Inquiry Search
Rec-ID | Code | Recommendation |
---|---|---|
REC312-2506 | 9 - Community education | The chairpersons of disaster management groups within the Townsville Disaster District, supported by the Queensland Police Service, Queensland Fire and Emergency Services and the Queensland Reconstruction Authority develop a district action plan based on the capability enhancement strategy. |
Rec-ID | Code | Recommendation |
---|---|---|
REC310-2487 | 39 - Disaster Risk Management | The state’s arrangements for disaster management, including recovery, are articulated in the Disaster Management Act (2003), the Queensland Reconstruction Authority Act (2011), the State Disaster Management Plan and the Queensland Recovery Plan. To enable state-level arrangements to better support community-led recovery and to improve Queensland’s recovery governance |
REC310-2486 | 9 - Community education | State arrangements for on-the-ground support to recovering local governments should be in line with Queensland’s disaster management arrangements, and ensure the best balance between local relationships, suitable capability and sufficient capacity. |
REC310-2483 | 9 - Community education | 09-Community education/engagement/preparedness |
REC310-2482 | 9 - Community education | Practical guidance on what community-led recovery means, and how it can be best implemented should be captured and shared with all who have responsibility for it. This should be done to help individuals and communities to take the lead in recovery and so that community-led recovery becomes the norm following disasters and other events. |
REC310-2481 | 22 - Role of local Gvt | Greater clarity about responsibilities for recovery at the community, local, and district levels should be considered in any future review of the Disaster Management Act (2003). |
Rec-ID | Code | Recommendation |
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REC002-4002 | 19 - Offences | Where safety-lamps are necessary - gas being present for (say) one month after being found in dangerous quantity - they should be securely locked by a man duly appointed, and tampering with them must be punishable by a simple and inexpensive process of law. |
REC002-4011 | 32 - Doctrine, standards, and reform | The Commission feel that the 4th clause in the present Act, relating to the spacing of cut-throughs, should be amended to admit of any convenient or safe system of mining being pursued. This is a matter of detail that would be better out of the Act. The Commission would advise that the word should not occur at all, and that, if bratticing be used, or the air by some other satisfactory device be conveyed to the face, scope would be given to Managers to introduce systems of mining adapted to the circumstance of each particular coal-seam, with advantage to all concerned. |
REC002-4001 | 35 - Business and Industry in relation to industry | The Commission consider that in all mines where gas exists the course of the air should be directed to sweep along the working-faces; in mines worked by Pillar and Stall, bratticing must be resorted to to carry the gas from the face as it issues, and so prevent any accumulation of explosive gases or of gases inimical to life. In cases where gas exists it would be better that no bords should be broken off the back or return heading or supplied with air fouled by dangerous gases. The panel system of working by confining and localising districts, or some modification thereof, might be pursued with advantage. |
REC002-4010 | 35 - Business and Industry in relation to industry | The Commission do not approve of removing any responsibility from the management by increasing the power or number of the Inspectors. The visits of these officials should, so far as possible, be visits of surprise. |
REC002-4008 | 35 - Business and Industry in relation to industry | Where dust exists in quantity, and under conditions favourable for ignition, it should be periodically and sufficiently dampened by water |
REC002-4004 | 35 - Business and Industry in relation to industry | Where safety-lamps are used, and the obligation is laid upon the men to cleanse the same, all examinations, tests, and repairs to these should be done by the owners. |
REC002-4013 | 19 - Offences | Infringement of the regulations by either party should be followed by a summary form of justice, instituted before two Magistrates. |
REC002-4003 | 35 - Business and Industry in relation to industry | Where gas exists, and no provisions are made for its constant removal, no shots should be fired, and, where permitted in a gassy mine, shots should be fired only by a man specially appointed, and at such hours when the miners are not within the mine. All shots should be tamped by stone well damped, and only copper or wooden tools should be employed. As far as possible the use of explosives should be discouraged, and skilful mining encouraged. Danger-boards should be placed further from the faces whence gas issues (say), where practicable, 50 yards. |
REC002-4012 | 38 - Agency/Department Reporting | Complete sets of daily-report books should be provided, and kept in the mine or office, to be overlooked by the Inspector during his periodical visits. |
Rec-ID | Code | Recommendation |
---|---|---|
REC258-2530 | 24 - Govt responsibility | The Australian Government appoints an additional Australian Transport Safety Bureau Commissioner with aviation operational and safety management experience. |
REC258-2537 | 32 - Doctrine, standards, and reform | The Civil Aviation Safety Authority delegates responsibility for the day-to-day operational management of airspace to Airservices Australia, including the designation of air routes, short term designations of temporary Restricted Areas, and temporary changes to the classification of airspace for operational reasons. |
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. |
REC258-2562 | 32 - Doctrine, standards, and reform | The Civil Aviation Safety Authority amends the current Terms of Reference of the Industry Complaints Commissioner so that: |
REC258-2529 | 32 - Doctrine, standards, and reform | The Australian Transport Safety Bureau and the Civil Aviation Safety Authority utilise the provision in their bilateral Memorandum of Understanding to accredit CASA observers to ATSB investigations. |
REC258-2536 | 32 - Doctrine, standards, and reform | The Australian Transport Safety Bureau and the Civil Aviation Safety Authority amend the wording of their existing Memorandum of Understanding to make it more definitive about interaction, coordination, and cooperation. |
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. |
REC258-2561 | 24 - Govt responsibility | The Australian Government amends regulations so that background checks and the requirement to hold an Aviation Security Identification Card are only required for unescorted access to Security Restricted Areas, not for general airside access. This approach would align with international practice. |
REC258-2528 | 25 - Inquiry, audit, lessons management and after action review | The Australian Transport Safety Bureau investigates as many fatal accidents in the sport and recreational aviation sector as its resources will allow. |
REC258-2535 | 32 - Doctrine, standards, and reform | Airservices Australia, in conjunction with the Department of Infrastructure and Regional Development and the Civil Aviation Safety Authority, reconsiders the policy on ‘Assessment of Priorities’ that stipulates that air traffic controllers sequence arriving aircraft based on category of operation, rather than on the accepted international practice of ‘first come, first served’. |
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. |
REC258-2556 | 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. |
REC258-2527 | 32 - Doctrine, standards, and reform | The Department of Infrastructure and Regional Development plays a stronger policy role in the State Safety Program. |
REC258-2533 | 32 - Doctrine, standards, and reform | The Civil Aviation Safety Authority: |
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. |
REC258-2555 | 32 - Doctrine, standards, and reform | The Civil Aviation Safety Authority changes the current two-tier regulatory framework (act and regulations) to a three-tier structure (act, regulations and standards), with: |
REC258-2526 | 24 - Govt responsibility | The Australian Government develops the State Safety Program into a strategic plan for Australia’s aviation safety system, under the leadership of the Aviation Policy Group, and uses it as the foundation for rationalising and improving coordination mechanisms. |
REC258-2531 | 32 - Doctrine, standards, and reform | The Civil Aviation Safety Authority’s Board exercises full governance control. The nonexecutive directors should possess a range of appropriate skills and backgrounds in aviation, safety, management, risk, regulation, governance and government. |
REC258-2538 | 32 - Doctrine, standards, and reform | The Department of Infrastructure and Regional Development and Department of Defence (and appropriate agencies) establish an agreed policy position on safety oversight of civil operations into joint user and military airports. |
REC258-2554 | 32 - Doctrine, standards, and reform | Recreational Aviation Administration Organisations, in coordination with the Civil Aviation Safety Authority, develop mechanisms to ensure all aircraft to be regulated under CASR Part 149 are registered. |
Rec-ID | Code | Recommendation |
---|---|---|
REC256-1561 | 24 - Govt responsibility | State and territory governments should be required to report on the following accountability requirements: |
REC256-1569 | 32 - Doctrine, standards, and reform | The provisions in the Queensland Sustainable Planning Act 2009 for injurious affection should be repealed. |
REC256-1575 | 24 - Govt responsibility | State and territory governments should develop benchmark prices for the reconstruction of essential public assets and submit these to the Australian Government for approval within one year. In developing these prices, they should consult with local governments and relevant experts, and draw on asset management plans. The prices should be reviewed and updated over time. |
REC256-1568 | 24 - Govt responsibility | State governments, where they have not already done so, should provide local governments with statutory protection from liability for releasing natural hazard information and making changes to local planning schemes where such actions have been taken ‘in good faith’ and in accordance with state planning policy and legislation. |
REC256-1574 | 32 - Doctrine, standards, and reform | The Australian Government should establish a framework for the development of benchmark prices for the reconstruction of essential public assets. This should set out the broad parameters that state and territory governments should follow, without prescribing particular prices to be used. |
REC256-1567 | 24 - Govt responsibility | State and territory governments should: |
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: |
REC256-1566 | 24 - Govt responsibility | State and territory governments should prioritise and accelerate implementation of the Enhancing Disaster Resilience in the Built Environment Roadmap, including reviewing the regulatory components of vendor disclosure statements. The Land Use Planning and Building Codes Taskforce should be tasked to identify and consider options for regular, low-cost dissemination of hazard information to households by governments and insurers. |
REC256-1571 | 24 - Govt responsibility | State and territory taxes and levies on general insurance should be phased out and replaced with less distortionary taxes. |
REC256-1562 | 32 - Doctrine, standards, and reform | The Australian Government should: |
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: |
REC256-1576 | 21 - Role of Commonwealth Government | Within three years, the Australian Government should develop and implement a framework for untied grants for community recovery assistance to state and territory governments. This framework should take into account factors such as the type, location and scale of a disaster, and the number of people affected. |
Rec-ID | Code | Recommendation |
---|---|---|
REC244-2599 | 32 - Doctrine, standards, and reform | That the MFS, CFS and SES be incorporated into a departmental structure under the direction of a Chief Executive based on interstate developments over the past two decades, which establishes this arrangement as the benchmark for the governance of Emergency Services in Australia. The MFS, CFS and SES would operate as separate units under the ultimate direction of the CEO. |
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. |
REC244-2605 | 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. |
REC244-2625 | 32 - Doctrine, standards, and reform | Sections 42 and 97 be amended to provide greater flexibility in the engagement of contractors by Senior MFS and CFS Officers. Consideration be given to providing similar powers in Section 118 to enable the SES to engage contractors. |
REC244-2610 | 32 - Doctrine, standards, and reform | Amend Regulation 33 (6) and (8) to include respectively ‘notice given’ and ‘permit application’ using the online medium. |
REC244-2630 | 32 - Doctrine, standards, and reform | Clarify that Section 128 of the F&ES Act is not compromised by any other legislation. |
REC244-2615 | 32 - Doctrine, standards, and reform | In consultation with stakeholders including CFA, develop a Forest Industry Brigade standard for inclusion in the Fire and Emergency Services Regulations. |
REC244-2636 | 32 - Doctrine, standards, and reform | Amend the F&ES Act to provide for the operation of interstate fire and emergency service workers in South Australia. The issue of liability may need to be considered. |
REC244-2603 | 32 - Doctrine, standards, and reform | Should the State Bushfire Coordination Committee continue to exist under the F&ES Act, then Section 71 of the Act be amended to provide for the appointment of an independent presiding member of the committee. |
REC244-2624 | 32 - Doctrine, standards, and reform | The F&ES Act be amended to clarify the meaning of ‘closure’ in Section 38 and that provisions relating to the extension and rescission of closure orders be reviewed. |
REC244-2609 | 32 - Doctrine, standards, and reform | That the proposed ‘Permit Information Management System’ (PIMS) be implemented as soon as possible and incorporated into the Call Receipt and Dispatch process. Following implementation, amend Regulation 33 (5) (d) and (10) (c) in line with the automated notification process. |
REC244-2629 | 32 - Doctrine, standards, and reform | The power of the Chief Officer to appoint officers from the staff of the SES as well as appoint volunteer officers of the SES be clarified. A command structure section (similar to Section 70) be incorporated into the Act and include the power to register, appoint, disqualify and terminate volunteer members. |
REC244-2614 | 32 - Doctrine, standards, and reform | Consider the amendment of Section 82 (2) to include the power to order the cessation of harvesting or any other actions (including the lighting of fires authorised under Section 81) that because of the weather conditions, may cause a fire, if ignited, to get out of control. |
REC244-2635 | 32 - Doctrine, standards, and reform | The requirement to consult with members of the unit and the SESVA before an SES Unit is dissolved should remain but the need for public meetings be removed from the regulations. |
REC244-2602 | 32 - Doctrine, standards, and reform | That South Australia’s Hazard Leader Plan for Rural Fire, prepared in accordance with the State Emergency Management Plan, replace the F&ES Act requirement for a separate State Bushfire Management Plan. |
REC244-2623 | 32 - Doctrine, standards, and reform | That the F&ES Act be amended to enable fire safety inspections in and outside fire districts. |
REC244-2608 | 32 - Doctrine, standards, and reform | Consider whether Regulation 71 be amended to extend the range of offences for which expiation fees apply to include a breach of any permit condition imposed by an authorised officer. |
REC244-2628 | 32 - Doctrine, standards, and reform | Amend the F&ES Act to reflect the SES expanded responsibilities as Hazard Leader for ‘Extreme Weather’ including their community education role. |
REC244-2613 | 32 - Doctrine, standards, and reform | Should the State Bushfire Coordination Committee continue to exist under the F&ES Act amend Section 94 (4) (c) to refer to the ‘State Bushfire Coordination Committee’. |
REC244-2633 | 32 - Doctrine, standards, and reform | Amend Section 143 to strengthen the capacity of the ESOs to recover outstanding debts (e.g. penalty for late payment provisions). |
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. |
REC244-2622 | 32 - Doctrine, standards, and reform | Amend Sections 28, 61 and 110 to provide the Chief Officers greater flexibility over organisational structure. |
REC244-2607 | 32 - Doctrine, standards, and reform | Amend Regulation 41 to exempt the use of prescribed appliances when a Hot Work Permit compliant with AS1674.1 has been issued. |
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. |
REC244-2612 | 32 - Doctrine, standards, and reform | Develop a code of practice which is referenced by the F&ES Act for burning off including the option to issue seasonal permits for relevant purposes throughout the State. |
REC244-2632 | 32 - Doctrine, standards, and reform | Section 142 be amended to include the SES |
REC244-2600 | 25 - Inquiry, audit, lessons management and after action review | An external audit of shared services performed by SAFECOM and services now provided by the three ESOs which have the potential to be shared, be undertaken to determine the most efficient and cost effective way such services can be delivered to the sector. The three ESO Chiefs need to have input into this process. |
REC244-2620 | 25 - Inquiry, audit, lessons management and after action review | Review employment conditions under the F&ES Act to align with those under the Public Sector Act unless there is a compelling reason to the contrary. |
REC244-2606 | 22 - Role of local Gvt | The Act be amended to require the mandatory appointment of Authorised Officers by each rural council or council that has within its area a Designated Urban Bushfire Risk Area(s) with an option for the CFS Chief Officer to exempt council from this requirement (similar to Section 105B). |
REC244-2626 | 32 - Doctrine, standards, and reform | Section 70 (5) be amended to preclude a person from being elected as a group officer, brigade captain or brigade lieutenant if he or she is an employee of the CFS. |
REC244-2611 | 32 - Doctrine, standards, and reform | Review the format and necessity for Schedules 9 and 10 of the Regulations |
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 |
---|---|---|
REC239-2655 | 24 - Govt responsibility | That the Queensland Ambulance Service is transferred to Queensland Health by a machinery-of-Government change as soon as is practicable and that the Commissioner report directly to the Director General Queensland Health. |
REC239-2686 | 24 - Govt responsibility | That primacy of control should rest with the State Disaster Coordinator. This position should, by default, be the Deputy Commissioner, Regional Operations, Queensland Police Service. |
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. |
REC239-2759 | 24 - Govt responsibility | That the new Chief Executive Officer Portfolio Business be accountable for delivering the reformed Communications Centre arrangement by the 2017–18 financial year in time for the Commonwealth Games of 2018. |
REC239-2662 | 24 - Govt responsibility | That responsibility for prisoner transport and non-managerial roles within the larger watch-houses is transferred to Queensland Corrective Service. |
REC239-2693 | 32 - Doctrine, standards, and reform | That the presence of police in State Disaster Coordination Centre response teams is mandated and formalised through documented standard operating procedures. |
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. |
REC239-2769 | 9 - Community education | That the Chief Executive Officer portfolio business and Commissioner of Police in line with the government’s open data policy consider introducing an improved social media style forum for interaction with the community and stakeholders across the portfolio. |
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. |
REC239-2700 | 24 - Govt responsibility | That the position of Inspector General Emergency Management (in addition to some of the responsibilities of the chief executive officer under the current Disaster Management Act 2003) will: |
REC239-2732 | 24 - Govt responsibility | There be a formation of an Office of Portfolio Business, providing support and governance across a range of corporate functions, which are essential to the delivery of frontline services. The Review team considers that the functions of the Operations Business and Strategy Directorate should become part of that Office and that any exception should be carefully considered by those charged with implementation of approved recommendations. |
REC239-2774 | 39 - Disaster Risk Management | Those final determinations of disaster management districts include consultation with the Local Government Association Queensland, the Queensland Fire and Rescue Service and other Government departments. |
REC239-2685 | 24 - Govt responsibility | That primacy of control for disaster operations remains with the Queensland Police Service and be reinforced. |
REC239-2708 | 24 - Govt responsibility | That the role of the Inspector General Emergency Management not extend to conducting reviews on behalf of agencies and that the role consider the effectiveness of all agencies and how their work contributes to a whole of Government response. |
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. |
REC239-2661 | 24 - Govt responsibility | That Queensland Corrective Service remains a separate program within the Department of Justice and Attorney-General so that while opportunities for improved services and efficacy can be realised, there is a clear separation from the youth justice services. |
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. |
REC239-2721 | 24 - Govt responsibility | That the Chief Executive Officer Portfolio Business collaborate with the two portfolio Commissioners to: |
REC239-2768 | 9 - Community education | Recommendation: That: |
REC239-2674 | 38 - Agency/Department Reporting | That Queensland Corrective Service continues to develop its proposed recidivism index as a priority, including place and program based measures. |
REC239-2699 | 24 - Govt responsibility | That the Minister establish a public sector office to be headed by an Inspector General of Emergency Management. The Inspector General of Emergency Management will be responsible for most of the functions listed under part 16A of the current Disaster Management Act 2003. |
REC239-2728 | 32 - Doctrine, standards, and reform | That the Fire and Rescue Act 1990 be amended so that Commissioner’s position is not limited to a “person with professional experience in fire prevention and fire fighting”. |
REC239-2773 | 38 - Agency/Department Reporting | That should the Mobile Strategy in its current form be approved by government the CEO Portfolio Business and the Deputy Commissioner Operations: |
REC239-2684 | 38 - Agency/Department Reporting | The Chief Executive Officer Portfolio Business establishes a set of performance indicators to provide a transparent process for government to monitor its performance. |
REC239-2705 | 32 - Doctrine, standards, and reform | That the Inspector General Emergency Management assess the effectiveness of plans and policy in relation to SES deployment and command and control. |
REC239-2756 | 32 - Doctrine, standards, and reform | That the Chief Executive Officer Portfolio Business consider ‘big data’ problems and solutions in line with the outcome of the efficiency review into the Queensland Police Service and ensure alignment with whole of government solutions. |
REC239-2660 | 24 - Govt responsibility | That Queensland Corrective Services be transferred to the Department of Justice and Attorney-General by a machinery-of-Government change as soon as is practicable. |
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. |
REC239-2718 | 32 - Doctrine, standards, and reform | That the Department of Fire and Emergency Services be created through the renaming and amendment to the existing Fire and Rescue Service Act 1990 including: |
REC239-2767 | 38 - Agency/Department Reporting | Recommendation: That the CEO Portfolio Business collaborates with the two portfolio Commissioners to: |
REC239-2673 | 38 - Agency/Department Reporting | That Queensland Corrective Service, in consultation with key partners in the criminal justice and social services sectors, develops specific performance indicators focused on efficiencies and customer/stakeholder outcomes across the criminal justice system. |
REC239-2697 | 32 - Doctrine, standards, and reform | That the Queensland Police Service Disaster Management Unit work with emergency management staff in the new portfolio to produce the State disaster management plan. |
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: |
REC239-2772 | 38 - Agency/Department Reporting | That the roll-out of the mobile service program business case mentioned earlier |
REC239-2679 | 24 - Govt responsibility | To remove the Queensland Ambulance Service and Queensland Corrective Services from the Department of Community Safety—we recommend that it be renamed the Department of Fire and Emergency Services and be led by a Commissioner. |
REC239-2704 | 32 - Doctrine, standards, and reform | That the current SES memoranda of agreement between the Department of Community Safety and local governments be revised to include a clear statement as to the command and control arrangements between State and respective local governments. These arrangements should also be reflected in the local disaster management plans. |
REC239-2755 | 32 - Doctrine, standards, and reform | That the Queensland Police Service bring this practice to the attention of the Privacy Commissioner and discuss a new service wide policy on the retention of data to ensure that their officers are not acting in breach of the law. |
REC239-2782 | 24 - Govt responsibility | That transparency of the Ministerial direction be achieved through publishing and monitoring for effectiveness. |
REC239-2659 | 9 - Community education | That Queensland Health continues to recognise and foster the important contributions of Local Ambulance Committees to supporting effective community focused ambulance services across the State. |
REC239-2688 | 22 - Role of local Gvt | That in establishing new disaster districts, the first guiding principle must be to align with local government boundaries and that divergence should only occur when there is a need to address a unique local circumstance. |
REC239-2717 | 32 - Doctrine, standards, and reform | That the ‘Functions of Chief Executive’ under the Disaster Management Act 2003 are amended to remove those functions that will become the role of the proposed Inspector General 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. |
REC239-2668 | 32 - Doctrine, standards, and reform | That as part of reviewing its legislation, Queensland Corrective Service should ensure that amendments be made to ensure a stronger onus is placed upon a more efficient process to receive prisoners with a view to reducing the time spent in police watch houses. |
REC239-2696 | 32 - Doctrine, standards, and reform | That the Queensland Police Service Disaster Management Unit be given responsibility for production of the State disaster management plan for the State Disaster Management Group’s approval. |
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. |
REC239-2771 | 38 - Agency/Department Reporting | That the Queensland Police Service Commissioner addresses the situation regarding statistical reporting. The Commissioner, in collaboration with the Chief Executive Officer Portfolio Business and the Queensland Fire and Rescue Service Commissioner should also examine the opportunity to acquire the services of a qualified and experienced Chief Information Officer or Chief Digital Officer in line with other Queensland and Australian government agencies. |
REC239-2678 | 24 - Govt responsibility | That probation and parole should continue to work together with the Queensland Police Service to reduce the risk of reoffending and reduce crime. |
REC239-2702 | 32 - Doctrine, standards, and reform | That the Queensland Police Service and SES develop clear operational protocols to ensure that SES assistance is not exploited. |
REC239-2749 | 24 - Govt responsibility | That the Prostitution Licensing Authority be moved to the Department of Justice and Attorney General Office of Fair Trading. |
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. |
REC239-2657 | 24 - Govt responsibility | That negotiation takes place between Queensland Health and the Queensland Ambulance Service to determine the broad governance requirements of any such arrangements. |
REC239-2687 | 24 - Govt responsibility | That funding, staffing and responsibility associated with administration of the NDRP be transferred from Emergency Management Queensland to the Department of Local Government, Community Recovery and Resilience. |
REC239-2712 | 24 - Govt responsibility | That Emergency Management Queensland be integrated with the current Queensland Fire and Rescue to become the Department of Fire and Emergency Services. |
REC239-2763 | 25 - Inquiry, audit, lessons management and after action review | That the proposed efficiency review includes a focus on the rank structure of both the Queensland Police Service and the proposed Fire and Emergency Services. |
REC239-2666 | 32 - Doctrine, standards, and reform | That a system should be designed so that the prisoner and the prisoner’s prescribed drugs are treated as one and therefore travel together through the system for whatever purpose. |
REC239-2695 | 32 - Doctrine, standards, and reform | That the Disaster Management Act 2003 be amended to: |
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. |
REC239-2770 | 9 - Community education | That the efficiency review of the Queensland Police Service develop options for better management of community expectations and divesting the organisation of historical practices. |
REC239-2676 | 32 - Doctrine, standards, and reform | That any changed arrangements to the operations of Queensland Corrective Service ensure anti-corruption, prisoner management, and accountability processes are defined and established. |
REC239-2701 | 24 - Govt responsibility | That the Inspector General Emergency Management provide continuing advice to Government on the level of interoperability in disaster management arrangements, as well as the level of interoperability being achieved within the new portfolio. |
REC239-2735 | 32 - Doctrine, standards, and reform | That the new Department of Fire and Emergency Services develop a common doctrine to protect people from fire and emergencies. |
REC239-2776 | 25 - Inquiry, audit, lessons management and after action review | That the proposed efficiency review of the Queensland Police Service examine whether: |
Rec-ID | Code | Recommendation |
---|---|---|
REC237-0817 | 32 - Doctrine, standards, and reform | That section 3(c) of the Rural Fires Act 1997, which sets out the objects of the Act, be extended to include protecting infrastructure, environmental, economic, cultural, agricultural and social assets from damage. |
REC237-0822 | 32 - Doctrine, standards, and reform | That section 74 of the Rural Fires Act 1997 be amended to require public authorities to report to the Commissioner of the NSW Rural Fire Service within one month of the end of the financial year on activities undertaken to reduce bush fire hazards on managed land during the preceding financial year. |
REC237-0827 | 32 - Doctrine, standards, and reform | The Panel notes and endorses the NSW bush fire management system based on a multi-agency, tenure blind approach using locally focused Bush Fire Management Committees, Bush Fire Management Plans and the Bush Fire Environmental Assessment Code as best practice. |
REC237-0832 | 32 - Doctrine, standards, and reform | That the NSW Rural Fire Service investigate use of appropriate modelling, such as PHOENIX RapidFire and the Bayesian Network analysis, to quantify the level of bush fire risk to critical values and assets. |
REC237-0821 | 32 - Doctrine, standards, and reform | That the definition of “bush fire hazard reduction work” in the Dictionary of the Rural Fires Act 1997 be amended to include the establishment or maintenance of fire trails. |
REC237-0826 | 32 - Doctrine, standards, and reform | That the NSW Rural Fire Service hold discussions with the Commonwealth Department of Sustainability, Environment, Water, Population and Communities about hazard reduction and roadside vegetation, including potential changes to the NSW Bush Fire Environmental Assessment Code. |
REC237-0831 | 32 - Doctrine, standards, and reform | That Bush Fire Management Committees be required to take into account fuel age and fire frequency thresholds when developing Bush Fire Risk Management Plans |
REC237-0820 | 32 - Doctrine, standards, and reform | That the Rural Fires Act 1997 be amended to allow the Commissioner of the NSW Rural Fire Service to carry out hazard reduction on land without the consent of the owner after reasonable attempts to contact the landowner have failed, without serving a notice under section 66 of the Rural Fires Act. |
REC237-0825 | 1 - Land-use and building regs | That the NSW Rural Fire Service hold discussions with the Department of Planning and Infrastructure and Local Government NSW on ways to improve compliance with development consents under section 76A of the Environmental Planning and Assessment Act 1979. |
REC237-0830 | 9 - Community education | That Bush Fire Risk Management Plans be tabled at Local Emergency Management Committees for comment. |
REC237-0819 | 32 - Doctrine, standards, and reform | That section 56 of the Rural Fires Act 1997 be amended to give the Commissioner of the NSW Rural Fire Service the power to direct a Bush Fire Management Committee to amend its Bush Fire Risk Management Plan if it is inadequate, in the opinion of the Commissioner. |
REC237-0824 | 32 - Doctrine, standards, and reform | That section 100I of the Rural Fires Act 1997 be amended to allow hazard reduction certificates to be issued for annual low impact works for a period of three years, where appropriate. |
REC237-0829 | 9 - Community education | That Bush Fire Risk Management Plans be posted on the NSW Rural Fire Service website. |
REC237-0818 | 32 - Doctrine, standards, and reform | That section 9(4)(b) of the Rural Fires Act 1997, which sets out the functions of the NSW Rural Fire Service, be amended to include protecting infrastructure, environmental, economic, cultural, agricultural and social assets from damage. |
REC237-0823 | 32 - Doctrine, standards, and reform | That section 74 of the Rural Fires Act 1997 be amended to require public authorities to report monthly to the Commissioner of the NSW Rural Fire Service on activities undertaken to reduce bush fire hazards on managed land during the preceding month and the reasons why any planned activities did not take place. |
REC237-0828 | 9 - Community education | That the NSW Rural Fire Service develop a strategy to better inform the community and NSW Rural Fire Service members about the NSW bush fire management system and its components. |
Rec-ID | Code | Recommendation |
---|---|---|
REC207-2874 | 32 - Doctrine, standards, and reform | Formalise and standardise service levels provided to emergency services. |
REC207-2897 | 21 - Role of Commonwealth Government | Additional frontline meteorologists and specialised centres and systems: |
REC207-2882 | 39 - Disaster Risk Management | Review disaster recovery and business continuity plans. |
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 |
REC207-2873 | 21 - Role of Commonwealth Government | Boost the Bureau’s flood warning capacity by: |
REC207-2896 | 21 - Role of Commonwealth Government | Lower yield options identified by the Bureau: |
REC207-2880 | 32 - Doctrine, standards, and reform | Ensure the Bureau puts in place necessary planning and governance arrangements to develop its bid for capital funding to maintain its critical supercomputing capacity |
REC207-2887 | 21 - Role of Commonwealth Government | Centralise media services and establish protocols for media activity. |
REC207-2872 | 21 - Role of Commonwealth Government | Boost the number of frontline meteorologists to build response capacity in regional forecasting centres. |
REC207-2896 | 21 - Role of Commonwealth Government | Lower yield options identified by the Bureau: |
REC207-2878 | 21 - Role of Commonwealth Government | Complete workforce planning project and succession plans as a matter of urgency. |
REC207-2900 | 21 - Role of Commonwealth Government | Explore use of social media to enhance data gathering from authorised and informal sources and to disseminate weather information |
REC207-2886 | 21 - Role of Commonwealth Government | Explore options to limit forecaster intervention in site-specific web forecasts. |
REC207-2895 | 21 - Role of Commonwealth Government | Fund delivery of improved seasonal forecasting services by: |
REC207-2876 | 21 - Role of Commonwealth Government | Focus the Bureau’s evolving environmental information role on natural hazards in the first instance. |
REC207-2899 | 21 - Role of Commonwealth Government | Improved seasonal forecasting capabilities: |
REC207-2884 | 32 - Doctrine, standards, and reform | Focus leadership practices to re-orient culture away from customisation and experimentation and towards reliable, efficient and consistent documented processes |
REC207-2894 | 21 - Role of Commonwealth Government | Phase out seasonal prediction development and modelling and rely on products generated elsewhere |
REC207-2875 | 32 - Doctrine, standards, and reform | Agree clear allocation of responsibilities to state and local government for flood management, with defined boundaries on the Bureau’s role and: |
REC207-2898 | 21 - Role of Commonwealth Government | Upgrade to the Bureau’s supercomputing capacity: |
REC207-2883 | 32 - Doctrine, standards, and reform | Start a project to introduce organisational process thinking with a view to standardising processes and product specifications. |
REC207-2891 | 21 - Role of Commonwealth Government | Cease or reduce the Ionospheric Prediction Service or offer it as a commercial service. |
Rec-ID | Code | Recommendation |
---|---|---|
REC205-1899 | 24 - Govt responsibility | Local governments’ uncertainty about their legal liability is a barrier to effective climate change adaptation. State governments should clarify the legal liability of councils with respect to climate change adaptation matters and the processes required to manage that liability. |
REC205-1904 | 24 - Govt responsibility | State and territory taxes and levies on general insurance constitute a barrier to effective adaptation to climate change. State and territory governments should phase out these taxes and replace them with less distortionary taxes. |
REC205-1898 | 24 - Govt responsibility | To help clarify roles and responsibilities of local government for climate change adaptation, the state and Northern Territory governments should publish and maintain a comprehensive list of laws that delegate regulatory roles to local governments. This would assist both state and local governments to assess whether local governments have the capacity to discharge their roles effectively. |
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: |
REC205-1897 | 9 - Community education | The Australian Government initiative to improve the coordination and dissemination of flood-risk information should proceed in the most cost-effective way, be regularly updated and be expanded over time to encompass other natural hazards. Guidelines to improve the quality and consistency of risk information should also be regularly updated and take climate change into account where feasible. |
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: |
REC205-1896 | 24 - Govt responsibility | Australian governments should implement policies that help the community deal with the current climate by improving the flexibility of the economy. This would also build adaptive capacity to deal with future climate change. This includes reforms to: |
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: |
REC205-1895 | 32 - Doctrine, standards, and reform | Reforms to address barriers to effective climate change adaptation should be assessed on a case-by-case basis to determine whether they are likely to deliver net benefits to the community. This should include consideration of any risks to their implementation. |
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 |
---|---|---|
REC189-2908 | 21 - Role of Commonwealth Government | To ensure that NOPSEMA is in a strong position to perform its functions effectively: |
REC189-2906 | 21 - Role of Commonwealth Government | In order to improve the effectiveness of National Offshore Petroleum Safety and Environmental Management Authority (NOPSEMA), with similar benefits for State or Territory regulators, attention should be given to the following actions. |
REC189-2914 | 32 - Doctrine, standards, and reform | The review team recommend that: |
REC189-2913 | 21 - Role of Commonwealth Government | In developing and improving its policies and practices for stakeholder engagement, NOPSA should ensure that: |
REC189-2910 | 21 - Role of Commonwealth Government | NOPSA should: |
REC189-2909 | 32 - Doctrine, standards, and reform | Equipping the regulator with a wider range of compliance tools under the legislation should continue to be a policy priority. The aim should be to enhance the regulator’s capacity to secure compliance in an appropriately graduated way. The opportunity should be taken to ensure that the regulator and inspectors can, in appropriate cases, bring proceedings that do not require referral to the Commonwealth Director of Public Prosecutions, such as actions for civil penalties or injunctions. |
Rec-ID | Code | Recommendation |
---|---|---|
REC177-3359 | 32 - Doctrine, standards, and reform | The National Plan should be reviewed to clarify the arrangements to apply in Commonwealth waters regarding key roles and responsibilities, including in relation to the ESC, in the event of an oil spill. This should also address any necessary training required. |
REC177-3378 | 25 - Inquiry, audit, lessons management and after action review | In view of the numerous well integrity problems in all of the Montara Oilfield wells, the Minister should commission a detailed audit of all the other offshore wells operated by PTTEPAA to determine whether they too may suffer from well integrity problems. |
REC177-3275 | 32 - Doctrine, standards, and reform | Well Operations Management Plan (WOMPs) submitted by licensees to the regulator(s) should continue to be the primary framework document for achieving well integrity. |
REC177-3300 | 32 - Doctrine, standards, and reform | Licensees and rig operators should install an additional barrier whenever (i) there is any real doubt as to the integrity of any barrier; (ii) whenever the risk of flow from a reservoir increases materially in the course of operations; and (iii) where the consequences of a blowout are grave (for example, for reef systems or shorelines). |
REC177-3302 | 32 - Doctrine, standards, and reform | Industry, regulators, and training/research institutions should develop standards that address best practices for cementing operations (including liaising, as appropriate, with overseas regulators) with a view to overcoming problems which can effect the integrity of cemented casing shoes, annulus and cement plugs. |
REC177-3322 | 32 - Doctrine, standards, and reform | Batched drilling operations should only be undertaken after careful assessment of the special risks which such operations give rise to; well control must be maintained during the course of batched drilling operations. |
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. |
REC177-3349 | 21 - Role of Commonwealth Government | In the meantime, the Minister should: |
REC177-3366 | 32 - Doctrine, standards, and reform | The National Plan should be reviewed: |
REC177-3284 | 32 - Doctrine, standards, and reform | Memoranda of Agreement should be entered into between operators in relation to provision of emergency assistance in the event of blowouts. |
REC177-3309 | 32 - Doctrine, standards, and reform | If performance of barrier installation is outsourced by a licensee, the contractor (for example, the cementing company) should be engaged on terms which clearly require the provision of expert advisory services by the contractor with respect to barrier integrity. |
REC177-3327 | 32 - Doctrine, standards, and reform | Information relevant to well control must be captured and communicated within and between licensees and rig operators (and relevant third party contractors), in a manner which ensures it comes to the attention of relevant personnel. In particular, protocols should be developed to ensure that changes in shift and hitch do not operate as communication barriers. |
REC177-3354 | 32 - Doctrine, standards, and reform | NOPSA develop a policy of engagement with operators so as to enable experts (including safety experts) to canvas all available options for well control in the event of a blowout. |
REC177-3372 | 21 - Role of Commonwealth Government | OSCPs should be endorsed by AMSA prior to regulatory approval to ensure that they align with the National Plan. Once field operations commence, the capability of operators should be assessed against their plans, and exercises conducted to ensure the plans remain effective. |
REC177-3290 | 38 - Agency/Department Reporting | The successful installation of every barrier should be the subject of written verification within and between licensees and rig operators; and should be the subject of explicit reporting to the relevant regulator(s). |
REC177-3315 | 32 - Doctrine, standards, and reform | PCCCs should be installed in a timely manner (for example, to prevent corrosion in the MLS apparatus). Non‐installation in order to park a BOP is not acceptable. |
REC177-3377 | 32 - Doctrine, standards, and reform | The Minister consider legislative amendments to the OPGGS Act which make clear that |
REC177-3274 | 21 - Role of Commonwealth Government | The Minister should appoint a senior policy adviser to investigate and report on the best means to implement the recommendations contained in this Chapter 3 of this report. |
REC177-3298 | 32 - Doctrine, standards, and reform | Reliance upon one barrier against a blowout must not take place except with the prior written approval of the relevant regulator and then only in a true emergency situation (see below). |
REC177-3320 | 32 - Doctrine, standards, and reform | Any pro‐formas used by licensees, rig operators and contractors for recording information about installation of barriers should explicitly provide for ‘exception reporting’, that is, the form should include provision for recording any unforseen or untoward events which occur in the course of installation. |
REC177-3343 | 32 - Doctrine, standards, and reform | The OPGGS Act should be amended to allow for a power to suspend a petroleum production licence (in addition to the current power to cancel a licence or suspend its conditions). |
REC177-3363 | 32 - Doctrine, standards, and reform | DEWHA, in concert with AMSA and with expert input, should develop ‘off the shelf’ monitoring programs that can be speedily implemented following incidents in Commonwealth waters. In this context, the utility of the current Scientific Monitoring program should be peer reviewed to inform future policy. |
REC177-3283 | 32 - Doctrine, standards, and reform | A separate, identifiable barrier manual should be agreed upon and used by licensees, rig operators, and cementing contractors. These manuals should set out best industry practice in relation to achieving and maintaining well integrity. They should describe barrier types, barrier standards, general principles of well integrity, testing and verification methods and technologies, standard operating procedures (including procedures for the capture and communication of relevant information within and between relevant stakeholder entities). Barrier manuals should address blowout control during drilling, completion, re‐entry, tie‐back of casing strings and so on. Barrier manuals should be the subject of expert external review, and should be regularly updated. |
REC177-3308 | 32 - Doctrine, standards, and reform | Volumes of cement used in connection with barrier installation should be calculated with the assistance of a pro‐forma which records all relevant baseline data, which should be verified by onshore personnel. |
REC177-3326 | 32 - Doctrine, standards, and reform | Prior to commencement of drilling operations, senior representatives of the licensee and rig operator should exchange certificates to the effect that their respective key personnel and contractors have been informed in writing of agreed well control arrangements. |
REC177-3353 | 32 - Doctrine, standards, and reform | The regulatory regime should also impose an obligation on an operator to ascertain the availability, and provide details to the regulator, of any potential relief well rigs, prior to the commencement of drilling operations (including prior to each phase of a drilling operation where applicable). |
REC177-3371 | 21 - Role of Commonwealth Government | The Government should examine the scope for a single environment plan to meet the regulatory requirements of both the OPGGS Act and the EPBC Act. This could possibly be achieved by way of bilateral agreements and accreditation arrangements and/or legislative amendment. |
REC177-3289 | 39 - Disaster Risk Management | The use/type of barriers (including any change requests relating thereto) must be the subject of consultation between licensees and rig operators prior to installation. A proper risk assessment should be carried out, agreed upon, and documented in writing before installation. Joint written certification as to the appropriateness of the use of particular barriers should take place before installation. Senior onshore representatives of stakeholder entities should be involved in that certification process. |
REC177-3314 | 32 - Doctrine, standards, and reform | Secondary barriers (including PCCCs) should only be installed, tested, and removed with a BOP in place unless a documented risk assessment indicates that well control can be maintained at all times. |
REC177-3335 | 32 - Doctrine, standards, and reform | Licensees, rig operators and relevant third party contractors should develop well control competency standards for key personnel in other entities involved in well control operations. |
REC177-3358 | 21 - Role of Commonwealth Government | The body established to undertake a central coordination and facilitation role in the event of any future blowout in Commonwealth waters should undertake to make all relevant information publically available from one, authoritative and easy to access source. |
REC177-3376 | 21 - Role of Commonwealth Government | In carrying out a review of PTTEPAA’s permit and licence, the Minister should have regard to this Report, particularly (i) the adverse findings set out in this Chapter; and (ii) the extent to which PTTEPAA has implemented the Action Plan submitted to the Inquiry, or otherwise addressed the matters canvassed in this Report. |
REC177-3297 | 32 - Doctrine, standards, and reform | A minimum of two barriers should be in place at all times (including during batched operations) whenever it is reasonably practicable to do so. |
REC177-3319 | 32 - Doctrine, standards, and reform | Drilling programs dealing with barrier installation should incorporate relevant aspects of manufacturer’s instructions. |
REC177-3342 | 32 - Doctrine, standards, and reform | Written (rather than verbal) approval from the DA (or new regulator) should be obtained before the commencement of well activities that lead to a physical change of a wellbore, other than in a true emergency situation (requiring amendment to regulation 17 of the Management of Well Operations Regulations). |
REC177-3362 | 32 - Doctrine, standards, and reform | Procedures for the approval of development projects should ensure that conditions of approval are comprehensive and clearly set out the obligations of their proponents in relation to environmental matters (including expected monitoring and remediation obligations). |
REC177-3280 | 32 - Doctrine, standards, and reform | Well construction and management plans should include provision for an independent compliance review of well integrity (i) in the event of stipulated triggers; and (ii) at least once in the period between perceived achievement of well integrity and production. The independent compliance review should be undertaken by an expert who is not involved in the day‐to‐day drilling operations. Reviews should be completed in sufficient time to enable results to be implemented in a meaningful manner. |
REC177-3307 | 32 - Doctrine, standards, and reform | Any indication of a compromised cemented shoe which cannot be resolved with a high measure of confidence should result in the installation of additional well control barrier(s). |
REC177-3325 | 32 - Doctrine, standards, and reform | Relevant personnel from licensees and rig operators should meet face to face to agree on, and document, well control issues/arrangements prior to commencement of drilling operations. Well control should be regarded as a so‐called SIMOP to signify its critical importance to both licensees and rig operators, and to ensure that they each take responsibility for achievement and maintenance of well control. |
REC177-3348 | 21 - Role of Commonwealth Government | Responsibility for well integrity should be moved to NOPSA (as also proposed by the Productivity Commission). |
REC177-3352 | 32 - Doctrine, standards, and reform | The regulator, rather than the responsible Minister, should be given the power to direct an operator to use a particular rig for the purpose of well control operations, if appropriate in the circumstances, and the power should be used in the future if that rig is the best option available. This would necessarily involve the operator fully compensating for the use of the rig and any other associated costs. The Inquiry suggests that this power could be invoked and given effect as a condition of an operator’s licence. |
REC177-3370 | 32 - Doctrine, standards, and reform | Environment plans and OSCPs should be made publicly available as a condition of approval of proposals under the OPGGS Act, and should clearly set out Scientific Monitoring requirements in the event of an oil spill. |
REC177-3287 | 38 - Agency/Department Reporting | Licensees should be subject to an express obligation to inform regulators of problems which arise in the course of installing barriers, even if they consider that well integrity is not thereby compromised. The information should be provided by way of special report, rather than included in a standard reporting document (such as a DDR). The information provided should include risk assessment details. |
REC177-3313 | 32 - Doctrine, standards, and reform | Barriers should not be installed or removed off‐line. The derrick should be located over a well at the time of removal and installation of any barrier. This will enable more decisive action to be taken in the event a problem arises. |
REC177-3334 | 32 - Doctrine, standards, and reform | Licensees, rig operators, and relevant third party contractors should develop well control competency standards for their key personnel. Wherever possible, the competencies of key personnel should be benchmarked against their roles and responsibilities. |
REC177-3357 | 21 - Role of Commonwealth Government | In any future similar blowout or offshore emergency situation, the Minister appoint (through either a NOPR or the relevant Department) a senior public servant to establish and oversight a central coordinating body that will facilitate interaction between regulators, industry, AMSA and the owner/operator. Primary responsibility for stopping a blowout should remain with the owner/operator but should be subject to direction from the central coordinating body in consultation with stakeholders (including the owner/operator). |
REC177-3375 | 21 - Role of Commonwealth Government | For the purposes of that review, the Minister should issue a ‘show cause’ notice to PTTEPAA under s 276 of the OPGGS Act. |
REC177-3296 | 32 - Doctrine, standards, and reform | Use of single strings of intermediate casing to penetrate hydrocarbon bearing zones should be carefully risk assessed. Multiple strings of intermediate casing have the advantage of isolating lost circulation zones and sealing off anomalous pressure zones. If intermediate casing is set in a hydrocarbon zone it should be treated as production casing. |
REC177-3318 | 32 - Doctrine, standards, and reform | Manufacturers should be consulted about how to address non‐routine operational problems affecting their well control equipment. |
REC177-3341 | 32 - Doctrine, standards, and reform | The definition of ‘good oilfield practice’ in the OPGGS Act is unduly narrow. The current definition is incapable of application except where things ‘are generally accepted as good and safe’. The definition should be amended such that ‘good oilfield practice includes…’. |
REC177-3361 | 32 - Doctrine, standards, and reform | The National Plan should be revised to ensure that it fully comprehends environmental matters and that it recognises the importance of the prompt implementation of Scientific Monitoring to facilitate the assessment of the environmental impacts of an incident. |
REC177-3277 | 32 - Doctrine, standards, and reform | The concept of ‘good oilfield practice’ should be supplemented by the requirement to incorporate into WOMPs non‐exhaustive minimum compliance standards in relation to well control: for example, stipulations as to when BOPs and/or well control systems must be in place and when they can be removed and minimum barrier requirements (a number of other factors that should be stipulated are outlined in other recommendations below). |
REC177-3306 | 32 - Doctrine, standards, and reform | It should be standard industry practice to re‐test a cemented casing shoe (that is, after WOC) whenever the plugs do not bump or the float valves apparently fail. Standard industry practice should require consideration of other tests in addition to a repeat pressure test. |
REC177-3324 | 32 - Doctrine, standards, and reform | The mere fact that the rig is over the platform should not be regarded by licensees or regulators as sufficient justification for reliance on only one barrier. The default position should be that producible wells are shut‐in when a rig is moved on and off a platform, or when a drilling unit is moved between wells on a platform. |
REC177-3347 | 21 - Role of Commonwealth Government | The proposal of the Productivity Commission’s Research Report (Review of Regulatory Burden on the Upstream Petroleum (Oil and Gas) Sector, April 2009) to establish a NOPR should be pursued at a minimum. |
REC177-3351 | 21 - Role of Commonwealth Government | In the future, and in the interests of ensuring that all possible well control options are comprehensively pursued to exhaustion, decisions as to well control response options should be the result of collaboration between the regulator and the operator rather than leaving one party to make unilateral judgements as to the appropriateness of various well control operations. The regulator should provide transparent and contemporaneous explanations to the public of all well control options under consideration at any particular time. |
REC177-3368 | 32 - Doctrine, standards, and reform | The regulatory framework should provide that in respect of all activities in Commonwealth waters: |
REC177-3286 | 39 - Disaster Risk Management | Problems which arise in the course of installing barriers must be the subject of consultation between licensees, rig operators, and contractors (if used). A proper risk assessment should then be carried out and remedial steps (including further testing/verification) should be agreed upon, and documented in writing before the performance of remedial work whenever practicable. Joint written certification as to resolution of the problem should take place before resumption of drilling operations. Senior onshore representatives of stakeholder entities should be involved in that certification process. |
REC177-3312 | 32 - Doctrine, standards, and reform | The BOP and rig should not move from a well until barrier integrity has been verified. |
REC177-3330 | 39 - Disaster Risk Management | Decision‐making about well control issues should be professionalised. Industry participants must recognise that decision‐makers owe independent duties to the public, not just their employer or principal, in relation to well control. Risk management in the context of well control needs to be understood as an ethical/professional duty. Self‐regulation contemplates self‐regulation by the industry, not just by individual licensees and operators. |
REC177-3356 | 39 - Disaster Risk Management | The regulator should pre‐assess and review in a generic sense, and in conjunction with the offshore petroleum industry, available options for well control in the event of a blowout. Being ‘match fit’ in this sense will enable a quicker and more effective response in terms of safety assessment, and will ensure that expectations of both operator and regulator are more readily aligned. |
REC177-3374 | 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. |
REC177-3292 | 32 - Doctrine, standards, and reform | Licensees should be subject to an express obligation to inform regulators of the proposed removal of a barrier, even if they consider that well integrity is not thereby compromised. The information should be provided by way of special report, rather than included in a standard reporting document (such as a DDR). The information provided should include risk assessment details. Removal of a barrier should not take place without prior written approval of the relevant regulator(s). |
REC177-3317 | 32 - Doctrine, standards, and reform | Any equipment (including PCCCs) used as, or to install, a barrier should be manufactured for that purpose and be generally recognised as fit for purpose. If equipment is designed in‐house by a licensee or rig operator it should not be approved for use unless and until it is subjected to expert external analysis. |
REC177-3340 | 32 - Doctrine, standards, and reform | To better ensure that ‘risks’ are identified and managed in accordance with sound engineering principles and good oilfield practice, it is recommended that regulation 25(1)(a)(i) and (2)(a)(i) of the Management of Well Operations Regulations, be reworded as follows: ‘A titleholder must not commence / continue a well activity if…a well integrity hazard exists in relation to the well’. |
REC177-3360 | 42 - Culture and Heritage | DEWHA should participate in training programs and exercises relevant to an oil spill in the marine environment. |
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. |
REC177-3276 | 32 - Doctrine, standards, and reform | WOMPs should be comprehensive and freestanding, rather than an overarching document cross‐referencing many other documents (although the Inquiry also recommends a freestanding well control manual; this should be a guide to rig and onshore personnel on good oilfield practice). |
REC177-3301 | 32 - Doctrine, standards, and reform | The industry standard of two barriers should be replaced with the concept of ‘two or more barriers’ as a minimum standard. A minimum standard when operations proceed normally should never be regarded as a sufficient standard in other circumstances. |
REC177-3305 | 32 - Doctrine, standards, and reform | Cement integrity should be evaluated wherever practicable by way of cement evaluation tests, rather than relying on pre‐operational calculations of cement and displacement fluid volumes. |
REC177-3323 | 32 - Doctrine, standards, and reform | Where multiple wells are drilled, operations and occurrences at one well must be carefully assessed for any implications with respect to well control at other wells. |
REC177-3346 | 21 - Role of Commonwealth Government | A single, independent regulatory body should be created, looking after safety as a primary objective, well integrity and environmental approvals. Industry policy and resource development and promotion activities should reside in government departments and not with the regulatory agency. The regulatory agency should be empowered (if that is necessary) to pass relevant petroleum information to government departments to assist them to perform the policy roles. |
REC177-3350 | 32 - Doctrine, standards, and reform | The recommendations of the Inquiry in relation to suitable ways of achieving well integrity contained in Chapter 3 be included in a guidance manual that is issued for the assistance of industry and regulators. |
REC177-3367 | 32 - Doctrine, standards, and reform | Procedures and accountabilities should be established to ensure, in the event of a future incident, that: |
REC177-3285 | 39 - Disaster Risk Management | Pre‐drilling assessments should include a risk assessment of the worst‐case blowout scenario. |
REC177-3311 | 32 - Doctrine, standards, and reform | Horizontal or high angle penetration of a reservoir should be avoided wherever practicable until such time as the apparent problems associated with the cementing of a casing shoe in these situations are satisfactorily overcome. If a casing string does penetrate a well horizontally or at a high angle, standard practice should be to install two secondary barriers in addition to the cemented casing shoe. |
REC177-3328 | 32 - Doctrine, standards, and reform | All communications between on‐rig and onshore personnel relating to well control should be documented in a timely manner. |
REC177-3355 | 32 - Doctrine, standards, and reform | The Inquiry also supports Bills and Agostini’s recommendation: ‘…in relation to safety case development and compliance overall, that NOPSA revise its approach to interacting with operators prior to the safety case assessment process and subsequently direct more resources into its advisory functions. We further recommend that NOPSA develop and implement a formal plan for supporting and guiding each operator prior to safety case acceptance, as well as for ongoing compliance with that safety case, recognising the unique experience, capabilities and assessed risk of that operator. Each plan needs to include advice, education and liaison meetings with the operators. The plan needs to be continuously reviewed and reassessed based on the latest information, including the interaction with the operator’. |
REC177-3373 | 32 - Doctrine, standards, and reform | Arrangements should be developed to minimise duplication between the EPBC Act and the OPGSS Act Environment Regulation. |
REC177-3291 | 39 - Disaster Risk Management | Removal of a barrier must be the subject of consultation between licensees and rig operators prior to removal. A proper risk assessment should be carried out and agreed upon, and documented in writing before removal. Joint written certification as to the appropriateness of removal should take place before removal. Senior onshore representatives of stakeholder entities should be involved in that certification process. |
REC177-3316 | 32 - Doctrine, standards, and reform | Wells should be re‐entered with a BOP in place unless a documented risk assessment indicates that well control can be maintained at all times. |
REC177-3339 | 32 - Doctrine, standards, and reform | The Inquiry supports the objective (rather than prescriptive) approach to regulation now followed in Australia. However, the pendulum has swung too far away from prescriptive standards. In some areas relating to well integrity there needs to be minimum standards. |
Rec-ID | Code | Recommendation |
---|---|---|
REC165-0092 | 32 - Doctrine, standards, and reform | Executive Officers to DDCs be serving Police Officers. Regional and Area officers of EMQ be members of Local and District Disaster Management Groups to enable them to fulfil their Statewide support and governance roles. |
REC165-0078 | 32 - Doctrine, standards, and reform | The basic tenet of a local community response as the foundation of Queensland's Disaster Management framework, with a clear description of the relationships between the levels and description of the phases of Disaster Management, needs to be more strongly emphasised in the "objects" of the legislation and "how objects are to be achieved". |
REC165-0080 | 32 - Doctrine, standards, and reform | The State Disaster Management Plan incorporate linkages with all Lead Agencies and officers in control of National Plan or Agreement response. All of these Plans and Agreements should have a formal requirement to ensure officers in charge work within the State's Disaster Management framework to deliver Disaster Management responses. |
REC165-0099 | 32 - Doctrine, standards, and reform | The suggested summary of legislative changes guide the legislative response to the report incorporating consultation with key stakeholders at State, District and Local levels. |
REC165-0079 | 32 - Doctrine, standards, and reform | The Act be amended (Sections 45, 46, 47) to enable verbal directions in times of disaster responses from a State Controller to DDC to Local Controller, which must be committed to writing promptly to formalise the record. |
REC165-0091 | 32 - Doctrine, standards, and reform | EMQ resources be directed to continually improving, monitoring and regularly evaluating the State's Disaster Management system with a priority focus on providing support to Local Government levels including interlinking exercises involving District and State arrangements. |
REC165-0098 | 24 - Govt responsibility | The SDMG take into account key improvement initiatives and change processes suggested when deciding on an effective implementation strategy for agreed recommendations. |
REC165-0084 | 32 - Doctrine, standards, and reform | The State Disaster Management Group focus on Disaster Management strategy and policy with sub-committees or appropriate levels in the Disaster Management system assigned detailed disaster planning or risk management assessment roles. New group members be provided with an induction briefing about the State's Disaster Management arrangements by the Executive Officer prior to attending their first meeting. |
REC165-0097 | 24 - Govt responsibility | Revised governance arrangements be implemented involving Disaster Management Groups at the three levels supported by EMQ as outlined in this report to achieve continuous improvement in the Disaster Management arrangements in the State. A new provision in Section 5 emphasise the discretion available to all involved in the Disaster Management system to take action to prevent impending loss of life even if contrary to the agreed arrangements. |
REC165-0083 | 32 - Doctrine, standards, and reform | The Chairperson of SDMG (where leadership is not already defined in relevant National Plans) nominate a senior officer to assume overall responsibility for control and coordination of each disaster event to ensure a decisive and effective response. At Local level the Act provide for the CEO in consultation with the LDMC to appoint a public official/s with required training and competence as Local Controller. |
REC165-0094 | 32 - Doctrine, standards, and reform | The Act be amended to make it clear that Disaster Controllers/Coordinators at all levels are to be authorised public officials with the necessary training and authority to properly discharge the role and provide an effective direct line of support, coordination and control of disaster events. The Act and State Plan provide guidance about appropriate role and functions of elected representatives during all disaster event phases. The Major Incidents Group and State Security Committee be merged to become the State Disaster and Security Council with role as suggested in this report. |
REC165-0088 | 32 - Doctrine, standards, and reform | The State Disaster Management Act be strengthened by a description of the phases of Disaster Management with emphasis on the key elements within each phase including the recovery phase; Lead Agencies and nominated leaders in each area of Queensland for each of the four key elements of recovery be identified and provided with the appropriate training and familiarisation of their role to ensure the adequacy of planning at District and Local level throughout Queensland; Lead Agencies be responsible for maintaining strong relationships with counterparts at the Federal Government level to ensure necessary Federal support for State and Local recovery initiatives after disaster events; Response arrangements remain in place until the State Controller is satisfied that recovery leadership arrangements are in place at Local, District and State levels; Recovery leadership and support from State level remain in place until local recovery is substantially completed. |
REC165-0093 | 32 - Doctrine, standards, and reform | The Department of Community Safety (through EMQ) be assigned in the Act with the responsibility to develop, maintain, monitor and continuously improve the State's Disaster Management arrangements and systems. The Executive Director, EMQ, be a member of SDMG with the Director-General, Department of Community Safety. The position of Executive Officer, SDMG, be assigned appropriate support roles to SDMG. An officer other than the Executive Director, EMQ, or the State Controller of a disaster event, perform the role of Executive Officer to the SDMG. A dedicated Assistant Commissioner of Police be assigned the role of control, coordination and overall responsibility for Queensland's response to disaster events other than those subject to National Plans and Agreements. |
Rec-ID | Code | Recommendation |
---|---|---|
REC161-3029 | 32 - Doctrine, standards, and reform | In relation to safety case development and compliance overall, that National Offshore Petroleum Safety Authority revise its approach to interacting with operators prior to the safety case assessment process and subsequently and direct more resources into its advisory functions. We further recommend that National Offshore Petroleum Safety Authority develop and implement a formal plan for supporting and guiding each operator prior to safety case acceptance, as well as for ongoing compliance with that safety case, recognising the unique experience, capabilities and assessed risk of that operator. Each plan needs to include advice, education and liaison meetings with the operators. The plan needs to be continuously reviewed and reassessed based on latest information, including the interaction with the operator. Implementation should be reviewed at a senior level within National Offshore Petroleum Safety Authority. |
REC161-3035 | 24 - Govt responsibility | That Ministerial Council on Mineral and Petroleum Resources liaise with Ministers with environmental and planning responsibilities, and if necessary Council of Australian Governments, to ensure that environmental requirements for oil and gas projects are not imposed subsequent to safety assessments and do not increase the risk of major accident events. |
REC161-3040 | 32 - Doctrine, standards, and reform | We recommend the Commonwealth consider a plain English rewrite of the Navigation Act 1912 with the aim of producing a modern, performance-based Act. |
REC161-3023 | 32 - Doctrine, standards, and reform | That the Commonwealth undertake legislative change that will ensure that when any floating facility reverts to a ‘navigable form’, the relevant provisions of the Navigation Act and the OHSMI Act will apply regardless of any voyage criteria. This will help to ensure that all Australian seafarers are covered. |
REC161-3028 | 24 - Govt responsibility | That Ministerial Council on Mineral and Petroleum Resources continue to support a duty of care safety case regime for best practice offshore petroleum industry regulation augmented to include regulation of integrity. Since the safety case is at the centre of the duty of care co-regulatory regime, we consider that the requirement for the implementation of the safety case at facilities involved in the exploitation of petroleum resources should be provided for within the Offshore Petroleum and Greenhouse Gas Storage Act 2006 itself. |
REC161-3033 | 32 - Doctrine, standards, and reform | That the Commonwealth Petroleum (Submerged Lands) (Management of Safety on Offshore Facilities) Regulations 1996 regulations be amended to explicitly enable assessment of safety culture, leadership, and consideration of operator past history, motivation and current capacity in approvals of safety cases. National Offshore Petroleum Safety Authority should be able to audit against these criteria and challenge operators on these issues. |
REC161-3039 | 32 - Doctrine, standards, and reform | We recommend that AMSA should have a role in assuring continuing marine standards that are not inconsistent with Offshore Petroleum and Greenhouse Gas Storage Act (OPGGS) Act provisions and that AMSA needs defined powers to assist NOPSA in minimising risk in the offshore petroleum industry. Potential mechanisms for achieving this outcome include: providing AMSA with defined powers and obligations under the OPGGS Act, thereby ensuring that the Authority becomes an effective inspector/regulator of vessels while they are deemed to be facilities; or revising the current Commonwealth maritime legislation disapplication provisions of the OPGGS Act with the aim of achieving the same goal. If it can be readily achieved and is an efficient regulatory option, we believe the first option is preferable. |
REC161-3027 | 32 - Doctrine, standards, and reform | That powers should be conferred on National Offshore Petroleum Safety Authority to enable it to effectively regulate safety and integrity for all facilities and pipelines in the water and the WA islands which export gas by pipeline. National Offshore Petroleum Safety Authority’s authority should extend to the nearest valve on the mainland above the shore crossing. |
REC161-3032 | 32 - Doctrine, standards, and reform | That the Offshore Petroleum and Greenhouse Gas Storage Act 2006 and its subsidiary regulations be amended to enable National Offshore Petroleum Safety Authority to have a broader range of graduated compliance tools including the ability to impose a civil fine on an operator per day of non compliance with an improvement or prohibition notice. Legislation should also be considered that would enable National Offshore Petroleum Safety Authority to make public, with appropriate safeguards, specific information concerning its enforcement actions including the name of the operator, the breach, and the enforcement action required including potential penalties. |
REC161-3038 | 32 - Doctrine, standards, and reform | We recommend that the Commonwealth Petroleum (Submerged Lands) (Management of Safety on Offshore Facilities) Regulations (MOSO) be amended to ensure that the safety case for a floating facility specifically identifies when command structure changes occur (which may be well before departing the site and associated zone). We also recommend that the OPGGS Act be amended so that a vessel becomes a facility when any part of it comes within 500 metres of the site and continues to be a facility until no part of the vessel remains within 500 metres of the site. |
REC161-3026 | 32 - Doctrine, standards, and reform | That the Commonwealth consider a plain English rewrite of the Navigation Act 1912 with the aim of producing a modern, performance-based Act. |
REC161-3031 | 32 - Doctrine, standards, and reform | That National Offshore Petroleum Safety Authority develop a robust risk assessment matrix for use in assessing and responding to the changing risk associated with each facility and the operator. Further, we recommend that National Offshore Petroleum Safety Authority increase auditing frequency and duration to audit each manned facility on average twice per year (covering each staff swing), but more often if the risk matrix indicates this is necessary; and that audits should average several days actually on major facilities. |
REC161-3037 | 32 - Doctrine, standards, and reform | We recommend that the Commonwealth undertake legislative change that will ensure that when any floating facility reverts to a ‘navigable form’, the relevant provisions of the Navigation Act and the OHSMI Act will apply regardless of any voyage criteria. This will help to ensure that all Australian seafarers are covered. |
REC161-3025 | 32 - Doctrine, standards, and reform | That Australian Maritime Safety Authority should have a role in assuring continuing marine standards that are not inconsistent with Offshore Petroleum and Greenhouse Gas Storage Act 2006 provisions and that Australian Maritime Safety Authority needs defined powers to assist National Offshore Petroleum Safety Authority (NOPSA) in minimising risk in the offshore petroleum industry. Potential mechanisms for achieving this outcome include: providing Australian Maritime Safety Authority with defined powers and obligations under the Offshore Petroleum and Greenhouse Gas Storage Act 2006, thereby ensuring that the Authority becomes an effective inspector/regulator of vessels while they are deemed to be facilities; or revising the current Commonwealth maritime legislation disapplication provisions of the Offshore Petroleum and Greenhouse Gas Storage Act 2006 with the aim of achieving the same goal. If it can be readily achieved and is an efficient regulatory option, we believe the first option is preferable. |
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. |
REC161-3036 | 32 - Doctrine, standards, and reform | That the Commonwealth and States/Northern Territory legislate to establish a properly resourced and empowered independent national safety investigation capacity to investigate serious oil and gas industry (including pipeline) incidents including near miss events that could have led to a major accident event. We further recommend that the regulatory investigatory powers under the Offshore Petroleum and Greenhouse Gas Storage Act 2006 be reviewed in the context of powers for the proposed independent national safety investigator, noting that the regulator must retain those investigatory powers necessary in order to fulfil its legislative functions. |
REC161-3024 | 32 - Doctrine, standards, and reform | That the Commonwealth Petroleum (Submerged Lands) (Management of Safety on Offshore Facilities) Regulations 1996 Regulations be amended to ensure that the safety case for a floating facility specifically identifies when command structure changes occur (which may be well before departing the site and associated zone). We also recommend that the Offshore Petroleum and Greenhouse Gas Storage Act 2006 be amended so that a vessel becomes a facility when any part of it comes within 500 metres of the site and continues to be a facility until no part of the |
Rec-ID | Code | Recommendation |
---|---|---|
REC158-3438 | 32 - Doctrine, standards, and reform | That the port/channel managers coordinate marine emergency management planning in the port and are required to ensure that individual port stakeholder marine emergency management arrangements plans are integrated with the whole of port marine emergency management arrangements. |
REC158-3424 | 32 - Doctrine, standards, and reform | That legislation is prepared by the Department of Transport to ensure marine emergency management arrangements are clarified and provide: |
REC158-3448 | 24 - Govt responsibility | That the Director of Marine Safety works with the Australian Maritime Safety Authority to ensure that State and port emergency arrangements interface appropriately with the National Maritime Emergency Response Arrangements. |
REC158-3429 | 38 - Agency/Department Reporting | That the nominated marine safety authority is required to ensure that incident notification and data recording requirements for Victorian commercial ports are consistent and adhered to. |
REC158-3437 | 32 - Doctrine, standards, and reform | That port/channel managers coordinate marine emergency planning for the port and are required to ensure that marine emergency arrangements are integrated with whole of port emergency management plans. |
REC158-3441 | 32 - Doctrine, standards, and reform | That, where practical, risk assessments, emergency planning, training and exercising are integrated to minimise duplication of effort. |
REC158-3428 | 38 - Agency/Department Reporting | That the nominated marine safety authority, in consultation with the Emergency Services Commissioner and senior emergency services personnel, is responsible for monitoring the implementation and auditing against appropriate performance standards, risk management guidelines and good practice guidelines. |
REC158-3436 | 32 - Doctrine, standards, and reform | That Harbour Masters are the designated principle marine specialists within the port and work directly with emergency services to provide advice and the interface with the marine legislative powers, to manage a marine emergency. |
REC158-3440 | 32 - Doctrine, standards, and reform | That the Water Division Emergency Response Plan is amended, by the Water Division emergency response coordinator, to provide a framework to coordinate a marine response that crosses declared port water boundaries and requires resource coordination and prioritisation. |
REC158-3427 | 32 - Doctrine, standards, and reform | That the standards and guidelines determined by the nominated marine safety authority require port/channel managers to conduct a marine emergency risk assessment using AS/NZ 4360:2004 Risk Management and, in addition, must require port/channel managers to: |
REC158-3454 | 24 - Govt responsibility | That the Department of Transport ensures that key stakeholders are engaged during the implementation of the approved Review recommendations. |
REC158-3435 | 32 - Doctrine, standards, and reform | That Harbour Masters have the appropriate powers, authority, accountability, skills, responsibility and indemnity to provide a coordinated response of marine resources in support of emergency services, except where the nominated marine safety authority is the control agency for a marine pollution or marine casualty emergency. |
REC158-3439 | 32 - Doctrine, standards, and reform | That the port marine emergency management arrangements are integrated with the Victorian Water Division Emergency Response Plan. |
REC158-3426 | 32 - Doctrine, standards, and reform | That the nominated marine safety authority, in consultation with the Emergency Services Commissioner, senior emergency services personnel and relevant port stakeholders, is responsible for establishing appropriate performance standards, risk management guidelines and good practice guidelines for marine emergency management. |
REC158-3453 | 32 - Doctrine, standards, and reform | That, where applicable, consideration is given to legislative amendment that will enable the findings of this report to be applied to areas inside State waters but outside commercial port waters. |
REC158-3434 | 32 - Doctrine, standards, and reform | That the accountability relationship between Harbour Masters and the Director of Marine Safety is strengthened in the relevant legislation. |
REC158-3425 | 32 - Doctrine, standards, and reform | Consequential or complementary amendments to the Emergency Management Act are required to ensure that: |
REC158-3452 | 25 - Inquiry, audit, lessons management and after action review | That the nominated marine safety authority undertakes a further assessment to determine the recommendations from this Review that may also be applicable to State waters outside commercial port waters. |
REC158-3433 | 24 - Govt responsibility | That Harbour Masters are employed by a government body and remain geographically located at the port. |
Rec-ID | Code | Recommendation |
---|---|---|
REC152-3405 | 32 - Doctrine, standards, and reform | Clarity of Role with regard to legislative and policy requirements |
Rec-ID | Code | Recommendation |
---|---|---|
REC151-3070 | 32 - Doctrine, standards, and reform | Crown law opinion be obtained to determine whether additional functions now undertaken by the Commission following the devolvement of the functions of the Security and Emergency Management Office (SEMO) require an amendment to the FES Act. |
REC151-3091 | 32 - Doctrine, standards, and reform | Regulation 48 regarding prescribed offences be amended to include Section 79(2)(e) or its equivalent under the amendment proposed in Recommendation 22 above. |
REC151-3111 | 32 - Doctrine, standards, and reform | Crown law opinion be obtained as to what amendments, if necessary or appropriate, are required to satisfy Recommendation 29.9(7) of the Wangary Coronial Inquest, that a dedicated bushfire prevention officer be appointed. |
REC151-3075 | 32 - Doctrine, standards, and reform | Section 92 include the facility to issue a warrant for the relevant authority to break into land or buildings for the purposes of determining what measures have been taken for the prevention, control or suppression of fire or for the prevention of, or for dealing with, the escape of hazardous materials; and that costs and expenses in doing so are recoverable. |
REC151-3095 | 24 - Govt responsibility | SAFECOM re-evaluate and determine a more meaningful definition of fire districts. |
REC151-3085 | 32 - Doctrine, standards, and reform | With the implementation of the Ministerial Review of Bushfire Management in South Australia, consideration should be given to provisions within Part 4, Division 7 of the principal FES Act which would be more appropriately placed in the Regulations. |
REC151-3102 | 32 - Doctrine, standards, and reform | Regulations 22 and 62 be reviewed to ensure reports regarding conduct must be relevant to the enquiry. |
REC151-3069 | 32 - Doctrine, standards, and reform | Consistent with the requirement for Emergency Service Organisations, the FES Act be amended to require South Australian Fire and Emergency Commission (SAFECOM) to submit a workforce plan to the Board. |
REC151-3090 | 32 - Doctrine, standards, and reform | Following the amendment to Section 79 as proposed above in Recommendation 22, a definition of, ‘properly constructed fire place’ and ‘properly constructed incinerator’ be included in the new Regulation. |
REC151-3110 | 32 - Doctrine, standards, and reform | Further to Recommendations 11 and 12 above concerning the joining of Sections 56 and 83 of the FES Act, that these existing provisions be examined to determine whether they provide sufficient authority to address Recommendation 29.9(4) of the Wangary Coronial Inquest so as to require the owners or occupiers of rural land to create fire breaks and/or the removal of flammable materials from the land, as measures for preventing the outbreak of a bushfire, or for preventing the spread or extension of a bushfire. |
REC151-3074 | 32 - Doctrine, standards, and reform | Sections 56 and 83 (amended as suggested above) include the facility to issue a warrant for the relevant authority to break into land or buildings to carry out requirements regarding flammable undergrowth or material; and that costs and expenses in doing so are recoverable. |
REC151-3094 | 32 - Doctrine, standards, and reform | Where in the FES Act reference is made to ‘South Australian Volunteer Fire-Brigades Association’ this be removed and replaced with, ‘Country Fire Service Volunteers Association’. |
REC151-3084 | 32 - Doctrine, standards, and reform | Section 79(1) – provisions relating to lighting or maintaining a fire in the open air during the fire danger season be retained in the principal FES Act; Section 79(2) be amended to provide that a fire may be lit or maintained in accordance with the Regulations; provisions specifying the conditions under which a fire can be lit or maintained, and currently under Section 79(2), be placed in the Regulations. |
REC151-3101 | 32 - Doctrine, standards, and reform | Divisions and Subdivisions and Regulations 22 and 62 headings relating to conduct and discipline be changed to have similar wording and should include, “Conduct, Discipline and Grievance Procedures for Members”. |
REC151-3068 | 32 - Doctrine, standards, and reform | The FES Act be amended so as to allow the Chief Executive (CE) to manage the Commission (SAFECOM) Office by removing provisions relative to the SAFECOM Board’s managerial and administrative oversight of the Commission. |
REC151-3089 | 32 - Doctrine, standards, and reform | The definition of ‘officer’ in Section 3 be amended to include reference to the designation being made by the Chief Officer. |
REC151-3106 | 32 - Doctrine, standards, and reform | A schedule for revocation of permits be included in the Regulations. |
REC151-3073 | 32 - Doctrine, standards, and reform | Sections 56 and 83 be repealed and replaced with a single section which unifies their provisions. |
REC151-3094 | 32 - Doctrine, standards, and reform | Where in the FES Act reference is made to ‘South Australian Volunteer Fire-Brigades Association’ this be removed and replaced with, ‘Country Fire Service Volunteers Association’. |
REC151-3082 | 32 - Doctrine, standards, and reform | The Regulations be amended to include appropriate references to the Unit Managers Advisory Group (SASES) consistent with those of the Group Committee (SACFS). |
REC151-3100 | 32 - Doctrine, standards, and reform | Section 70(12) (relating to disciplinary action) be amended to include, where the officer is an employee of a government agency, the Chief Officer shall advise an appropriate representative of the agency prior to any disciplinary action being taken. |
REC151-3065 | 32 - Doctrine, standards, and reform | The FES Act be amended to create the position which currently has the working title of ‘Commissioner of Fire and Emergencies’ to replace the position of CE and that the FES Act be amended in places where this position is mentioned. |
REC151-3088 | 32 - Doctrine, standards, and reform | Sections 68 and 116 – provisions relating to the establishment/dissolution of SACFS Brigades and SASES Units be amended so as to retain the head of power in the principal FES Act and that the procedural provisions within each of these sections be placed in the Regulations. |
REC151-3105 | 32 - Doctrine, standards, and reform | With the implementation of the Ministerial Review of Bushfire Management in South Australia, the provisions in Sections 84 and 85 be reviewed in terms of enforcing hazard reduction on council or Crown land. |
REC151-3072 | 32 - Doctrine, standards, and reform | Provisions in the FES Act relating to, “land management principles” be reviewed in consultation with appropriate agencies and having due regard to the recommendations of the Wangary Coronial Inquest. |
REC151-3093 | 32 - Doctrine, standards, and reform | Where in the FES Act reference is made to, ‘an officer of the National Parks and Wildlife Service’ this be removed and replaced with, ‘an officer of the Department for Environment and Heritage’. |
REC151-3081 | 32 - Doctrine, standards, and reform | So as to increase the pool of volunteers from which the Minister can appoint Advisory Board members, Section 18(3)(c) and (d) be amended to include nominations from the Group Committee (SACFS) and Unit Managers Advisory Group (SASES). |
REC151-3097 | 32 - Doctrine, standards, and reform | Regulation 8(4)(b) be amended to allow persons of or above 16 years of age to register as fire-fighters. |
REC151-3064 | 32 - Doctrine, standards, and reform | The FES Act be amended to include a definition of ‘operations’ and/or ‘operational’. |
REC151-3087 | 32 - Doctrine, standards, and reform | Section 90 – provisions relating to smoking, and throwing burning material be removed from the principal FES Act and placed in the Regulations. |
REC151-3104 | 32 - Doctrine, standards, and reform | SAFECOM in consultation with SAMFS consider the merits of amending Sections 49- 51 to replace the right to appeal from the District Court to the South Australian Industrial Relations Commission. |
REC151-3071 | 24 - Govt responsibility | The comprehensive prevention, preparedness, response and recovery (PPRR) approach to the management of bushfires as recommended by the Ministerial Review of Bushfire Management in South Australia is supported: its implementation should consider issues raised by councils and should also be considerate of the recommendations of the Wangary Coronial Inquest. |
REC151-3092 | 19 - Offences | Expiation fees be reviewed so as to be consistent with the seriousness of the offences. |
REC151-3076 | 32 - Doctrine, standards, and reform | Provisions in Section 11(1)(e)(i) and (ii) relating to appointments of volunteer associations to the SAFECOM Board be removed. |
REC151-3096 | 32 - Doctrine, standards, and reform | All Regulations relating to constitutions be deleted; the FES Act be amended to allow the Chief Officers to prescribe the constitution; and the process for the management of a SACFS brigade/group and a SASES unit to be in the form of an administrative instruction. |
REC151-3063 | 32 - Doctrine, standards, and reform | The preamble of the Fire and Emergency Services (FES) Act be amended to include a stronger emphasis on the strategic and policy purposes of the Commission, highlighting its key role in the governance of the emergency services sector. |
REC151-3086 | 32 - Doctrine, standards, and reform | Section 88 – requirement to carry fire extinguishers in a caravan be removed from the principal FES Act and placed in the Regulations. |
REC151-3103 | 32 - Doctrine, standards, and reform | Provisions be included in the Regulations for mediation in appropriate circumstances. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC149-3141 | 32 - Doctrine, standards, and reform | NOPSA should complete the next revision of Safety Case guidelines in consultation and agreement with stakeholders and continue its program to achieve consistency with a firmer hand from the CEO and management. |
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. |
REC149-3140 | 32 - Doctrine, standards, and reform | The industry should provide advice to NOPSA on where the regulations do not provide sufficient clarity and consider developing broad policy/process guidelines in consultation with the regulator to provide clarity and consistency. Regulators should not take personal views or preferences. |
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. |
REC149-3139 | 39 - Disaster Risk Management | The industry should develop in conjunction with the Regulator a process for addressing the need to maintain the risk profile of a facility moving into extended life operation at the same risk profile as when it was within design life. |
REC149-3145 | 25 - Inquiry, audit, lessons management and after action review | NOPSA should consider an audit regime that targets Greenfields operations at commencement of operations. |
REC149-3130 | 32 - Doctrine, standards, and reform | The regulations pertaining to vessels of opportunity or their interpretation should be changed to facilitate a risk based approach to regulation. This approach will be consistent with the approach taken in other jurisdictions. |
REC149-3138 | 38 - Agency/Department Reporting | The current KPI measures used by the Regulator and industry need to be reassessed and the performance indicators need to be related to the risk profiles of the industry. The industry needs to develop the indicators, which need to be agreed and measured by the industry in discussion with other stakeholders. The KPI's selected should be published in comparison with the worldwide offshore industry and with other industries. NOPSA should continue discussions with Australian Safety and Compensation Council (ASCC) with a view to adopting their goals. |
REC149-3143 | 21 - Role of Commonwealth Government | The role of the advisory Board, namely to give advice to Ministers and NOPSA when asked, should be made clear to Board members and all stakeholders. The Board and NOPSA should consider the need for a clear description of who does what based on the legislated responsibilities of the NOPSA CEO. |
REC149-3129 | 32 - Doctrine, standards, and reform | The consequences of the disapplication of the Navigation Act 1912 should be analysed, the actual consequences identified and unintended consequences addressed. |
REC149-3134 | 32 - Doctrine, standards, and reform | Improved and agreed guidelines for Safety Case application and assessment, including suggested structure and content, would alleviate many current problems related to Safety Case processes. |
REC149-3142 | 19 - Offences | NOPSA should use encouragement as the primary tool of enforcing compliance provided willingness to improve is exhibited by the players. |
Rec-ID | Code | Recommendation |
---|---|---|
REC140-3572 | 32 - Doctrine, standards, and reform | A DHHS website be developed to list policies, procedures and guidelines relevant to critical care retrieval including the NETS policies. |
REC140-3575 | 24 - Govt responsibility | The preferred model for the Tasmanian Medical Retrieval Services is to have TMRS and NETS staff based in RHH. The fixed wing would remain based in Launceston (for the present) with the helicopter to remain based in Hobart. |
REC140-3574 | 38 - Agency/Department Reporting | Formation of a subcommittee of the DHHS Tasmanian Medical Retrieval Services Committee to identify risk exposures, system problems and potential solutions. The subcommittee should review data, problem cases, system issues and generate a risk register. Meetings should occur at least quarterly. |
Rec-ID | Code | Recommendation |
---|---|---|
REC123-3879 | 32 - Doctrine, standards, and reform | Melbourne Airport Emergency Planning Committee review the Airport Emergency Plan, to consider the use of alternative locations for staging, evacuation, assembly and incident coordination, to increase separation of emergency operations from non emergency activity be adopted. |
REC123-3878 | 32 - Doctrine, standards, and reform | Melbourne Airport management, the emergency services and airlines develop risk based tactical plans that, where safe and appropriate, allow the staged or progressive closure or re-opening of terminal space to support continuity of airport operations during emergencies. |
REC123-3877 | 25 - Inquiry, audit, lessons management and after action review | All agencies review formal and informal incident notification processes to ensure they support the earliest possible reporting of emergencies to all stakeholders involved in the Airport Emergency Plan and in so doing, ensure early access to specialist advice and support. |
REC123-3882 | 41 - Emergency Management exercises | The Office of the Emergency Services Commissioner convene a working group of key emergency services and emergency management agencies to develop a flow chart based on scenario testing, to support decision making and the assessment of response requirements to medical, hazardous materials and CBR emergencies including their transition from one type to another. |
REC123-3874 | 32 - Doctrine, standards, and reform | Melbourne Airport Emergency Planning Committee review the Airport Emergency Plan to confirm that planning and response arrangements appropriately consider the protection of public safety, the current security environment and the timely restoration of airport operations, and that it is consistent with state emergency response planning arrangements. |
REC123-3881 | 32 - Doctrine, standards, and reform | Reference to the Aviation Rescue and Fire Fighting service in Part 6 of the Emergency Management Manual Victoria, table of control and support agencies, be extended to include its responsibility for hazardous materials emergencies at the airport. |
REC123-3880 | 32 - Doctrine, standards, and reform | Victoria Police, Melbourne Airport management, airlines and emergency services develop a Memorandum of Understanding for media coordination and public communications at Melbourne Airport that documents the responsibility for media coordination during emergencies to Victoria Police. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC121-3698 | 32 - Doctrine, standards, and reform | No RailCorp train should enter into revenue service or remain in service if, in the opinion of the driver in charge of that train, any defect in it creates a risk of injury. |
REC121-3729 | 38 - Agency/Department Reporting | All reports of the Chief Investigator of OTSI should be delivered, upon completion and without being reviewed, to ITSRR and the Minister for Transport Services. |
REC121-3770 | 32 - Doctrine, standards, and reform | A safety management system regulation should be promulgated, specifying the requirements of safety management systems in all accredited organisations, using Annexure I to this report as a guide |
REC121-3655 | 32 - Doctrine, standards, and reform | Procedures should be put in place by RailCorp to ensure that electrical power supply to the area of an accident can be immediately isolated, if necessary, in the event of a rail accident, so as to reduce any risk of exposure of emergency response personnel to injury or harm. |
REC121-3686 | 32 - Doctrine, standards, and reform | The standard in relation to the collection and use of data from data loggers should provide that such information must be accessed in the circumstances of any accident or incident and can be accessed to monitor driver performance generally. |
REC121-3705 | 32 - Doctrine, standards, and reform | The ITSRR should develop standards for periodic medical examinations which include the following: |
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. |
REC121-3775 | 38 - Agency/Department Reporting | The Minister for Transport Services must table in Parliament, each such quarterly report by ITSRR. |
REC121-3662 | 32 - Doctrine, standards, and reform | The rail displan should provide for the site controller to have complete control of the site, with other agencies co-ordinating with and supporting him or her, until the rescue phase of the emergency response has been completed. |
REC121-3692 | 32 - Doctrine, standards, and reform | Communications protocols and procedures should be standardised and mandated by regulations making them a condition of accreditation. |
REC121-3721 | 24 - Govt responsibility | The ITSRR should ensure that OTSI, as a division of ITSRR, co-operates and assists the ATSB in the conduct of any independent investigation by the ATSB of any rail accident or incident in New South Wales. |
REC121-3762 | 32 - Doctrine, standards, and reform | The Chief Executive of ITSRR should have sole accountability and responsibility for the regulation of rail safety in New South Wales. |
REC121-3674 | 32 - Doctrine, standards, and reform | Uniform verbal descriptions identifying that power has been isolated should be developed by RailCorp and utilised by all railway personnel, electrical service providers and all emergency response personnel. |
REC121-3697 | 38 - Agency/Department Reporting | All train drivers’ defects reports should be entered by RailCorp into a computerised record and tracked to finalisation. |
REC121-3728 | 32 - Doctrine, standards, and reform | Any barriers to communication between OTSI and ITSRR should be removed, so as to ensure that any findings made by OTSI in relation to any investigation it conducts are reported immediately to ITSRR. |
REC121-3769 | 32 - Doctrine, standards, and reform | The ITSRR should continue to participate in the development of a national system for rail safety regulation, provided that any ultimate agreement between the States and Territories and the Australian Government does not produce a safety outcome for New South Wales that is less than would be achieved by the implementation of all the recommendations contained in this report. |
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. |
REC121-3685 | 32 - Doctrine, standards, and reform | The ITSRR should impose a standard in relation to the collection and use of data from data loggers. |
REC121-3704 | 28 - Personal responsibility | RailCorp should continue its system of voluntary self-identification and rehabilitation of employees with alcohol or drug related problems. |
REC121-3750 | 32 - Doctrine, standards, and reform | ITSRR should initiate and/or participate in the development of a national standard for crashworthiness of all passenger trains. |
REC121-3774 | 38 - Agency/Department Reporting | The ITSRR must provide a quarterly report to the Minister for Transport Services on the progress made by RailCorp in implementing these recommendations, including: |
REC121-3661 | 32 - Doctrine, standards, and reform | The rail displan should include provision for the appointment of a rail emergency management co-ordinator at the RMC, and an on-site rail commander with the sole function of assisting and supporting the emergency services during the rescue phase of the emergency response. |
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. |
REC121-3720 | 24 - Govt responsibility | The New South Wales Government should make the necessary arrangements with the Australian Government, including any necessary legislation, for the Australian Transport Safety Bureau (ATSB) to have the power to investigate all rail accidents occurring on the New South Wales rail network the investigation of which may advance the knowledge of the causes of rail accidents in Australia. |
REC121-3761 | 32 - Doctrine, standards, and reform | Legislative changes should be enacted to ensure the complete independence of ITSRR from the Minister for Transport Services. |
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. |
REC121-3696 | 32 - Doctrine, standards, and reform | Defects reporting, recording and rectification should be integrated with the RailCorp regimes for train maintenance. |
REC121-3727 | 32 - Doctrine, standards, and reform | The relevant legislation should be amended to provide expressly that OTSI and the Chief Investigator have the power to initiate a rail accident or incident investigation. |
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. |
REC121-3651 | 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. |
REC121-3684 | 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. |
REC121-3701 | 32 - Doctrine, standards, and reform | Train inspections should be carried out at the time of stabling RailCorp trains, as well as a part of train preparation prior to entering service. |
REC121-3742 | 19 - Offences | The risk of abuse of internal passenger emergency door releases should be further reduced by introducing significant penalties for any improper use of such an emergency facility. It should be a criminal offence for anyone to use or tamper improperly with an emergency escape facility in a train. |
REC121-3773 | 32 - Doctrine, standards, and reform | The ITSRR should ensure that RailCorp establishes a safety management system containing the 29 elements identified in the SMSEP report, and ensure the ongoing monitoring and improvement of the safety management system established. |
REC121-3660 | 32 - Doctrine, standards, and reform | The rail displan should include the use by all emergency response personnel of a uniform incident command system, involving procedures for such matters as the establishment of inner and outer perimeters, control of access to the site, orderly evacuation of injured passengers and the establishment of a staging area remote from the accident site, in a unified command structure with the site controller co-ordinating the various emergency services through representatives of each service. |
REC121-3690 | 32 - Doctrine, standards, and reform | All communications protocols must be strictly enforced by all accredited rail organisations. |
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. |
REC121-3760 | 32 - Doctrine, standards, and reform | The Advisory Board established under the Transport Legislation Amendment (Safety and Reliability) Act 2003 must be abolished. |
REC121-3671 | 32 - Doctrine, standards, and reform | The RailCorp emergency response plan should include a requirement for the debriefing of all senior rail and emergency response personnel involved in any rail accident, so as to determine the way or ways in which emergency response arrangements for rail accidents can be continually improved, and thereafter implement such improvements. |
REC121-3695 | 10 - Infrastructure | There should be interoperability of communications equipment between all trains operating on the New South Wales rail network. |
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. |
REC121-3767 | 24 - Govt responsibility | All accredited rail organisations should be required to re-apply every three years to ITSRR for accreditation. |
REC121-3683 | 39 - Disaster Risk Management | RailCorp should undertake risk assessments of each of its activities as follows: |
REC121-3700 | 39 - Disaster Risk Management | Maintenance plans on all trains should be revised annually. |
REC121-3736 | 32 - Doctrine, standards, and reform | The RailCorp passenger containment policy must be abandoned. |
REC121-3772 | 32 - Doctrine, standards, and reform | RailCorp should establish a safety management system containing the 29 elements identified in the SMSEP report which is in volume 2 of this report. |
REC121-3659 | 32 - Doctrine, standards, and reform | A railway disaster plan, or rail displan, should be developed by RailCorp and the emergency services to ensure co-ordinated inter-agency response to rail accidents and incidents on the RailCorp network. |
REC121-3688 | 32 - Doctrine, standards, and reform | Communications procedures must be standardised throughout the rail network, so that all railway employees describe the same subject matter in an identical way. |
REC121-3712 | 38 - Agency/Department Reporting | RailCorp and ITSRR should co-operate with national programs for the collection, collation, trend analysis and dissemination of safety critical information. |
REC121-3758 | 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. |
REC121-3668 | 32 - Doctrine, standards, and reform | The RailCorp emergency response plan should include action checklists of the steps that each employee is required to take, and the order for specific employees to follow in case of emergency. |
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. |
REC121-3723 | 38 - Agency/Department Reporting | All ATSB accident investigation reports should be made public. |
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. |
REC121-3679 | 32 - Doctrine, standards, and reform | The rail safety regulator should set standards for the design, manufacture, testing and commissioning of rolling stock to ensure that the rolling stock is fit for its purpose. |
REC121-3699 | 32 - Doctrine, standards, and reform | All reported train defects should be certified by a person in a supervisory position in RailCorp as having been rectified. |
REC121-3730 | 32 - Doctrine, standards, and reform | Legislation should be enacted and any necessary arrangements made, to enable the ATSB to review any reports of any investigation by a rail organisation or the OTSI into any serious incident or accident in New South Wales. |
REC121-3771 | 32 - Doctrine, standards, and reform | RailCorp should establish an integrated safety management system which includes the following: |
REC121-3657 | 10 - Infrastructure | All signal telephones must be maintained by RailCorp in proper working order. |
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. |
REC121-3710 | 39 - Disaster Risk Management | The ITSRR should have permanent access to the RailCorp intranet. |
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. |
REC121-3776 | 38 - Agency/Department Reporting | The Minister for Transport Services should retain, independently of ITSRR, safety auditors to provide a report to the Minister confirming or qualifying the contents of each such ITSRR quarterly report. |
REC121-3667 | 32 - Doctrine, standards, and reform | RailCorp should develop and implement an emergency response plan for management of all rail accidents. Such a plan should be subsumed by the rail displan in the case of serious accidents or incidents. |
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. |
REC121-3722 | 38 - Agency/Department Reporting | The ATSB should deliver any report of any such rail accident which it investigates to the Board of any rail organisation involved in the accident, ITSRR and the Minister for Transport Services. |
REC121-3763 | 32 - Doctrine, standards, and reform | The ITSRR should publish guidelines to be followed by accredited organisations. |
Rec-ID | Code | Recommendation |
---|---|---|
REC008-3991 | 32 - Doctrine, standards, and reform | The Commission recommends that the provisios of section 185 of the "Mining Act 1905" relating to exits from coal mines be extended to metalliferous mines employing more than 20 men in any one shift. |
Rec-ID | Code | Recommendation |
---|---|---|
REC004-3995 | 32 - Doctrine, standards, and reform | That the standard double arrester, fitted to the locomotives during the summer months, be subjected to more careful daily inspection before and after each journey during such months, in addition to the present periodical examination by the locomotive foreman and boiler inspector; and that any omission of this duty on the part of the running staff be severely punished. |
REC004-3993 | 32 - Doctrine, standards, and reform | That in any case where there is primá facie evidence of a fire, creating damage to the extent of $100 or upwards in value, having been caused by the escape of particles of lighted matter from a locomotive engine, or by the action of railway employes in burning off grass or other inflammable material along any line of railway, a Special Board of Inquiry shall investigate and report on the subject, such Board to consist of a Police Magistrate as Chairman, with a railway officer and a competent person chosen from outside the State service as members. |
REC004-4000 | 32 - Doctrine, standards, and reform | That section 22 of the Police Offences Act 1890 be amended, to enable the burning of grass and debris along the railway lines in the summer season to be carried out at an earlier hour than two o'clock in the afternoon, when, in the judgement of the railway inspectors, it is safe and necessary to do so. |
REC004-3999 | 10 - Infrastructure | That, in view of the fact that along many of the lines, between the road-bed and the fences, there are numbers of dry inflammable stumps, which, when they catch fire, are very difficult to extinguish, and that the surface of the ground surrounding these stumps is usually chipped by the permanent-way men every summer, thus causing considerable expense without removing the risk of fire, the Railway Department should remove this source of danger, by grabbing them out and burning them as early as may be found practicable. |
REC004-3998 | 19 - Offences | That a by-law be made forbidding, under a heavy penalty, any persons travelling in such trains to throw lighted tobacco, cigars, cigarettes, pipe ashes, matches, or other inflammable matter on the railway line or right-of-way, or in any part of a railway carriage except the receptacles duly provided for the purpose. |