to enable them to deliver swiftwater awareness training to all first responders including emergency services, SA Police and council crews. |
REC295-1321 | 16 - Training and behaviour | Through the Emergency Management Workforce Project, identify and provide training and development for SA’s emergency management sector personnel (government agencies, and non-government agencies including volunteers). State Emergency Management Committee should consider supporting recommendations from stage two of the project when the project report is tabled. |
REC295-1284 | 16 - Training and behaviour | Deliver consistent and regular training in the use of the SA Government Radio Network to all users to maximise the efficiency and effectiveness of the network in times of emergency e.g. reduce the issues associated with network busy signals. |
REC295-1300 | 17 - Assets and technology | That the State Emergency Service explores options for providing suitable personal protective clothing to personnel from supporting emergency services during major flooding events and sandbagging operations. |
REC295-1320 | 17 - Assets and technology | Review existing electronic information systems used by emergency services organisations and other government agencies, and: a) establish a single incident information system across the Emergency Services Sector (MFS, CFS and SES), and b) identify opportunities to consolidate incident information systems of other agencies |
REC295-1276 | 25 - Inquiry, audit, lessons management and after action review | That SA Health undertake a review of their emergency management arrangements. Health State Controllers should be consulted during this review and arrangements should be consistent throughout the department and across the State and compatible with State emergency management arrangements and information systems |
REC295-1328 | 25 - Inquiry, audit, lessons management and after action review | Update the SEMP Part 3, Annex F ‘Debriefs’ to provide more guidance regarding the types of debriefs, when they are required to be undertaken and at what level and guidance for undertaking and recording debriefs, and implementing lessons identified. |
REC295-1299 | 17 - Assets and technology | That systems for Automatic Vehicle Location and personnel tracking be implemented within the emergency services sector. |
REC295-1317 | 25 - Inquiry, audit, lessons management and after action review | Review representation in the State Emergency Centre including: a) determining if there is a more suitable functional support group e.g. the Procurement Functional Support Group, to replace the Logistics Functional Support Group, and if so, Chief Procurement Officer, DPC, has responsibility for the management of this role within the State Emergency Centre. b) That when the State Crisis Centre is not operating from a physical location, a State Crisis Centre liaison officer is attached to the State Emergency Centre. |
REC295-1327 | 25 - Inquiry, audit, lessons management and after action review | Establish a lessons management capability across the SA emergency management sector to collect, analyse and track lessons identified during debriefs and reviews following events and other sources such as interstate and oversees reviews and inquiries. |
REC295-1297 | 25 - Inquiry, audit, lessons management and after action review | Engage an independent business analyst to review the current call, receipt and dispatch process for emergency services i.e. the Metropolitan Fire Service, Country Fire Service and State Emergency Service, from the initial call for assistance through to response of emergency service resources, including the allocation and coordination of multiple taskings. |
REC295-1315 | 25 - Inquiry, audit, lessons management and after action review | That a review of the role and effectiveness of the State Emergency Management Committee (SEMC) including: the legislative functions; membership including the chair; roles and responsibilities; and, SEMC Advisory Groups be undertaken. |
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. |
REC258-2541 | 16 - Training and behaviour | The Civil Aviation Safety Authority finalises its Capability Framework and overhauls its training program to ensure identified areas of need are addressed, including: |
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. |
REC258-2534 | 16 - Training and behaviour | The Civil Aviation Safety Authority develops a staff exchange program with industry. |
REC258-2551 | 25 - Inquiry, audit, lessons management and after action review | The Civil Aviation Safety Authority assures consistency of audits across all regions, and delivers audit reports within an agreed timeframe. |
REC258-2528 | 25 - Inquiry, audit, lessons management and after action review | The Australian Transport Safety Bureau investigates as many fatal accidents in the sport and recreational aviation sector as its resources will allow. |
REC258-2549 | 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. |
REC258-2548 | 17 - Assets and technology | The Civil Aviation Safety Authority shares the risk assessment outputs of Sky Sentinel, its computerised risk assessment system, with the applicable authorisation holder. |
REC258-2542 | 16 - Training and behaviour | The Civil Aviation Safety Authority publishes and demonstrates the philosophy of ‘just culture’ whereby individuals involved in a reportable event are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training. However, actions of gross negligence, wilful violations and destructive acts should not be tolerated. |
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: |
REC256-1565 | 13 - Mapping and data quality | Governments should task the Australia–New Zealand Emergency Management Committee with leading the development of guidelines for the collection and dissemination of natural hazard mapping, modelling and metadata. Guidelines should be developed for all hazards that need to be modelled and mapped at the local/regional level and where consistency across regions is desirable. |
REC256-1563 | 13 - Mapping and data quality | Governments at all levels should make new and currently held natural hazard data publicly available in accordance with open public sector information principles. When collecting new natural hazard data or undertaking modelling, all levels of government should: |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC244-2620 | 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. |
Rec-ID | Code | Recommendation |
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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. |
REC239-2777 | 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. |
REC239-2724 | 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. |
REC239-2741 | 16 - Training and behaviour | That the annual training calendar identify course, training location and the coordinating authority. |
REC239-2776 | 25 - Inquiry, audit, lessons management and after action review | That the proposed efficiency review of the Queensland Police Service examine whether: |
REC239-2710 | 13 - Mapping and data quality | That all agencies participating in these activities should, as far as legally possible, share data sets whether or not the relevance is immediately obvious. |
REC239-2740 | 16 - Training and behaviour | That impediments to the publication of an annual training calendar of core skills be removed. |
REC239-2775 | 17 - Assets and technology | That efforts by the courts, the Director of Public Prosecutions, the legal profession, Queensland Corrective Services and the Queensland Police Service to adopt technology for court processes should be supported through Government funding in so far as they create efficiencies, result in lower costs and produce better human rights outcomes. |
REC239-2709 | 17 - Assets and technology | That the information and communication technology solution being developed to provide situational awareness, decision support, event management and that logs critical decisions receives urgent attention to ensure timely completion. |
REC239-2729 | 16 - Training and behaviour | That the Queensland Fire and Rescue Service work to change the culture of entitlement so that firefighters recognise firefighting is only one of a range of skills they bring to their core role of emergency management. |
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. |
REC239-2671 | 16 - Training and behaviour | That all Queensland Corrective Service provision of training should be contestable. |
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: |
REC239-2763 | 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. |
REC239-2664 | 17 - Assets and technology | That Queensland Corrective Service should increase the use of technology as an alternative to court appearances and ensure the provision of appropriate number and level of facilities under its control. |
REC239-2778 | 17 - Assets and technology | That as the Queensland Police Service moves to a digital platform the strategy around effective targeting and alternative ANPR models should form part of the design architecture considerations. |
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. |
Rec-ID | Code | Recommendation |
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REC207-2885 | 13 - Mapping and data quality | Increased automation and outsourcing of observations |
REC207-2881 | 17 - Assets and technology | Extend ICT governance arrangements to all applications and subject in-house development to rigorous approval processes. |
Rec-ID | Code | Recommendation |
---|---|---|
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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REC199-0417 | 13 - Mapping and data quality | the state ensure that regional and local flood plans incorporate all available flood mapping and intelligence, including assessments of levees and flood consequence information. |
REC199-0448 | 16 - Training and behaviour | the state ensure that sector wide familiarity and understanding of the various systems for incident management is developed and maintained. Primarily, this should be achieved through multi-agency emergency management training and exercising involving usage of the various agency incident management systems. |
REC199-0475 | 16 - Training and behaviour | the Department of Planning and Community Development review the volunteer register and examine additional options to support councils in volunteer management, including the development of tools and staffing support. |
REC199-0408 | 13 - Mapping and data quality | the state, in consultation with Bureau of Meteorology and Melbourne Water, take the necessary action to ensure that all flood warnings issued are linked to the geographical location of the gauge the data was derived from. |
REC199-0416 | 26 - Research | the state establish appropriate arrangements to ensure the capacity to maintain technical expertise for flood intelligence is initiated, including appropriate agreements with commercial experts. |
REC199-0445 | 25 - Inquiry, audit, lessons management and after action review | the state develop and implement operational performance standards for each state agency involved in emergency management response and recovery and that: • each agency be assessed by the Emergency Services Commissioner periodically against these performance standards for both capability and capacity; and • where performance against these standards for either capability or capacity cannot be demonstrated by any agency – appropriate advice is communicated to the relevant Minister, departmental/agency head and State Emergency Response Coordinator; and – an action plan is developed and implemented to address the relevant capability or capacity deficiency in both the short and longer term. |
REC199-0463 | 16 - Training and behaviour | the state: • ensure an appropriate regime of regular emergency management training and exercising is introduced. This must be ‘all hazards’ and multi-agency focused and include all relevant stakeholders • designate an accountable officer to hold ongoing responsibility for conducting such exercises; and • designate the Emergency Services Commissioner as holding ongoing responsibility for auditing and reviewing this training and exercising. |
REC199-0407 | 25 - Inquiry, audit, lessons management and after action review | the state: • undertake a strategic review to identify areas at risk from flash or riverine flooding. Shortcomings in the flood gauging networks identified in the review should then be the focus of remedial action • seek to address as a priority any notable gaps in the total flood warning system as apparent in the 2010–11 floods (including south west Victoria, Wimmera and north central region) by enhancing mapping, gauging and education programs; and • seek a commitment from the Bureau of Meteorology to ensure any new gauges installed are utilised to enhance flood prediction capability and coverage. |
REC199-0415 | 16 - Training and behaviour | the state ensure that all personnel who are likely to become involved in incident management teams for floods receive basic flood awareness training prior to such involvement. |
REC199-0429 | 13 - Mapping and data quality | the state take into account any outcomes from the Commonwealth Government’s flood mapping reviews in the continual development of the Victorian flood database and to incorporate into the database flood data currently held by Melbourne Water. |
REC199-0462 | 16 - Training and behaviour | the state introduce a joint emergency management leadership training program that will deliver critical core competencies for all levels of management of major emergencies. Future appointments to senior operational emergency management positions should require successful accreditation at the appropriate level. |
REC199-0401 | 25 - Inquiry, audit, lessons management and after action review | the state task the Emergency Services Commissioner with the responsibility to establish an effective audit regime of the total flood warning system. |
REC199-0414 | 16 - Training and behaviour | the state ensure that all personnel who, because of their particular flood expertise, are likely to be potential participants in an Incident Control Centre are familiar with the requirements of the Australasian Inter-service Incident Management System structure |
REC199-0428 | 25 - Inquiry, audit, lessons management and after action review | the state clarify which agency is responsible for collecting post-flood extent and related data. This should include: • the development of guidelines to ensure consistent standards are applied to post-flood data collection; and • an appropriate process to ensure funding availability for such activities. |
REC199-0452 | 17 - Assets and technology | the state ensure that any new systems and equipment purchased by state emergency management agencies are interoperable with other relevant agencies to the fullest extent possible. This should involve the state establishing a procurement gateway process with input from the Emergency Services Commissioner. |
REC199-0413 | 14 - Incident Mgt Teams | the state clarify the role of intelligence cell staff (for example, hydrologists and/or Catchment Management Authority) who are utilised in Incident Control Centres during flood events |
REC199-0420 | 13 - Mapping and data quality | the state establish standards for flood mapping to ensure they are kept contemporary and meet the purposes of landuse risk planning and emergency response. In doing so, maps should extend where appropriate to include Probable Maximum Flood, over a range of Annual Exceedence Probability levels and be explicitly linked to a stream gauge. |
REC199-0450 | 25 - Inquiry, audit, lessons management and after action review | the state ensure that appropriate record management processes are developed and implemented and that these processes also provide record accountability for multi-agency operations. Agency processes should be standardised to the fullest extent possible |
REC199-0482 | 25 - Inquiry, audit, lessons management and after action review | the state task the Emergency Services Commissioner with the responsibility to develop and undertake the regular audit of emergency management plans at all levels. |
REC199-0410 | 17 - Assets and technology | the state take the necessary measures to upgrade existing manual stream and rain gauges and ensure that all future gauges provide a seamless transfer of data from the gauges to the Bureau of Meteorology. |
Rec-ID | Code | Recommendation |
---|---|---|
REC177-3329 | 17 - Assets and technology | Logistics management of well control equipment should be conducted in such a way as to operate as a check against deficient well control practices, for example, use of serial numbers to track availability, testing, and deployment of well control equipment. |
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. |
REC177-3344 | 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. |
REC177-3304 | 26 - Research | It is recommended that industry, regulators, and training/research institutions liaise with one another with a view to developing better techniques for testing and verifying the integrity of cemented casing shoes as barriers (particularly in atypical situations such as where the casing shoe is located within a reservoir in a horizontal or high angle position at great depth). |
REC177-3333 | 16 - Training and behaviour | Licensees and rig operators (and third party contractors involved in well control operations) should specifically assess, and document, the nature and extent of knowledge/skills of relevant personnel in relation to well control (including familiarity of personnel with agency‐specific requirements and procedures). Training needs and opportunities should be identified. This process should take place on engagement and at appropriate intervals. |
REC177-3332 | 16 - Training and behaviour | A specific focus on well control training should be mandatory for key personnel involved in well control operations (including both on‐rig personnel and onshore personnel in supervisory capacities). |
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. |
REC177-3331 | 16 - Training and behaviour | Existing well control training programs should be reviewed by the industry, regulators and training providers, with a focus on well control accidents that have occurred (in Australia and overseas). |
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. |
Rec-ID | Code | Recommendation |
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REC164-0075 | 16 - Training and behaviour | SERCon consider development of an education program for other government and non-government agencies (with |
REC164-0073 | 25 - Inquiry, audit, lessons management and after action review | SERCon consider that the proposed State Recovery Committee provide an interim report to government on these and |
Rec-ID | Code | Recommendation |
---|---|---|
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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REC149-3136 | 16 - Training and behaviour | There is a need for industry in consultation with NOPSA to establish a priority programme of accredited education modules in the Safety Case regime targeting stakeholders in the regime at their respective levels to improve the understanding of the Safety Case and correspondent responsibilities. |
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. |
REC149-3137 | 16 - Training and behaviour | As professional competency is one of the key pillars of any Safety Case, commitment to training for current and future needs remains a fundamental requirement for achieving best practice outcomes in safety. Industry should be encouraged to build on its training commitment now being made to achieve a competent and fully accredited workforce over the next five years. |
Rec-ID | Code | Recommendation |
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REC140-3573 | 13 - Mapping and data quality | Databases with a common minimum data set complete with incident monitoring should be established for TAS Air Ambulance, TMRS and NETS missions. |
REC140-3559 | 17 - Assets and technology | A service level agreement is negotiated with the Police department that will cover access, tasking, price, equipment and staffing. This will enable a more strategic use of the helicopter. |
REC140-3565 | 17 - Assets and technology | The TMRS medical equipment inventory requires an overhaul. The TMRS medical equipment should be located with the TMRS team. |
REC140-3556 | 17 - Assets and technology | The use of hospital transport vehicles to support retrieval operations be investigated. |
REC140-3564 | 17 - Assets and technology | The medical equipment used in retrieval and air ambulance duties undertaken by helicopter and fixed wing must be standardised. |
REC140-3555 | 16 - Training and behaviour | The Tasmanian Ambulance Service Clinical Advisory Committee review helicopter and fixed wing Flight Paramedic training and consider extending the scope of practice to embrace the role of retrieval paramedic in the Doctor/Paramedic retrieval team setting. |
REC140-3563 | 17 - Assets and technology | An additional secure emergency oxygen supply source to be located in the BK 117 helicopter. An internal supply is preferred. |
REC140-3561 | 17 - Assets and technology | Development of a helipad at Mersey Hospital. |
REC140-3560 | 17 - Assets and technology | RHH requires a helipad. Plans to rebuild RHH must include a helipad at its earliest stage of conception. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC121-3757 | 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. |
REC121-3663 | 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. |
REC121-3717 | 16 - Training and behaviour | RailCorp must establish a task analysis for particular categories of employees, to identify the specific skills and responsibility of those employees or groups of employees, and thereafter undertake a training needs analysis, to develop the skills required in particular areas. |
REC121-3672 | 16 - Training and behaviour | All emergency response personnel should be specifically trained in the features of railways which are relevant to their work, such as the location and means of operation of all emergency door releases on trains, the location and use of signal telephones, the methods by which electrical power can be isolated and the means by which they can readily identify and obtain information from the on-site rail commander. |
REC121-3726 | 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. |
REC121-3693 | 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. |
REC121-3756 | 16 - Training and behaviour | RailCorp should ensure that where the safety competency of any manager is deficient such manager is required to undertake professional development courses to raise his or her safety competency level to an adequate standard. |
REC121-3656 | 17 - Assets and technology | Satellite telephones should be provided by RailCorp to all rail commanders at any emergency. |
REC121-3716 | 16 - Training and behaviour | Train driver and guard training should encourage teamwork and discourage authority gradients. |
REC121-3670 | 16 - Training and behaviour | The RailCorp emergency response plan should be provided to all emergency response agencies. The officers of each emergency service should be trained in any rail specific features of the plan, so as to better ensure inter-agency co-ordination in the circumstances of an emergency. |
REC121-3725 | 13 - Mapping and data quality | The data and information management system should be compatible with any data and information management system established by the ATSB for the designated interstate rail network, provided that the establishment of a compatible system does not reduce the amount or quality of the information obtained by ITSRR below the optimum levels which it needs to conduct trend analysis, and otherwise properly manage the safety of rail operations in New South Wales. |
REC121-3691 | 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. |
REC121-3753 | 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. |
REC121-3654 | 16 - Training and behaviour | All train guards should be trained by RailCorp in the use of the Metronet radio and instructed to use it in any emergency. |
REC121-3715 | 16 - Training and behaviour | RailCorp should use its simulators to train drivers and guards in methods of dealing with degraded operations on the rail network. |
REC121-3768 | 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. |
REC121-3669 | 16 - Training and behaviour | All operational rail staff should be trained by RailCorp in the action check list relevant to each. |
REC121-3724 | 13 - Mapping and data quality | The ITSRR should establish a data and information management system, containing all data and information that it requires, to continually monitor the safety of the New South Wales rail system. |
REC121-3677 | 16 - Training and behaviour | A training centre for emergency services personnel should be established by RailCorp. The emergency services personnel should be required to undertake training at such a centre, which should be equipped with features replicating railway infrastructure and rolling stock. |
REC121-3751 | 16 - Training and behaviour | RailCorp should make it a condition of employment that all level 2 managers have or obtain a formal qualification in system safety management. |
REC121-3652 | 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. |
REC121-3714 | 16 - Training and behaviour | RailCorp should use its simulators in an interactive manner. |
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. |
REC121-3666 | 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. |
REC121-3719 | 16 - Training and behaviour | The position of team leader should be created by RailCorp to be responsible for a group of approximately 30 train drivers, with responsibility to ensure that each train driver’s training needs are being met and that any safety concerns of train drivers are being properly addressed. The team leaders are to have direct access to the Chief Executive of RailCorp if any safety concerns they have are not addressed. |
REC121-3676 | 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. |
REC121-3746 | 16 - Training and behaviour | All emergency services personnel should be trained in the location and operation of emergency door release mechanisms on all rail cars. |
REC121-3650 | 16 - Training and behaviour | Staff at the Rail Management Centre (RMC) should receive training from RailCorp to enable them to quickly and accurately assess that an emergency has occurred and to provide precise and reliable information to emergency response personnel about the location of the emergency, the available access to the site and the resources necessary. |
REC121-3713 | 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. |
REC121-3758 | 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. |
REC121-3665 | 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. |
REC121-3718 | 16 - Training and behaviour | Training should be based upon a needs analysis, to determine what skills a particular person will require to carry out the tasks of any position safely and efficiently, and instruction and practice, to acquire and demonstrate those skills. |
REC121-3675 | 16 - Training and behaviour | All rail employees should be trained by their employer to commence any emergency communication with the words “Emergency, emergency, emergency”, thereafter to identify themselves, the train, its location, what has occurred, the approximate passenger load and whether death or injuries have occurred. |
REC121-3744 | 16 - Training and behaviour | All RailCorp operational personnel should be trained in the location and operation of external emergency door release mechanisms. |