Inquiry Search
Rec-ID | Code | Recommendation |
---|---|---|
REC313-2513 | 33 - Relief and recovery | Assessing the availability and skillsets of the resources needed to respond to a major disaster recovery event. |
REC313-2512 | 38 - Agency/Department Reporting | Documenting results and recommendations from disaster recovery tests. |
REC313-2509 | 33 - Relief and recovery | Developing detailed recovery procedures. |
REC313-2508 | 25 - Inquiry, audit, lessons management and after action review | Regularly reviewing these plans to ensure that they reflect the current operating environment. |
REC313-2516 | 33 - Relief and recovery | Documenting disaster recovery risks in agency risk registers, along with controls and treatment plans. |
Rec-ID | Code | Recommendation |
---|---|---|
REC310-2488 | 33 - Relief and recovery | The basic capacity needs of each functional recovery group and how this can be scaled up should be identified. Plans for functional recovery groups should reflect this in clear statements for every level of the system, for all relevant entities about their required function, role and responsibilities during recovery. |
REC310-2485 | 33 - Relief and recovery | Recovery plans at all levels should include transition arrangements. They should be implemented during recovery. The arrangements should: |
REC310-2484 | 33 - Relief and recovery | There remains a need to maximise the effect of all offers of assistance to recovering communities. This recommendation presents an opportunity to resolve any outstanding aspects of Recommendation 4 and Actions in Response from the Cyclone Debbie Review Action Plan: |
Rec-ID | Code | Recommendation |
---|---|---|
REC309-2478 | 25 - Inquiry, audit, lessons management and after action review | The progress of recovery for this event be reviewed incrementally over the next 2 to 3 years, with a formal, independent report provided on the effectiveness of the recovery after 3 years. |
REC309-2468 | 33 - Relief and recovery | State Government agencies with key roles and responsibilities around disaster recovery provide increased support in the development of recovery at the local level (pre-event). |
REC309-2472 | 38 - Agency/Department Reporting | A single point of truth be established for accurately capturing and reporting on disaster management group activation levels for any given timeframe. |
Rec-ID | Code | Recommendation |
---|---|---|
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 |
---|---|---|
REC296-1357 | 10 - Infrastructure | Monthly test results need to be accurately recorded. |
REC296-1362 | 10 - Infrastructure | Carry out a detailed audit of the current Hospital essential loads to determine the current load requirements of the Hospital. |
REC296-1351 | 10 - Infrastructure | From the above assessment determine the existing generator load requirements and provide a new generator to meet those loads. |
REC296-1356 | 10 - Infrastructure | Accurate records need to be provided as to what is done for each service. |
REC296-1361 | 10 - Infrastructure | Prepare and carry out a testing regime and testing strategy and ensure testing of the generator is done every month for 4 hours over that month and under full Hospital load with test result recorded every 15 minutes. |
REC296-1350 | 10 - Infrastructure | Remove any loads that do not need to be on essential power. |
REC296-1355 | 10 - Infrastructure | Replacement of all original pipes and hoses not yet done. |
REC296-1360 | 10 - Infrastructure | Carry out regular load bank testing on the generator with a load bank large enough to fully load the generator to 110% which will clean out the engine and also identify whether the generator is capable of providing full load for a sustained length of time. |
REC296-1349 | 10 - Infrastructure | Conduct an assessment of the current essential loads and determine if there are loads that should not be on essential power. |
REC296-1354 | 10 - Infrastructure | Monthly and annual maintenance servicing needs to be scheduled for the generator to DPTI or CHSA schedule requirements. |
REC296-1359 | 10 - Infrastructure | Renegotiate the maintenance contract at the end of the current contract and have DPTI through AGFMA take on the maintenance contract. |
REC296-1353 | 10 - Infrastructure | Regular annual testing at 100% on a load bank needs to be scheduled into a maintenance schedule. |
REC296-1358 | 10 - Infrastructure | If the existing generator is capable of providing the current essential power requirements then the generator needs a major inspection and overhaul all items that may need to be replaced due to age and condition. This includes checking compression, oil pressure, coolant pumping and all other critical components and may actually require providing a temporary generator while the Hospital generator receives a major inspection and possible re build. A ball park figure to do this would be $50,000.00 plus cranage and transport to Detroit workshop probably another $10,000.00 then a temporary generator would need to be hired and installed which could run into $10’s of thousands of dollars depending on how long the engine was out of service. For the money that would be spent checking and rebuilding the existing engine it would be recommended to replace the generator with a new generator. |
REC296-1363 | 10 - Infrastructure | Due to the age of the generator, reliability and reparability risk due to age and the apparent under capacity of the generator it is recommend to replace the generator with a new generator and associated control system designed for the current load requirements and allowance for some future expansion. |
REC296-1352 | 10 - Infrastructure | A monthly testing regime needs to be developed that will allow the generator to be tested at full essential load capacity and to ensure that 4 hour monthly testing can be done every month. |
Rec-ID | Code | Recommendation |
---|---|---|
REC295-1334 | 33 - Relief and recovery | Conduct a review into South Australia’s arrangements for relief and recovery grant, Local Government Disaster Recovery Assistance Arrangements and Natural Disaster Relief and Recovery Arrangement claims, the review should include governance coordination and criteria for provision and processing of relief/recovery grants |
REC295-1317 | 25 - Inquiry, audit, lessons management and after action review | Review representation in the State Emergency Centre including: a) determining if there is a more suitable functional support group e.g. the Procurement Functional Support Group, to replace the Logistics Functional Support Group, and if so, Chief Procurement Officer, DPC, has responsibility for the management of this role within the State Emergency Centre. b) That when the State Crisis Centre is not operating from a physical location, a State Crisis Centre liaison officer is attached to the State Emergency Centre. |
REC295-1275 | 33 - Relief and recovery | That SA Health, develop an emergency plan to manage an extended power outage or black system event which, in addition to the requirements outlined in recommendation 16: |
REC295-1315 | 25 - Inquiry, audit, lessons management and after action review | That a review of the role and effectiveness of the State Emergency Management Committee (SEMC) including: the legislative functions; membership including the chair; roles and responsibilities; and, SEMC Advisory Groups be undertaken. |
REC295-1326 | 14 - Incident Mgt Teams | Establish a State-wide resourcing capability to support incident management teams, regional coordination centres, zone emergency centres, relief centres, recovery centres and State control centres. some of the features of such a capability should include: a) multi-agency, cross-government, State-wide pool of incident management and emergency management personnel building on the State incident management team concept currently facilitated by the Country Fire Service, and expanded to include all hazards, multiagency teams with a roster that provides year-round coverage b) a system that enables staff and volunteers from any agency to identify their availability for upcoming shifts c) a rostering system that enables one or more incident management teams, staging areas, regional coordination centres, State control centres and relief centres to develop, maintain and distribute rosters and structure charts in a more coordinated manner d) identifying areas of expertise for key incident and emergency management functions (e.g. public information, alerts and warning, media liaison, logistics and resource management) that would benefit from a coordinated and resource pooling approach and take steps to implement (consider the Mapping Functional Support Group model as a potential service delivery model). |
REC295-1297 | 25 - Inquiry, audit, lessons management and after action review | Engage an independent business analyst to review the current call, receipt and dispatch process for emergency services i.e. the Metropolitan Fire Service, Country Fire Service and State Emergency Service, from the initial call for assistance through to response of emergency service resources, including the allocation and coordination of multiple taskings. |
REC295-1276 | 25 - Inquiry, audit, lessons management and after action review | That SA Health undertake a review of their emergency management arrangements. Health State Controllers should be consulted during this review and arrangements should be consistent throughout the department and across the State and compatible with State emergency management arrangements and information systems |
REC295-1328 | 25 - Inquiry, audit, lessons management and after action review | Update the SEMP Part 3, Annex F ‘Debriefs’ to provide more guidance regarding the types of debriefs, when they are required to be undertaken and at what level and guidance for undertaking and recording debriefs, and implementing lessons identified. |
REC295-1286 | 10 - Infrastructure | That the Attorney General’s Department consult with local government regarding potential for them to provide logistical support associated with backup power supply to SA Government Radio Network towers in the event of an emergency. |
REC295-1327 | 25 - Inquiry, audit, lessons management and after action review | Establish a lessons management capability across the SA emergency management sector to collect, analyse and track lessons identified during debriefs and reviews following events and other sources such as interstate and oversees reviews and inquiries. |
REC295-1279 | 10 - Infrastructure | Install UPS on traffic lights on main Central Business District (CBD) and arterial roads to allow an effective movement of traffic during a loss of power. |
Rec-ID | Code | Recommendation |
---|---|---|
REC286-1443 | 14 - Incident Mgt Teams | Build capacity to enable Incident Management Teams to manage the likely increased frequency and intensity of major fire events. |
REC286-2070 | 25 - Inquiry, audit, lessons management and after action review | Test the Biosecurity Act 2015. |
REC286-2084 | 10 - Infrastructure | Establish emergency services ICT redundancy arrangements for damage loss of communications infrastructure. |
REC286-2031 | 10 - Infrastructure | Improve information about electricity demand during heatwaves. |
REC286-1460 | 25 - Inquiry, audit, lessons management and after action review | Review seismic monitoring network alert systems to ensure emergency managers are on the contact lists. |
REC286-1442 | 25 - Inquiry, audit, lessons management and after action review | Review legislation relating to Fuel Stove only areas, Fire Permit System and Total Fire Bans to ensure appropriate incentives to modify individuals’ behaviour. |
REC286-2071 | 29 - Operational Health and Safety | Implement a social marking program to promote improved respiratory etiquette and hygiene. |
REC286-1438 | 25 - Inquiry, audit, lessons management and after action review | Consider outcomes of national review of warnings and review resilience of warning systems’ infrastructure. |
REC286-2055 | 29 - Operational Health and Safety | Personal protective equipment (masks, gowns, gloves, goggles) – review fit-testing vs fit-checking. |
Rec-ID | Code | Recommendation |
---|---|---|
REC285-2517 | 38 - Agency/Department Reporting | The report recommends that Ambulance Tasmania collects data to allow regular and meaningful comparison of clinical outcomes at the regional level, to better allocate resources and to rapidly identify problems. |
REC285-2524 | 25 - Inquiry, audit, lessons management and after action review | The report recommends that Ambulance Tasmania investigate why the level of multiple responses had increased. |
REC285-2520 | 25 - Inquiry, audit, lessons management and after action review | The report recommends that Ambulance Tasmania investigate whether the additional resources in the North and North West regions were effective in reducing average response times. |
REC285-2525 | 38 - Agency/Department Reporting | The report recommends that Ambulance Tasmania outline what KPIs are measured and provide targets or benchmarks to define what is good or poor performance. |
REC285-2518 | 38 - Agency/Department Reporting | The report recommends that regional summary reports of clinical reviews be standardised to facilitate review and comparison across regions. |
Rec-ID | Code | Recommendation |
---|---|---|
REC284-1374 | 10 - Infrastructure | Provide walls around critical electrical infrastructure within the main plant area to provide security and protection from catastrophic water system failures. |
REC284-1368 | 10 - Infrastructure | Improvements to installation to be implemented as follows: - Lighting within the generator enclosure and immediately adjacent to be emergency battery-backed type. - Improvements to the spatial layout within the main generator enclosure should be investigated, including allowance for the control panel door to open 180o (only 90o currently); moving the fuel pumps to a more accessible location, and ensuring clear access to the day tank for manual filling if required. - Improvements to communications facilities between critical areas, including fixed phone line connections between the main control room, main generator control panel in the P (energy) Building, and the generator enclosure, and allowing link to offsite specialist advice. - Where generator maintenance requires operations outdoors (not applicable to main generator, but applicable to others), a shelter over the relevant area should be provided to allow safe work during wet or hot weather. - Written emergency procedures to be prepared covering credible failure scenarios with step by step checklists and recommended actions. |
REC284-1373 | 10 - Infrastructure | Review generator installations details as noted in report and implement physical improvements where possible. |
REC284-1367 | 10 - Infrastructure | Add to generator test procedure a checklist at the end of testing which includes checking that all systems are back to normal positions and includes a requirement to leave the day tank full where there is a bulk tank/day tank arrangement. |
REC284-1372 | 10 - Infrastructure | As part of the electrical master plan update recommended above, a complete and consistent set of single line diagrams describing the electrical distribution network be prepared. Relevant diagrams to be laminated and displayed in the main substations. Labelling to all main electrical equipment be reviewed and updated in accordance with the final documents. |
REC284-1366 | 10 - Infrastructure | A detailed review of the fuel control and BMS systems (for all generators) be carried out and actions taken to: 1) Ensure that the fuel alarm system is operational and properly calibrated, and ensure that the alarms are connected to the BMS. 2) Ensure that the BMS transmits these alarms effectively to the maintenance staff. 3) If this review demonstrates risk of fuel control systems not adequately reporting alarms, consider an independent day tank level switch to be installed in each generator fuel tank, directly connected to the BMS. 4) Consider the feasibility of adding a “fuel system not in auto” or “fuel system fault/fail safe watchdog” or “pre-alarm identifying that the generator is about to shut down without intervention” feature to current systems – subject to details of each individual generator system. |
REC284-1371 | 10 - Infrastructure | Generator dual redundant starter systems should be considered. |
REC284-1365 | 10 - Infrastructure | The electrical master plan for the site should be updated to include planning for the scheduled replacement or refurbishment of those parts of the infrastructure that have not been renewed in the last 10 years. This planning to consider other upgrades or plans for the FMC overall. |
REC284-1370 | 10 - Infrastructure | Review control system for the main generator normal/essential changeover system and ensure that it has effective backup/manual or redundant operations, and suitable testing facilities. The Essential board that supplies the main generator power to Blocks A, B, C (except theatres), D, E (except certain critical engineering plant) (MD-1-4P-10E), is a potential single point of failure of a significant portion of the emergency power system and as part of the Master Plan update should be considered as a priority. |
REC284-1369 | 10 - Infrastructure | Review all generator locations for arrangements for temporary generator installation, including design of modifications as required for electrical connections and spatial requirements at installation locations, to be documented in an emergency procedure. |
Rec-ID | Code | Recommendation |
---|---|---|
REC281-1207 | 33 - Relief and recovery | Communicating in Recovery: The Office of Emergency Management: · considers the development of a communications and engagement strategy for major disaster events · progresses the development of the ‘Communicating In Recovery’ Guideline in the Local Recovery Toolkit. |
REC281-1206 | 33 - Relief and recovery | Transition from Response to Recovery: That Region Emergency Management Committees meet post event to: · consider available impact data · determine the need to establish a Recovery Committee · document the rationale for the decision · advise the Office of Emergency Management of the decision. |
REC281-1204 | 33 - Relief and recovery | Transition from Response to Recovery That the Office of Emergency Management, in consultation with the NSW Police Force Emergency Management Unit develops a template for handover of the Response to Recovery Phase of an emergency. |
REC281-1201 | 25 - Inquiry, audit, lessons management and after action review | Preventing Flood Related Fatalities: The NSW Government consider the recommendations from the Preventing Flood Related Fatalities Report when it is released. |
Rec-ID | Code | Recommendation |
---|---|---|
REC272-1415 | 25 - Inquiry, audit, lessons management and after action review | An audit of all local government areas vulnerable to storm tide events is completed and opportunities identified to resolve gaps in evacuation zone planning to ensure consistency with the Queensland Evacuation Guidelines for Disaster Management Groups and neighbouring local government areas. |
Rec-ID | Code | Recommendation |
---|---|---|
REC268-1424 | 25 - Inquiry, audit, lessons management and after action review | The Queensland Emergency Alert Guidelines is reviewed to reflect current practice and incorporate evidence-based improvements informed by lessons learned and research. |
REC268-1422 | 25 - Inquiry, audit, lessons management and after action review | The Queensland State Disaster Management Plan is reviewed to: |
Rec-ID | Code | Recommendation |
---|---|---|
REC267-1162 | 10 - Infrastructure | Telecommunications and Power Infrastructure |
REC267-1161 | 33 - Relief and recovery | VIP Visits |
REC267-1160 | 33 - Relief and recovery | Transition from Response to Recovery |
REC267-1156 | 33 - Relief and recovery | Streamlining NDRRA Grants Processes |
REC267-1155 | 33 - Relief and recovery | MP Recovery Reference Group |
REC267-1148 | 33 - Relief and recovery | Planning for Recovery Centres Recovery Centres are a proven means of providing support to affected communities. More comprehensive recovery planning is needed at local levels, including the identification of potential Recovery Centre sites in Local EM Plans to help facilitate streamlined establishment of the Centres in future events. Consideration should be given to developing a clear set of standard messaging regarding |
REC267-1163 | 33 - Relief and recovery | Corrections Volunteer Labour Teams |
Rec-ID | Code | Recommendation |
---|---|---|
REC263-1092 | 29 - Operational Health and Safety | CFA and VICSES should: implement risk management processes within regions, districts, brigades and units to understand and manage the local risks associated with their volunteer workforces |
Rec-ID | Code | Recommendation |
---|---|---|
REC262-1490 | 10 - Infrastructure | That the Emergency Services Telecommunications Authority critically reviews: |
REC262-1489 | 10 - Infrastructure | That the Emergency Services Telecommunications Authority reclassifies its State Emergency Communications Centres as critical national infrastructure. |
Rec-ID | Code | Recommendation |
---|---|---|
REC258-2549 | 25 - Inquiry, audit, lessons management and after action review | The Civil Aviation Safety Authority provides full disclosure of audit findings at audit exit briefings in accordance with international best practice. |
REC258-2528 | 25 - Inquiry, audit, lessons management and after action review | The Australian Transport Safety Bureau investigates as many fatal accidents in the sport and recreational aviation sector as its resources will allow. |
REC258-2556 | 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. |
REC258-2560 | 29 - Operational Health and Safety | The Civil Aviation Safety Authority devolve to Designated Aviation Medical Examiners the ability to renew aviation medical certificates (for Classes 1, 2, and 3) where the applicant meets the required standard at the time of the medical examination. |
REC258-2552 | 25 - Inquiry, audit, lessons management and after action review | The Civil Aviation Safety Authority implements a system of using third-party commercial audits as a supplementary tool to its surveillance system. |
REC258-2551 | 25 - Inquiry, audit, lessons management and after action review | The Civil Aviation Safety Authority assures consistency of audits across all regions, and delivers audit reports within an agreed timeframe. |
Rec-ID | Code | Recommendation |
---|---|---|
REC256-1573 | 25 - Inquiry, audit, lessons management and after action review | The Australian Government should schedule an independent and public review of the progress of reforms to natural disaster funding arrangements five years after implementation has commenced. This review should examine the operation and efficacy of the arrangements, including the: |
Rec-ID | Code | Recommendation |
---|---|---|
REC255-1579 | 38 - Agency/Department Reporting | The ANAO recommends that the Department of Defence take steps to strengthen the priority afforded by Defence units to meeting these reporting requirements. |
Rec-ID | Code | Recommendation |
---|---|---|
REC252-2570 | 25 - Inquiry, audit, lessons management and after action review | Western Australia Health should carry out targeted clinical audits in volunteer country sub-centres until longer term solutions are in place |
REC252-2571 | 38 - Agency/Department Reporting | St John Ambulance should develop quantitative performance targets for community paramedics and report these to Western Australia Health |
REC252-2570 | 25 - Inquiry, audit, lessons management and after action review | Western Australia Health should carry out targeted clinical audits in volunteer country sub-centres until longer term solutions are in place |
REC252-2566 | 38 - Agency/Department Reporting | Western Australia Health should require service providers to report more comprehensive performance data using additional cost and clinical indicators |
REC252-2565 | 38 - Agency/Department Reporting | Western Australia Health should include in contracts minimum standards for emergency and secondary ambulance services and effective mechanisms to monitor these |
Rec-ID | Code | Recommendation |
---|---|---|
REC244-2631 | 25 - Inquiry, audit, lessons management and after action review | Review Section 134 to ensure that it is not a deterrent to a group of farm fire units operating at an incident. |
REC244-2620 | 25 - Inquiry, audit, lessons management and after action review | Review employment conditions under the F&ES Act to align with those under the Public Sector Act unless there is a compelling reason to the contrary. |
REC244-2617 | 25 - Inquiry, audit, lessons management and after action review | When judging major incidents in the future, consideration be given to Eburn and Dover’s proposal to establish processes with a statutory basis that sufficiently balance the community’s interests in ensuring that true lessons, including lessons of error or neglect, are identified, whilst also protecting members of the emergency services. Processes need to be developed for emergency services such as those used in aviation and medicine, to facilitate open and honest disclosure of errors. |
REC244-2601 | 25 - Inquiry, audit, lessons management and after action review | That an independent review of the operational and geographic boundaries of the ESOs be conducted recognising the limitations of the current governance structures to adequately address such issues. Such a review needs to be performed periodically, but not less than every 8 years. |
REC244-2600 | 25 - Inquiry, audit, lessons management and after action review | An external audit of shared services performed by SAFECOM and services now provided by the three ESOs which have the potential to be shared, be undertaken to determine the most efficient and cost effective way such services can be delivered to the sector. The three ESO Chiefs need to have input into this process. |
Rec-ID | Code | Recommendation |
---|---|---|
REC242-2643 | 25 - Inquiry, audit, lessons management and after action review | That the Government consult broadly upon and review impediments to volunteering in the community and establish a taskforce to assist in removing barriers to volunteering, particularly with respect to: |
Rec-ID | Code | Recommendation |
---|---|---|
REC240-2653 | 38 - Agency/Department Reporting | That the Department of Health publicly reports a comprehensive suite of performance information, including: |
REC240-2652 | 38 - Agency/Department Reporting | That the Department of Health enhances management reporting processes over complaints by recording the number and nature of complaints, following up outstanding complaints formally and reporting complaints data to executive management. |
Rec-ID | Code | Recommendation |
---|---|---|
REC239-2767 | 38 - Agency/Department Reporting | Recommendation: That the CEO Portfolio Business collaborates with the two portfolio Commissioners to: |
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. |
REC239-2684 | 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. |
REC239-2758 | 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. |
REC239-2737 | 29 - Operational Health and Safety | That the workplace health and safety reporting system be reviewed to facilitate ease of reporting. |
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. |
REC239-2727 | 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: |
REC239-2773 | 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: |
REC239-2777 | 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. |
REC239-2673 | 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. |
REC239-2725 | 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. |
REC239-2772 | 38 - Agency/Department Reporting | That the roll-out of the mobile service program business case mentioned earlier |
REC239-2776 | 25 - Inquiry, audit, lessons management and after action review | That the proposed efficiency review of the Queensland Police Service examine whether: |
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. |
REC239-2771 | 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. |
REC239-2764 | 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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC236-2800 | 38 - Agency/Department Reporting | The committee recommends that where a safety action has not been completed before a report being issued that a recommendation should be made. If it has been completed the report should include details of the action, who was involved and how it was resolved. |
REC236-2793 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that CASA processes in relation to matters highlighted by this investigation be reviewed. This could involve an evaluation benchmarked against a credible peer (such as FAA or CAA) of regulation and audits with respect to: non-RPT passenger carrying operations; approach to audits; and training and standardisation of FOI across regional offices. |
REC236-2799 | 38 - Agency/Department Reporting | The committee recommends that the ATSB prepare and release publicly a list of all its identified safety issues and the actions which are being taken or have been taken to address them. The ATSB should indicate its progress in monitoring the actions every 6 months and report every 12 months to Parliament. |
REC236-2792 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that the investigation be re-opened by the ATSB with a focus on organisational, oversight and broader systemic issues. |
REC236-2806 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that the relevant agencies investigate appropriate methods to ensure that information about the incidence of, and variable weather conditions at, Norfolk Island is available to assist flight crews and operators managing risk that may result from unforseen weather events. |
REC236-2805 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that the relevant agencies review whether any equipment or other changes can be made to improve the weather forecasting at Norfolk Island. The review would include whether the Unicom operator should be an approved meteorological observer. |
REC236-2801 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that the ATSB review its process to track the implementation of recommendations or safety actions to ensure it is an effective closed loop system. This should be made public, and provided to the Senate Regional and Rural Affairs and Transport Committee prior to each Budget Estimates. |
REC236-2808 | 38 - Agency/Department Reporting | The committee recommends that in relation to mandatory and confidential reporting, the default position should be that no identifying details should be provided or disclosed. However, if there is a clear risk to safety then the ATSB, CASA and industry representatives should develop a process that contains appropriate checks and balances. |
REC236-2795 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that a short inquiry be conducted by the Senate Standing Committee on Rural and Regional Affairs and Transport into the current status of aviation regulatory reform to assess the direction, progress and resources expended to date to ensure greater visibility of the processes. |
Rec-ID | Code | Recommendation |
---|---|---|
REC231-2830 | 38 - Agency/Department Reporting | The Australian National Audit Office (ANAO) recommends that the Department of Regional Australia, Local Government, Arts and Sport improve its monitoring of the delivery of the Natural Disaster Recovery Work Plans for Queensland and Victoria by: |
Rec-ID | Code | Recommendation |
---|---|---|
REC230-2833 | 10 - Infrastructure | If recommendation 1 is not supported by the Australian Government, the committee recommends that the Minister for Broadband, Communications and the Digital Economy issue a Ministerial Direction to the Australian Communications and Media Authority to allocate as a minimum requirement, 20 MHz in the 800 MHz band for the purposes of a public safety mobile broadband network. |
REC230-2832 | 10 - Infrastructure | The committee recommends that the Minister for Broadband, Communications and the Digital Economy take appropriate measures to secure, for public service agencies, priority access to an additional 10 MHz of spectrum in the 700 MHz band for public safety purposes. |
REC230-2831 | 10 - Infrastructure | The committee recommends that the Minister for Broadband, Communications and the Digital Economy issue a Ministerial Direction to the Australian Communications and Media Authority to allocate 20 MHz of contiguous spectrum in the 700 MHz band for the purposes of a public safety mobile broadband network. |
Rec-ID | Code | Recommendation |
---|---|---|
REC222-1848 | 29 - Operational Health and Safety | The Western Australian Government amend current State occupational health and safety legislation so that it includes a definition for ‘health’ that includes psychological health. |
REC222-1847 | 25 - Inquiry, audit, lessons management and after action review | The Ministers for Emergency Services, Environment and Police ensure their departments undertake a formal review by 30 June 2013 of the welfare services addressing stress and trauma provided to both their career and volunteer members. |
REC222-1859 | 29 - Operational Health and Safety | The Attorney General and the Ministers for Health and Mental Health fund their departments to establish a peer support program by the end of 2013 for their staff undertaking stressful tasks during a disaster or critical incident. |
REC222-1858 | 29 - Operational Health and Safety | The Ministers for Environment, Police, Child Protection and Emergency Services fund additional chaplaincy services, particularly for staff and volunteers based in rural and regional Western Australia. |
REC222-1852 | 29 - Operational Health and Safety | The Minister for Health immediately establish the road trauma counselling service to be funded by the Road Trauma Trust Account. |
REC222-1850 | 29 - Operational Health and Safety | The Ministers for Emergency Services, Environment and Police ensure that their departments develop as a high priority a computer system for tracking their staff and the number of traumatic events they have attended over a particular period. |
REC222-1869 | 25 - Inquiry, audit, lessons management and after action review | The Ministers for Emergency Services, Environment and Police ensure their departments include provisions for regular external audits of invoices for payment in their next round of Employee Assistance Program contract negotiations. |
REC222-1853 | 38 - Agency/Department Reporting | The Ministers for Emergency Services, Environment and Police ensure their departments include in their annual reports the expenditure they have incurred on preparing their staff for critical incidents, and for managing their response to these incidents. |
REC222-1849 | 29 - Operational Health and Safety | Departmental chief executives of the Western Australia Police, Department of Environment and Conservation and the Fire and Emergency Services Authority should be made personally responsible for the psychological health (as a result of critical incident trauma) of their staff and volunteers. This obligation should be reflected in their performance agreements. |
REC222-1862 | 25 - Inquiry, audit, lessons management and after action review | The Minister for Emergency Services request the State Emergency Management Committee to review by June 2013 the sharing of data between the State’s emergency response agencies using the WebEOC software and any further enhancements that can be made to this process. |
Rec-ID | Code | Recommendation |
---|---|---|
REC221-2862 | 38 - Agency/Department Reporting | Housing should use risk based analysis of its tenant and property information, job order data and quality assurance results to better inform target setting for KPIs, job order controls, and the sampling used for completed work inspections before and after payment. This analysis should synthesise information from all sources and include a risk assessment of tenants and properties, as well as consideration of the various types of maintenance work being done (emergency, priority and routine, and planned maintenance). |
REC221-2861 | 38 - Agency/Department Reporting | Housing should further develop its Head Contractor key performance indicators to include quality, cost and tenant satisfaction. Currently performance reporting is focused entirely on timeliness indicators. |
Rec-ID | Code | Recommendation |
---|---|---|
REC208-0526 | 25 - Inquiry, audit, lessons management and after action review | That OEH’s testing procedures for determining the impact of pollution incidents incorporate additional requirements for the checking and verification of results before those results are released. |
Rec-ID | Code | Recommendation |
---|---|---|
REC205-1903 | 25 - Inquiry, audit, lessons management and after action review | The Australian Government should commission an independent public review of disaster prevention and recovery arrangements. This should be broader than the review currently being conducted by the Attorney-General’s Department. The review should cover the Natural Disaster Relief and Recovery Arrangements, as well as the funding mechanisms for disaster mitigation, including the National Partnership Agreement on Natural Disaster Resilience. This review should: |
REC205-1902 | 25 - Inquiry, audit, lessons management and after action review | The Council of Australian Governments should commission an independent public inquiry to develop an appropriate response to managing the risks of climate change to existing settlements. The inquiry should: |
Rec-ID | Code | Recommendation |
---|---|---|
REC190-1929 | 38 - Agency/Department Reporting | That the Queensland Reconstruction Authority consider extending the suite of internal performance indicators being used as the Authority matures. |
Rec-ID | Code | Recommendation |
---|---|---|
REC189-2911 | 29 - Operational Health and Safety | The review team recommend that: |
REC189-2907 | 29 - Operational Health and Safety | a) For the purposes of designing and implementing its regulatory activities, National Offshore Petroleum Safety Authority (NOPSA) should continue to identify priority hazards and risks and their underlying causes, in consultation with the NOPSA Advisory Board and stakeholders (see Theme 9, Stakeholder engagement). |
REC189-2912 | 29 - Operational Health and Safety | The review team recommend that the safety case system be strengthened by including provisions for a design notification scheme along the lines of that under the British Offshore Safety Case Regulations. |
Rec-ID | Code | Recommendation |
---|---|---|
REC188-2917 | 33 - Relief and recovery | The committee recommends that relevant Commonwealth agencies continue to monitor the wellbeing of their personnel and that counselling and support services should be provided for as long as necessary. |
REC188-2916 | 33 - Relief and recovery | The committee recommends that the Department of Regional Australia and DIAC liaise with the Christmas Island community to explore options for a permanent memorial to be erected on the island, at a site of the residents' choosing, for the victims of the tragedy. |
REC188-2915 | 33 - Relief and recovery | The committee recommends that Department of Immigration and Citizenship (DIAC) and its relevant contractors continue to monitor the wellbeing of the survivors and that counselling and support services should be provided for as long as is necessary. |
Rec-ID | Code | Recommendation |
---|---|---|
REC179-2977 | 38 - Agency/Department Reporting | The Department of Human Services should create evaluation guidelines for recovery operations, including links to planning. |
Rec-ID | Code | Recommendation |
---|---|---|
REC174-2985 | 25 - Inquiry, audit, lessons management and after action review | To provide adequate assurance on the validity of claims paid for disaster recovery assistance, the ANAO recommends that Centrelink: |
Rec-ID | Code | Recommendation |
---|---|---|
REC170-0062 | 25 - Inquiry, audit, lessons management and after action review | Agencies should: annually assess their capability to respond to emergencies and take measures to address any shortfalls |
Rec-ID | Code | Recommendation |
---|---|---|
REC165-0089 | 33 - Relief and recovery | The SDMG lead an initiative to deal at all levels with offers of assistance and donations from the general public in the event of disasters. |
REC165-0082 | 33 - Relief and recovery | Current procedures to activate disaster recovery funding arrangements be retained and processes be reinforced. |
Rec-ID | Code | Recommendation |
---|---|---|
REC161-3030 | 25 - Inquiry, audit, lessons management and after action review | That National Offshore Petroleum Safety Authority review the risk assessment of pipelines. National Offshore Petroleum Safety Authority should focus, in particular, on the efficacy of anti-corrosion systems, and recognise potential interference effects and MAE escalation risks associated with adjacent pipelines and unlicenced pipes even if they fall outside its direct regulatory responsibilities. |
Rec-ID | Code | Recommendation |
---|---|---|
REC160-3045 | 38 - Agency/Department Reporting | The ANAO recommends that Centrelink: |
REC160-3044 | 38 - Agency/Department Reporting | The ANAO recommends that the Business Continuity, Crisis Management and Security Sub committee: |
REC160-3042 | 38 - Agency/Department Reporting | In order to identify key business processes and provide for the regular comparative assessment of Maximum Allowable Outage periods (MAOs), the ANAO recommends that Centrelink: |
Rec-ID | Code | Recommendation |
---|---|---|
REC159-3055 | 38 - Agency/Department Reporting | ACTAS should implement systems to enable the accurate collection and measurement of non-emergency ambulance service bookings to facilitate monitoring of performance and the provision of accurate advice to Government. |
REC159-3050 | 38 - Agency/Department Reporting | ACTAS should log all emergency calls on CAD to document non-ambulance dispatch decisions, and to provide more complete data on demand. |
REC159-3047 | 38 - Agency/Department Reporting | ACTAS should develop a comprehensive performance management framework that includes key performance indicators and targets aligned to its service delivery activities, to help inform management and stakeholders of its performance. |
REC159-3062 | 38 - Agency/Department Reporting | ACTAS should develop a set of standards to measure and monitor patient satisfaction, so that improvements to the service can be made, based on patient satisfaction information. |
REC159-3058 | 25 - Inquiry, audit, lessons management and after action review | ACTAS should improve patient care processes by: |
REC159-3059 | 38 - Agency/Department Reporting | ACTAS should establish a clinical information database that: |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC158-3452 | 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. |
REC158-3429 | 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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC149-3147 | 29 - Operational Health and Safety | As all stakeholders have responsibility for safe outcomes, decisions regarding target subjects for safety promotion need to have the support of all stakeholders including NOPSA and the workforce. Industry, which ultimately has the responsibility for managing risk as well as funding the promotion, should take a leadership role in implementation. |
REC149-3144 | 29 - Operational Health and Safety | The Safety Case proponent should be allowed some flexibility to involve appropriate experience matched with the proposed workforce competencies to enable the Safety Case to be developed with value adding processes. Subsequent to the hiring of the workforce Final Government Response Offshore Petroleum Safety Regulation Inquiry and 2008 Review of NOPSA Operational Activities and preferably before the commencement of operations a review of the Safety Case should take place with the new workforce to ensure they understand the accepted Safety Case, its risks and Safety Management Plan. |
REC149-3135 | 29 - Operational Health and Safety | The initial acceptance of a new facility Safety Case should be in conjunction with inspection of a facility upon commencement of operations. |
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. |
REC149-3128 | 29 - Operational Health and Safety | National Offshore Petroleum Safety Authority (NOPSA) should develop guidelines in consultation with stakeholders to provide clarity and consistency to the process which ultimately will result in better safety outcomes. |
REC149-3145 | 25 - Inquiry, audit, lessons management and after action review | NOPSA should consider an audit regime that targets Greenfields operations at commencement of operations. |
Rec-ID | Code | Recommendation |
---|---|---|
REC147-3186 | 38 - Agency/Department Reporting | The Australian National Audit Office (ANAO) recommends that, in order to assist management decision making and to inform Parliament about performance, Emergency Management Australia (EMA) develop and report appropriate measures for its key emergency management activities and outcomes. |
Rec-ID | Code | Recommendation |
---|---|---|
REC146-3193 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that the Australian National Audit Office audit CASA's implementation and administration of its Safety Management Systems approach. |
Rec-ID | Code | Recommendation |
---|---|---|
REC144-3379 | 25 - Inquiry, audit, lessons management and after action review | The Committee recommends that a thorough review be undertaken of the communications and coordination between the separate agencies which make up the Emergency Services Agency, to assess the extent to which cultural factors are detrimental to the effective operation of the ESA. |
Rec-ID | Code | Recommendation |
---|---|---|
REC143-3588 | 33 - Relief and recovery | That, in line with recommendations contained in the 2004 Report to the Council of Australian Governments, greater flexibility should be introduced to WANDRA to enable damaged infrastructure to be upgraded to a more resilient standard where that is both feasible and cost-effective. |
REC143-3585 | 33 - Relief and recovery | That the Professional Assistance Grant is formally extended by WANDRA to include non rural businesses and that it be made available to assist with the clean up of disaster related damage to farms and businesses. (The Committee recognises that the amendments to WANDRA as of March 2007 address this recommendation). |
REC143-3583 | 33 - Relief and recovery | That the newly proposed index linked limits for Personal Hardship and Distress Relief Payments as outlined in the paper “National Disaster Relief Arrangements - An Analysis and Recommendations for Personal Hardship Distress Measures” be accepted by government. |
Rec-ID | Code | Recommendation |
---|---|---|
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 |
---|---|---|
REC123-3877 | 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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC121-3733 | 29 - Operational Health and Safety | RailCorp’s approach to occupational health and safety should be proactive and involve the systematic analysis of all current hazards, risks and controls and an assessment of their adequacy to reduce the risk of injury to, or death of, employees to an acceptable level. |
REC121-3765 | 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. |
REC121-3776 | 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. |
REC121-3676 | 14 - Incident Mgt Teams | A direct line of communication should be established between the RMC and Emergency Services Operations Control Centre by a “tie line” or otherwise, so as to ensure that in the case of a serious rail accident there is an open line of communication between the officer in charge of the management of the incident at the RMC and the various emergency response services. |
REC121-3739 | 29 - Operational Health and Safety | All passenger trains operating in New South Wales must be fitted with external emergency door releases which do not require any special key or other equipment to operate. |
REC121-3706 | 29 - Operational Health and Safety | RailCorp should establish a comprehensive safety document management system. |
REC121-3748 | 29 - Operational Health and Safety | All new rail cars must have appropriate signage and lighting identifying escape routes in the case of emergency. |
REC121-3694 | 25 - Inquiry, audit, lessons management and after action review | The ITSRR should conduct random audits of accredited rail organisations for compliance with communications protocols. |
REC121-3712 | 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. |
REC121-3653 | 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. |
REC121-3732 | 29 - Operational Health and Safety | If ITSRR accepts such a plan as an appropriate response to the existing weak safety culture, ITSRR should approve it and monitor the effectiveness of the plan. |
REC121-3764 | 29 - Operational Health and Safety | The ITSRR should not grant accreditation to any rail organisation unless it has an integrated safety management system in accordance with any safety management system regulation and the guidelines published from time to time by ITSRR. |
REC121-3758 | 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. |
REC121-3775 | 38 - Agency/Department Reporting | The Minister for Transport Services must table in Parliament, each such quarterly report by ITSRR. |
REC121-3738 | 29 - Operational Health and Safety | All passenger trains must be fitted with an internal passenger emergency door release. |
REC121-3666 | 14 - Incident Mgt Teams | The rail commander should have complete authority to direct and control any rail employees attending the site of a rail accident, in accordance with directions given or arrangements put in place by the site controller, until the rescue phase of the emergency response to the rail accident has been completed. |
REC121-3702 | 29 - Operational Health and Safety | Random alcohol testing should be continued. |
REC121-3747 | 29 - Operational Health and Safety | All trains should have windows available through which passengers can escape. |
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. |
REC121-3697 | 38 - Agency/Department Reporting | All train drivers’ defects reports should be entered by RailCorp into a computerised record and tracked to finalisation. |
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. |
REC121-3731 | 29 - Operational Health and Safety | RailCorp should develop a plan to be submitted to ITSRR to address the deficiencies in the safety culture of RailCorp, including: |
REC121-3759 | 29 - Operational Health and Safety | A Safety Reform Program Director (hereafter referred to as SRPD), reporting directly to the Chief Executive of RailCorp, should be retained to manage, as head of a Safety Reform Program Office, any safety reform program being undertaken by RailCorp. The SRPD should work with the Chief Executive and senior management to ensure the implementation of an integrated safety management system and the cultural change required. The SRPD must have qualifications suitable for recognition by the Australian Institute of Project Management as a master program director. He or she should report to and be under the control of the Chief Executive, to ensure that the accountability of the Chief Executive is not reduced. The SRPD should co-ordinate and integrate any existing rail safety reform programs and, in consultation with and with the authority of the Chief Executive he or she should: |
REC121-3757 | 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. |
REC121-3774 | 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: |
REC121-3737 | 29 - Operational Health and Safety | There must be a minimum of two independent methods of self-initiated emergency escape for passengers from all trains at all times. |
REC121-3665 | 14 - Incident Mgt Teams | The role of the rail commander should be to provide support and assistance to the site controller and emergency services personnel until the rescue phase of the emergency response to any rail accident is completed. |
REC121-3682 | 29 - Operational Health and Safety | All new rolling stock should be designed to be compatible with at least level 2 automatic train protection discussed in chapter 7 of this report. |
REC121-3743 | 29 - Operational Health and Safety | All passenger trains operating in New South Wales must have the external emergency door release clearly marked with the words “Emergency Door Release”. |
REC121-3691 | 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. |
REC121-3711 | 29 - Operational Health and Safety | The ITSRR should establish an electronic document control system to enable effective and reliable information to be gathered for monitoring the safety of the New South Wales rail system. |
REC121-3755 | 29 - Operational Health and Safety | The RailCorp Board should require a full review of the safety competence of RailCorp managers to ensure that each has the ability to bring about those safety reforms recommended in this report which are applicable to his or her position. |
REC121-3753 | 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. |
REC121-3729 | 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. |
REC121-3695 | 10 - Infrastructure | There should be interoperability of communications equipment between all trains operating on the New South Wales rail network. |
REC121-3735 | 29 - Operational Health and Safety | Risk assessments of occupational health and safety issues by RailCorp should include an analysis of broader public safety risks and not be confined to narrow occupational health and safety issues. |
REC121-3663 | 14 - Incident Mgt Teams | The incident command system should clearly identify the roles of the rail commander, site controller, police commander and commanders of the other emergency services, and the way in which each is to work together during the recovery phase of any rail accident. |
REC121-3681 | 29 - Operational Health and Safety | RailCorp should progressively implement, within a reasonable time, level 2 automatic train protection with the features identified in chapter 8 of this report. |
REC121-3741 | 29 - Operational Health and Safety | The operation of the train doors should have an override facility whereby the train driver or the guard can override an internal passenger emergency door release system if the door release is interfered with when there is no emergency. There should be an alarm, together with an intercom, in the train guard’s compartment so that, if a passenger attempts to initiate an emergency door release, there is an appropriate delay during which time an alarm sounds in the train guard’s compartment and the guard can then, after first attempting to speak via the intercom to the person concerned, if necessary, override the door release, and make an appropriate announcement over the intercom system in the train. |
REC121-3709 | 29 - Operational Health and Safety | RailCorp should provide access to electronic versions of safety documentation for all operational staff at their workplace. |
REC121-3754 | 29 - Operational Health and Safety | The RailCorp Board should ensure that RailCorp has an adequate and integrated safety management system, including adequate systems for risk assessment, clearly defined safety responsibilities and accountabilities for persons holding management positions, and specific performance criteria against which evaluations can be made of safety performance and accountability for safety performance of all managers. |
REC121-3726 | 25 - Inquiry, audit, lessons management and after action review | The OTSI should continue to conduct rail accident investigations on behalf of ITSRR and report directly to the Chief Executive of ITSRR. |
REC121-3723 | 38 - Agency/Department Reporting | All ATSB accident investigation reports should be made public. |
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. |
REC121-3734 | 29 - Operational Health and Safety | RailCorp should integrate its management of occupational health and safety into its overall safety management. |
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. |
REC121-3652 | 14 - Incident Mgt Teams | A designated staff member at the RMC should act as the rail emergency management co-ordinator. He or she should be the sole point of contact at the RMC with other rail personnel involved in the rail accident and emergency services personnel during the rescue phase of the emergency response. |
REC121-3680 | 29 - Operational Health and Safety | All trains must be fitted with a minimum of two independent engineering defences to minimise the risk of derailment or collision in the event of train driver incapacitation. |
REC121-3740 | 29 - Operational Health and Safety | The internal passenger emergency door release should be fitted with a facility which prevents it from operating unless the train is stationary. |
REC121-3707 | 29 - Operational Health and Safety | The safety document management system should provide for the distribution of electronic versions of safety documentation to relevant staff. |
REC121-3749 | 29 - Operational Health and Safety | All new rolling stock must be designed with an area of the roof through which emergency services personnel can access a rail car without encountering wiring or other equipment. That access point must be clearly marked with words such as “emergency services cut here”. |
REC121-3713 | 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. |
REC121-3722 | 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. |
REC121-3657 | 10 - Infrastructure | All signal telephones must be maintained by RailCorp in proper working order. |
Rec-ID | Code | Recommendation |
---|---|---|
REC119-3648 | 38 - Agency/Department Reporting | It is recommended that providers supply data to the Board: |
REC119-3649 | 25 - Inquiry, audit, lessons management and after action review | It is recommended that the Board: |
Rec-ID | Code | Recommendation |
---|---|---|
REC116-2107 | 10 - Infrastructure | The Working Group recommends that State/Territory emergency management plans should explicitly take the need for rapid assessment of damaged physical infrastructure into account. The importance of rapid physical infrastructure assessment in ensuring the supply of utilities including sewerage and drainage, electricity, water and gas to residential structures and other types should be recognised and considered. |
REC116-2122 | 33 - Relief and recovery | The Working Group recommends that States/Territories consider their ability to house large numbers of domestic pets, and where necessary, develop plans and arrangements that facilitate this need. |
REC116-2120 | 33 - Relief and recovery | The Working Group recommends that the National Recovery Coordinators Group considers the issue of emergency relief centres in the context of catastrophic disaster with a view to assisting jurisdictions to plan for the need to accommodate thousands of people following a disaster. |
REC116-2117 | 33 - Relief and recovery | The Working Group recommends that potential shortfalls in the capacity to deal with large numbers of unprotected children and other special needs groups in a catastrophic event be referred to the Disaster Recovery Sub Committee of Community Services Ministers’ Advisory Council (CSMAC) for consideration and report back. |
REC116-2103 | 33 - Relief and recovery | The Working Group recommends that jurisdictions plan for the logistics of supply and delivery of meals to large numbers of homebound persons in an attempt to identify possible ways of resolving existing shortcomings. |
Rec-ID | Code | Recommendation |
---|---|---|
REC111-3939 | 25 - Inquiry, audit, lessons management and after action review | It is recommended that the State Disaster Management Group and the Department of Emergency Services review the current disaster district boundary framework and its relevance to the regional boundaries established by other public sector lead entities to ensure that resources within the Disaster Management System are economically, efficiently and effectively allocated across Queensland. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |