Inquiry Search
Rec-ID | Code | Recommendation |
---|---|---|
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 |
REC002-4013 | 19 - Offences | Infringement of the regulations by either party should be followed by a summary form of justice, instituted before two Magistrates. |
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. |
REC002-4007 | 40 - Equipment and consumables | A measure of safety may be found in the use of high explosives combined with wet tamping, or, still better, water cartridges, instead of powder under any of its modifications. Encouragement ought also to be given to the use of patent multiple wedges and applicances of a like nature, for supplanting the use of explosives. Under all circumstances and conditions some provision should be adopted for compelling workmen to thoroughly undercut, shear, or nick, and generally to work the coal as directed by the Manager. |
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. |
REC002-4005 | 40 - Equipment and consumables | Where safety-lamps are used the lock should be of such a character as to prevent any workman opening it. If the "Protector" type of lamp be employed the necessity for a lock is the less necessary, as the unscrewing of this type of lamp extinguishes the light. |
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. |
REC002-4004 | 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. |
REC002-4010 | 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. |
REC002-4003 | 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. |
REC002-4009 | 16 - Training and behaviour | In gassy mines the Manager should be specially competent, and one possessing a thorough knowledge of the principles and practice of mining, the properties of gases, and systems of ventilation; and, above all, he must be prudent and cautious, yet resolute, possessing sound judgement. He must have absolute and supreme control over the whole operations, and of the men within the mine, to maintain rigid discipline, and be perfectly free and untrammelled by any outside influences. The competency of a manager should be certified by an examination before a specially-appointed Board. The Commission consider that better results may be obtained if such examinations be oral, and probably assume a more practical form than those hitherto conducted in Great Britain for the same object. |
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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC286-2030 | 32 - Doctrine, standards, and reform | Develop innovative response models of patient care to improve surge capacity. |
REC286-2062 | 32 - Doctrine, standards, and reform | Review State Special Emergency Plan: Human Influenza Pandemic Emergencies. |
REC286-2086 | 32 - Doctrine, standards, and reform | Develop SOP for recovery package. |
REC286-1437 | 9 - Community education | Continue the Bushfire Ready Neighbourhoods Program. |
REC286-2041 | 22 - Role of local Gvt | Development mechanisms to support small councils to manage treatment across the PPRR spectrum (across all hazards). |
REC286-2068 | 24 - Govt responsibility | Develop a disaster client record system. |
REC286-2095 | 37 - Funding | Investigate the costs and benefits of delivering a public education and awareness program. |
REC286-1444 | 16 - Training and behaviour | Maintain adequate seasonal fire crew resources across the fire agencies. |
REC286-2013 | 16 - Training and behaviour | State to develop a Swift Water rescue capability. |
REC286-2054 | 40 - Equipment and consumables | Personal protective equipment (masks, gowns, gloves, goggles) – review supply/distribution arrangements. |
REC286-2073 | 16 - Training and behaviour | Ensure people designing and certifying buildings are appropriately trained and qualified. |
REC286-1466 | 9 - Community education | Develop and deliver earthquake hazard awareness products. |
REC286-2029 | 32 - Doctrine, standards, and reform | Create a stakeholder plan template to aid heatwave preparedness and response in facilities occupied by people vulnerable to heatwaves (e.g. nursing homes) |
REC286-2060 | 32 - Doctrine, standards, and reform | Develop a flexible plan for establishing flu-specific services. |
REC286-2085 | 9 - Community education | Up-skill isolated communities in emergency PPRR skills. |
REC286-1434 | 16 - Training and behaviour | Improve the strategic resource-to-risk skills mix (recruitment, retention, capacity), including investigating difference models of volunteering within the TFS Brigade Network. |
REC286-2036 | 16 - Training and behaviour | Provide information on landslide hazards and risks to decision makers. |
REC286-2067 | 24 - Govt responsibility | Improve integration of health information systems. |
REC286-2093 | 37 - Funding | Investigate the costs and benefits in enhancing the current Tsunami warning arrangements with signage and audible warning systems at key exposed locations (e.g. Port Arthur and Kingston Beach). |
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. |
REC286-2053 | 40 - Equipment and consumables | Personal protective equipment (masks, gowns, gloves, goggles) – enhance stocktake methods. |
REC286-2072 | 35 - Business and Industry in relation to industry | Relax the requirement for medical certificates in the event of an outbreak. |
REC286-1462 | 32 - Doctrine, standards, and reform | Develop a strategic plan for the operation and management of the seismic monitoring network in Tasmania. |
REC286-2022 | 12 - EM agency and authority | Increase SES Capability and Capacity to respond to flood event. |
REC286-2059 | 24 - Govt responsibility | Enhance business continuity planning by the Tasmanian Health Service. |
REC286-2083 | 9 - Community education | Enhance the community development program. |
REC286-1481 | 32 - Doctrine, standards, and reform | Integrate clean-up arrangements into emergency plans. |
REC286-2035 | 9 - Community education | Include heatwave in existing preparedness programs. |
REC286-2065 | 16 - Training and behaviour | Deliver human influenza pandemic training and exercises in THS and other key organisations. |
REC286-2092 | 37 - Funding | Ensure sufficient investment in controls across the PPRR spectrum with a focus on Prevention and Mitigation. |
REC286-1440 | 9 - Community education | Expand the existing Fire Ready Schools Program with enhanced support and incorporate other sites used by vulnerable groups. |
REC286-2052 | 22 - Role of local Gvt | Undertake local level emergency management planning for areas at risk of debris flow. |
REC286-2071 | 29 - Operational Health and Safety | Implement a social marking program to promote improved respiratory etiquette and hygiene. |
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. |
REC286-2021 | 40 - Equipment and consumables | Review temporary bridge stockpile for adequacy (DSG). |
REC286-2058 | 24 - Govt responsibility | Clarify the relationship between the DHHS and THS in the establishment of flu services. |
REC286-2080 | 32 - Doctrine, standards, and reform | Formalise response triage arrangements. |
REC286-1477 | 16 - Training and behaviour | Develop and deliver flood incident response management training to SES personnel. |
REC286-2034 | 9 - Community education | Improve community educational information. |
REC286-2064 | 35 - Business and Industry in relation to industry | Encourage businesses to consider human influenza pandemics in business continuity planning. |
REC286-2091 | 37 - Funding | Investigate the costs and benefits in enhancing the current Tsunami detection buoy network. |
REC286-1439 | 9 - Community education | Continue the Community Bushfire Protection Program with a renewed focus on vulnerable groups. |
REC286-2043 | 22 - Role of local Gvt | Assessment of council’s capacity to manage land effectively. |
REC286-2070 | 25 - Inquiry, audit, lessons management and after action review | Test the Biosecurity Act 2015. |
REC286-1449 | 9 - Community education | Develop coastal inundation education materials that meet the needs of exposed communities. |
REC286-2019 | 24 - Govt responsibility | Assess water supply resilience in the case of an interruption. |
REC286-2057 | 16 - Training and behaviour | Provide training sessions to GPs to improve their understanding of their roles, options and obligations relating to human influenza pandemic. |
REC286-2076 | 36 - Volunteers | Review volunteering arrangements to improve recruitment and retention. |
REC286-1476 | 9 - Community education | Develop and implement a targeted community flood awareness program. |
REC286-2033 | 24 - Govt responsibility | Incorporate heatwave surge response planning into business continuity planning. |
REC286-2063 | 24 - Govt responsibility | Review Tas Govt interoperability arrangements. |
REC286-2088 | 9 - Community education | Develop a community education strategy for when to call 000, 131 444, and 132 500. |
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. |
REC286-2042 | 32 - Doctrine, standards, and reform | Increased regulation of landslide risk assessment. |
REC286-2069 | 24 - Govt responsibility | Implement a database management approach for notifiable disease record systems. |
REC286-2096 | 32 - Doctrine, standards, and reform | Review current all-hazards emergency management arrangements to evaluate if they adequately address Tsunami response and recovery requirements. |
REC286-1446 | 9 - Community education | Introduce child-centred household level disaster risk reduction strategies in school programs. |
REC286-2018 | 12 - EM agency and authority | Review flood response sustainment capacity of organisations. |
REC286-2055 | 29 - Operational Health and Safety | Personal protective equipment (masks, gowns, gloves, goggles) – review fit-testing vs fit-checking. |
REC286-2075 | 9 - Community education | Develop and implement a community storm safe awareness program. |
REC286-1470 | 32 - Doctrine, standards, and reform | Integrate Storage Operating Rules with downstream flood response plans. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC285-2518 | 38 - Agency/Department Reporting | The report recommends that regional summary reports of clinical reviews be standardised to facilitate review and comparison across regions. |
REC285-2523 | 32 - Doctrine, standards, and reform | The report recommends that Ambulance Tasmania regularly reviews its emergency and urgent determinants methodology to ensure that it continues to be best practice and in accordance with requirements of the National Academy of Emergency Medical Dispatch. |
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. |
REC285-2522 | 12 - EM agency and authority | The report recommends that Ambulance Tasmania reinforce the requirement to record factors contributing to response time outliers and the remedial action undertaken to address the contributing factors. |
REC285-2521 | 36 - Volunteers | The report recommends that Ambulance Tasmania investigate whether higher proportions of volunteers were impacting on mobilisation times in the North. |
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. |
REC285-2519 | 12 - EM agency and authority | The report recommends that Ambulance Tasmania develop strategies to improve response times to those of other jurisdictions and undertake cost benefit analysis of those strategies before deciding on implementation. |
Rec-ID | Code | Recommendation |
---|---|---|
REC279-1228 | 36 - Volunteers | Volunteer Workforce Plan: By December 2014, develop a volunteer workforce plan to focus resources for recruitment and retention on areas of greatest need. The plan should be based on regional capability plans that assess in a consistent way: a) how many volunteers they have and need b) the gaps and risks around volunteer numbers, skills and training |
REC279-1227 | 36 - Volunteers | Improve Analysis and Reporting: By December 2014, improve analysis and reporting on management information about volunteers, including: a) numbers, contribution, skills, profile, availability and turnover b) reasons for joining and leaving c) gaps in data completeness and quality This should enable SES to demonstrate an improvement in the completeness and accuracy of management information by April 2015 |
REC279-1232 | 16 - Training and behaviour | Volunteer Charter: by December 2014, agree a charter with volunteers that clarifies roles and expectations including commitments by: a) SES to support volunteers to prepare for and respond to emergencies b) SES to make the best use of volunteers’ time by introducing user-friendly systems and reducing the administrative burden on them c) volunteers to turn-out when called to respond to emergencies. |
REC279-1231 | 16 - Training and behaviour | Training Strategy: By April 2015, develop a training strategy that identifies volunteer training priorities and provides for ongoing review to ensure operational currency, flexibility of delivery and evaluation |
REC279-1230 | 36 - Volunteers | Volunteer Retention: By April 2015, develop strategies and resources to improve volunteer retention, including: a) induction and development of leaders b) health checks for units to identify and address areas for improvement c) pathways for volunteers to take on greater responsibility d) consultation and communication e) recognition for volunteers and their employers |
REC279-1229 | 12 - EM agency and authority | Recruitment Guidelines and Resources: By April 2015, update its recruitment guidelines and resources, and support units in better targeting recruitment |
Rec-ID | Code | Recommendation |
---|---|---|
REC266-1535 | 21 - Role of Commonwealth Government | To provide improved oversight and assurance in its administration of the Natural Disaster Relief and Recovery Arrangements, the Australian National Audit Office (ANAO) recommends that the Attorney‐General’s Department: |
REC266-1534 | 21 - Role of Commonwealth Government | The Australian National Audit Office (ANAO) recommends that the Attorney‐General’s Department significantly improve the administration of disaster relief and recovery funding by: |
Rec-ID | Code | Recommendation |
---|---|---|
REC258-2541 | 16 - Training and behaviour | The Civil Aviation Safety Authority finalises its Capability Framework and overhauls its training program to ensure identified areas of need are addressed, including: |
REC258-2529 | 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. |
REC258-2549 | 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. |
REC258-2534 | 16 - Training and behaviour | The Civil Aviation Safety Authority develops a staff exchange program with industry. |
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: |
REC258-2539 | 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. |
REC258-2562 | 32 - Doctrine, standards, and reform | The Civil Aviation Safety Authority amends the current Terms of Reference of the Industry Complaints Commissioner so that: |
REC258-2528 | 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. |
REC258-2547 | 12 - EM agency and authority | The Civil Aviation Safety Authority establishes small offices at specific industry centres to improve monitoring, service quality, communications and collaborative relationships. |
REC258-2533 | 32 - Doctrine, standards, and reform | The Civil Aviation Safety Authority: |
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. |
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. |
REC258-2561 | 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. |
REC258-2527 | 32 - Doctrine, standards, and reform | The Department of Infrastructure and Regional Development plays a stronger policy role in the State Safety Program. |
REC258-2546 | 12 - EM agency and authority | The Civil Aviation Safety Authority changes its organisational structure to a client-oriented output model. |
REC258-2532 | 12 - EM agency and authority | The next Director of Aviation Safety has leadership and management experience and capabilities in cultural change of large organisations. Aviation or other safety industry experience is highly desirable. |
REC258-2553 | 12 - EM agency and authority | The Civil Aviation Safety Authority establishes a safety oversight risk management hierarchy based on a categorisation of operations. Rule making and surveillance priorities should be proportionate to the safety risk. |
REC258-2537 | 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. |
REC258-2560 | 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. |
REC258-2526 | 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. |
REC258-2545 | 12 - EM agency and authority | The Australian Transport Safety Bureau transfers its safety education function to the Civil Aviation Safety Authority. |
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. |
REC258-2552 | 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. |
REC258-2536 | 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. |
REC258-2558 | 12 - EM agency and authority | The Civil Aviation Safety Authority applies a project management approach to the completion of all Civil Aviation Safety Regulation Parts not yet in force, with drafting to be completed within one year and consultation completed one year later, with: |
REC258-2542 | 16 - Training and behaviour | The Civil Aviation Safety Authority publishes and demonstrates the philosophy of ‘just culture’ whereby individuals involved in a reportable event are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training. However, actions of gross negligence, wilful violations and destructive acts should not be tolerated. |
REC258-2530 | 24 - Govt responsibility | The Australian Government appoints an additional Australian Transport Safety Bureau Commissioner with aviation operational and safety management experience. |
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. |
REC258-2535 | 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’. |
REC258-2556 | 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. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC256-1560 | 37 - Funding | The Australian Government should: |
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. |
REC256-1575 | 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. |
REC256-1559 | 37 - Funding | The Australian Government should gradually increase the amount of annual mitigation funding it provides to state and territory governments to $200 million. Initially, this funding should be distributed to state and territory governments in accordance with the allocation under the National Partnership Agreement on Natural Disaster Resilience. |
REC256-1567 | 24 - Govt responsibility | State and territory governments should: |
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. |
REC256-1558 | 37 - Funding | Funding to state and territory governments for community recovery should be provided as untied grants, with a transition period pending the development of a framework to assess community recovery costs. During the transition period, the Australian Government should continue to provide funding for community recovery through a reimbursement model. |
REC256-1566 | 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. |
REC256-1573 | 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: |
REC256-1557 | 37 - Funding | Where asset management plans at the local, state or territory level pre-identify and cost betterment of assets (improving asset resilience to natural disasters), the Australian Government should share 50 per cent of the betterment component of reconstruction costs following damage from a (eligible) natural disaster. |
REC256-1562 | 32 - Doctrine, standards, and reform | The Australian Government should: |
REC256-1571 | 24 - Govt responsibility | State and territory taxes and levies on general insurance should be phased out and replaced with less distortionary taxes. |
REC256-1577 | 37 - Funding | The Australian Government should develop a formula for allocating mitigation funding to state and territory governments on the basis of where such funding is likely to achieve the greatest net benefits, taking into account the future risks of natural disasters. This should be completed within five years and in consultation with state and territory governments. |
REC256-1556 | 37 - Funding | The Australian Government should fund natural disaster recovery by: |
REC256-1561 | 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. |
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. |
REC255-1578 | 32 - Doctrine, standards, and reform | The ANAO recommends that the Department of Defence review the minimum information necessary to be reported for each emergency DACC task to discharge accountability obligations, identify costs, undertake cost recovery where appropriate, maintain records for future use and learn from emergency DACC activities |
Rec-ID | Code | Recommendation |
---|---|---|
REC245-2590 | 12 - EM agency and authority | That: |
REC245-2598 | 24 - Govt responsibility | That government considers the establishment of a separate unit to implement and operate a Whole of Government network if existing stakeholders fail to make significant progress toward an agreed Whole of Government solution. |
REC245-2596 | 24 - Govt responsibility | That the Whole of Government project’s objectives should include meeting entity requirements and the consultant be asked to reevaluate the revised set of objectives. |
REC245-2592 | 37 - Funding | That duplication of infrastructure be costed and taken into account when considering whether to proceed with the Whole of Government network. |
Rec-ID | Code | Recommendation |
---|---|---|
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 |
REC237-0819 | 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. |
REC237-0830 | 9 - Community education | That Bush Fire Risk Management Plans be tabled at Local Emergency Management Committees for comment. |
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. |
REC237-0829 | 9 - Community education | That Bush Fire Risk Management Plans be posted on the NSW Rural Fire Service website. |
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. |
REC237-0834 | 37 - Funding | That the NSW Rural Fire Service apply for funding from the NSW Treasury for the development of a multi-agency business case for a BRIMS replacement that includes internal management, risk communication, community engagement capability and publishing activities on websites. |
REC237-0822 | 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. |
REC237-0828 | 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. |
REC237-0833 | 37 - Funding | That the NSW Rural Fire Service and the NSW Treasury explore ways to ensure that unspent hazard reduction funds be carried over to the next financial year in a timely manner and to ensure that hazard reduction funding has a seamless transition from one financial year to the next. |
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. |
REC237-0827 | 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. |
REC237-0820 | 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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC236-2796 | 32 - Doctrine, standards, and reform | The committee recommends that the ATSB-CASA Memorandum of Understanding be re-drafted to remove any ambiguity in relation to information that should be shared between the agencies in relation to aviation accident investigations, to require CASA to: |
REC236-2785 | 32 - Doctrine, standards, and reform | The committee recommends that the ATSB move away from its current approach of forecasting the probability of future events and focus on the analysis of factors which allowed the accident under investigation to occur. This would enable the industry to identify, assess and implement lessons relevant to their own operations. |
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. |
REC236-2790 | 12 - EM agency and authority | The committee recommends that an expert aviation safety panel be established to ensure quality control of ATSB investigation and reporting processes along the lines set out by the committee. |
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. |
REC236-2795 | 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. |
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. |
REC236-2784 | 32 - Doctrine, standards, and reform | The committee recommends that the minister, in issuing a new Statement of Expectations to the ATSB, valid from 1 July 2013, make it clear that safety in aviation operations involving passengers (fare paying or those with no control over the flight they are on, e.g. air ambulance) is to be accorded equal priority irrespective of flight classification. |
REC236-2789 | 32 - Doctrine, standards, and reform | The committee recommends that the Transport Safety Investigation Act 2003 be amended to require that the Chief Commissioner of the ATSB be able to demonstrate extensive aviation safety expertise and experience as a prerequisite for the selection process. |
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. |
REC236-2794 | 32 - Doctrine, standards, and reform | The committee recommends that CASA, in consultation with an Emergency Medical Services industry representative group (eg. Royal Flying Doctor Service, air ambulance operators, rotary wing rescue providers) consider the merit, form and standards of a new category of operations for Emergency Medical Services. The minister should require CASA to approve the industry plan unless there is a clear safety case not to. Scope for industry to assist as part of an audit team should also be investigated where standardisation is an issue. This should be completed within 12 months and the outcome reported publicly. |
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. |
REC236-2788 | 16 - Training and behaviour | The committee recommends that, as far as available resources allow, ATSB investigators be given access to training provided by the agency's international counterparts. Where this does not occur, resultant gaps in |
REC236-2804 | 32 - Doctrine, standards, and reform | The committee recommends that Airservices Australia discuss the safety case for providing a hazard alert service with Fijian and New Zealand ATC (and any other relevant jurisdictions) and encourage them to adopt this practice. |
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. |
REC236-2798 | 32 - Doctrine, standards, and reform | The committee recommends that, where relevant, the ATSB include thorough human factors analysis and discussion in future investigation reports. Where human factors are not considered relevant, the ATSB should include a statement explaining why. |
REC236-2787 | 16 - Training and behaviour | The committee recommends that the training offered by the ATSB across all investigator skills sets be benchmarked against other agencies by an independent body by, for example, inviting the NTSB or commissioning an industry body to conduct such a benchmarking exercise. |
REC236-2803 | 32 - Doctrine, standards, and reform | The committee recommends that the government consider setting a time limit for agencies to implement or reject recommendations, beyond which ministerial oversight is required where the agencies concerned must report to the minister why the recommendation has not been implemented or that, with ministerial approval, it has been formally rejected. |
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. |
REC236-2808 | 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. |
REC236-2797 | 12 - EM agency and authority | The committee recommends that all meetings between the ATSB and CASA, whether formal or informal, where particulars of a given investigation are being discussed be appropriately minuted. |
REC236-2786 | 32 - Doctrine, standards, and reform | The committee recommends that the ATSB be required to document investigative avenues that were explored and then discarded, providing detailed explanations as to why. |
REC236-2802 | 32 - Doctrine, standards, and reform | The committee recommends that where the consideration and implementation of an ATSB recommendation may be protracted, the requirement for regular updates (for example 6 monthly) should be included in the TSI Act. |
REC236-2791 | 37 - Funding | The committee recommends that the government develop a process by which the ATSB can request access to supplementary funding via the minister. |
REC236-2807 | 32 - Doctrine, standards, and reform | The committee recommends that the Aeronautical Information Package (AIP) En Route Supplement Australia (ERSA) is updated to reflect the need for caution with regard to Norfolk Island forecasts where the actual conditions can change rapidly and vary from forecasts. |
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: |
REC231-2829 | 32 - Doctrine, standards, and reform | The Australian National Audit Office (ANAO) recommends that the Department of Regional Australia, Local Government, Arts and Sport, in preparation for the forthcoming reviews of the National Partnership Agreements, identify the most effective means of obtaining the project level information on the respective reconstruction programs required by the Agreements to be reported on and, if appropriate, seek amendments to the Agreements. |
Rec-ID | Code | Recommendation |
---|---|---|
REC230-2835 | 37 - Funding | The committee recommends that the Australian Government direct an appropriate portion of the proceeds derived from the auction of spectrum to fund the allocation of 20 MHz of spectrum in the 700 MHz band for the purposes of a national public safety mobile broadband network. |
REC230-2834 | 32 - Doctrine, standards, and reform | The committee recommends that the Attorney-General's Department facilitate a public consultation process on a regulatory framework for overflow arrangements between public safety agencies and commercial carriers. |
Rec-ID | Code | Recommendation |
---|---|---|
REC229-2845 | 24 - Govt responsibility | The committee recommends that the Commonwealth government works with state and territory governments to continue to implement the recommendations of the Productivity Commission report, where possible, to improve coordination in relation to climate change adaptation. |
REC229-2843 | 32 - Doctrine, standards, and reform | The committee recommends that Commonwealth, state and territory governments ensure that all facilities caring for vulnerable groups, in particular hospitals, schools, childcare and aged care facilities, have emergency management plans, relevant to their geographic settings, in place and regularly revised. |
REC229-2839 | 32 - Doctrine, standards, and reform | The committee recommends that disincentives to insurance, such as taxes and levies applied by the states and territories, should be removed as part of a national reform process. |
Rec-ID | Code | Recommendation |
---|---|---|
REC208-0527 | 35 - Business and Industry in relation to industry | That the Office of Environment and Heritage require Orica to engage and fund appropriate independent experts to oversee any modifications to the plant in the next major maintenance overhaul of the plant in 2016 and in any upgrades to the plant prior to that date. |
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. |
REC208-0530 | 32 - Doctrine, standards, and reform | That, if necessary, regulation be amended to require Health to approve any script used by any party concerned, for door knocking or other information dissemination, if Health is not the first source of information to affected residents. |
REC208-0529 | 32 - Doctrine, standards, and reform | That, when developing requirements concerning pollution incident response management plans pursuant to the recent legislative amendments, the Office of Environment and Hertiage include appropriate definitions as to the meaning of ‘immediately’, and when ‘material harm to the environment is caused or threatened’. |
REC208-0528 | 32 - Doctrine, standards, and reform | That, as part of the Pollution Incident Management Response Plan to be developed for Orica’s Kooragang Island site, or by another appropriate mechanism, the Office of Environment and Heritage ensure that Orica’s incident-response procedures address the need to consider all relevant factors when assessing potential impacts, including the height and force of emissions as well as the location of any onsite fallout and whether there are off-site impacts following all serious incidents. |
Rec-ID | Code | Recommendation |
---|---|---|
REC207-2887 | 21 - Role of Commonwealth Government | Centralise media services and establish protocols for media activity. |
REC207-2873 | 21 - Role of Commonwealth Government | Boost the Bureau’s flood warning capacity by: |
REC207-2892 | 37 - Funding | Apply a consistent cost-recovery model to all services delivered to state/territory fire agencies. |
REC207-2878 | 21 - Role of Commonwealth Government | Complete workforce planning project and succession plans as a matter of urgency. |
REC207-2896 | 21 - Role of Commonwealth Government | Lower yield options identified by the Bureau: |
REC207-2886 | 21 - Role of Commonwealth Government | Explore options to limit forecaster intervention in site-specific web forecasts. |
REC207-2872 | 21 - Role of Commonwealth Government | Boost the number of frontline meteorologists to build response capacity in regional forecasting centres. |
REC207-2891 | 21 - Role of Commonwealth Government | Cease or reduce the Ionospheric Prediction Service or offer it as a commercial service. |
REC207-2877 | 37 - Funding | Explore opportunities to re-phase investments in large scale projects and programs such as the Strategic Radar Enhancement Program, the NexGen Forecast and Warning System Products and the Improving Water Information Program. |
REC207-2896 | 21 - Role of Commonwealth Government | Lower yield options identified by the Bureau: |
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 |
REC207-2900 | 21 - Role of Commonwealth Government | Explore use of social media to enhance data gathering from authorised and informal sources and to disseminate weather information |
REC207-2890 | 37 - Funding | Review and rebalance relative investment in long term climate modelling and medium-term seasonal outlook. |
REC207-2876 | 21 - Role of Commonwealth Government | Focus the Bureau’s evolving environmental information role on natural hazards in the first instance. |
REC207-2895 | 21 - Role of Commonwealth Government | Fund delivery of improved seasonal forecasting services by: |
REC207-2883 | 32 - Doctrine, standards, and reform | Start a project to introduce organisational process thinking with a view to standardising processes and product specifications. |
REC207-2899 | 21 - Role of Commonwealth Government | Improved seasonal forecasting capabilities: |
REC207-2889 | 37 - Funding | Review level of investment in research activities to free up budget and reduce pressure on computing capacity |
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: |
REC207-2894 | 21 - Role of Commonwealth Government | Phase out seasonal prediction development and modelling and rely on products generated elsewhere |
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 |
REC207-2898 | 21 - Role of Commonwealth Government | Upgrade to the Bureau’s supercomputing capacity: |
REC207-2888 | 35 - Business and Industry in relation to industry | Foster private sector service providers who can offer tailored services or broadcast high quality presentation of general purpose weather information |
REC207-2874 | 32 - Doctrine, standards, and reform | Formalise and standardise service levels provided to emergency services. |
REC207-2893 | 37 - Funding | Explore options to obtain revenue from advertising on the Bureau’s website |
REC207-2879 | 37 - Funding | Firm up approval processes and funding for any departures from provision of the basic product set |
REC207-2897 | 21 - Role of Commonwealth Government | Additional frontline meteorologists and specialised centres and systems: |
Rec-ID | Code | Recommendation |
---|---|---|
REC206-1894 | 21 - Role of Commonwealth Government | The Committee recommends that the Minister for Financial Services and Superannuation immediately establish a joint industry-Government action group to address evidence of the rising costs and market failure of insurance premiums across Australia. |
REC206-1883 | 32 - Doctrine, standards, and reform | The Committee recommends that the Australian Government amend the Insurance Contracts Act 1984 (Cth) so that from 1 July 2012 any derogation from Standard Cover is required to be communicated to policyholders as a departure from ideal standards: |
REC206-1888 | 24 - Govt responsibility | The Committee recommends that the Australian Government empower the Australian Securities and Investments Commission to regulate claims handling and settlement of financial service providers. This can be achieved by the Treasurer introducing legislation by 1 July 2012 to give effect to the measures contained in Schedule 1, Part 1 of the lapsed Insurance Contracts Amendment Bill 2010, so that breaches of the duty of utmost good faith in relation to claims handling constitute a breach of the Insurance Contracts Act. |
REC206-1893 | 21 - Role of Commonwealth Government | The Committee recommends that the Australian Government investigate ways to reduce the cost of calling 1300 numbers from mobile telephones in areas of natural disasters. |
REC206-1882 | 32 - Doctrine, standards, and reform | The Committee recommends that the Australian Government amend the Insurance Contracts Act 1984 (Cth) to make it obligatory that insurers offer to consumers the option of a general insurance policy that conforms to Standard Cover, as prescribed in the Insurance Contracts Regulations 1985 (Cth), from 1 July 2012, so that all insurers carry a product that provides full replacement in the event of total loss and cover for damages resulting from flood. |
REC206-1887 | 32 - Doctrine, standards, and reform | The Committee recommends that the Australian Securities and Investments Commission amend Regulatory Guideline 139 by 1 July 2012 to require the Financial Ombudsman Service to report regularly to the Australian Securities and Investments Commission and also to make public: |
REC206-1892 | 37 - Funding | The Committee recommends that the Australian Government allocate additional and continuing funding in the 2012–2013 budget to the Insurance Law Service to establish a consumer advisory position at the Financial Services Ombudsman. The position should be co-funded by the Insurance Law Service and the insurance industry. |
REC206-1886 | 21 - Role of Commonwealth Government | The Committee recommends that the Australian Government work with the Insurance Council of Australia to make the following amendments to the General Insurance Code of Practice by 1 July 2012: |
REC206-1891 | 37 - Funding | The Committee recommends that the Australian Government and relevant State and territory governments jointly allocate additional and continuing funding in the 2012–13 budget to the Insurance Law Service for the mobilisation of a temporary physical presence in areas of need following natural disasters. The service should be available to all persons in an affected disaster area and not subject to means-testing. |
REC206-1885 | 24 - Govt responsibility | The Committee recommends that the Australian Government introduce legislative changes required to remove the exemption for general insurers to unfair contract terms laws, and ensure its enactment by the end of 2012. |
REC206-1890 | 32 - Doctrine, standards, and reform | The Committee recommends that the Australian Securities and Investments Commission amend Regulatory Guideline 165 to: |
REC206-1884 | 24 - Govt responsibility | The Committee recommends that the Australian Parliament pass the Insurance Contracts Amendment Bill 2011 and ensure its enactment by 1 July 2012. The Committee further recommends that the standard definition of ‘flood’ be included in the definition of Standard Cover in the Insurance Contracts Regulations 1985. |
REC206-1889 | 32 - Doctrine, standards, and reform | The Committee recommends that the Australian Government introduce legislation by 1 March 2013 to make adherence to the General Insurance Code of Practice a compulsory requirement for all general insurers. |
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. |
REC205-1898 | 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. |
REC205-1897 | 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. |
REC205-1904 | 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. |
REC205-1896 | 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: |
REC205-1903 | 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: |
REC205-1895 | 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. |
REC205-1902 | 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 |
---|---|---|
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. |
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. |
REC189-2911 | 29 - Operational Health and Safety | The review team recommend 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. |
REC189-2914 | 32 - Doctrine, standards, and reform | The review team recommend that: |
REC189-2908 | 21 - Role of Commonwealth Government | To ensure that NOPSEMA is in a strong position to perform its functions effectively: |
REC189-2913 | 21 - Role of Commonwealth Government | In developing and improving its policies and practices for stakeholder engagement, NOPSA should ensure that: |
Rec-ID | Code | Recommendation |
---|---|---|
REC186-0398 | 9 - Community education | The committee recommends emergency service organisations in collaboration with television and radio broadcasters, the print media and other relevant organisations, use regular and ongoing public education well in advance of an emergency situation as an opportunity to teach the public about their responsibilities during an emergency and how they can appropriately prepare themselves for such an event. |
REC186-0397 | 21 - Role of Commonwealth Government | The committee recommends the Commonwealth Government require guaranteed access to emergency call services for people with a disability at all times. |
REC186-0396 | 32 - Doctrine, standards, and reform | The committee recommends that the Commonwealth Government together with national, state and territory emergency service organisations and radio and television broadcasters, develop a secure database of up-to-date contact details for key personnel to be used during an emergency. |
Rec-ID | Code | Recommendation |
---|---|---|
REC185-1931 | 37 - Funding | The committee recommends that the Commonwealth Grants Commission ensures that as part of the current redesign of its data request, state and territory governments are required to include their past insurance and reinsurance receipts for natural disaster insurance premiums. These data must be taken into account by the Commission in determining the states' GST share. |
Rec-ID | Code | Recommendation |
---|---|---|
REC174-2987 | 9 - Community education | To improve customer awareness of the availability of disaster recovery assistance, the ANAO recommends that Centrelink: |
REC174-2986 | 32 - Doctrine, standards, and reform | The ANAO recommends that Centrelink assess the reliability of emergency recovery payment data and reports generated from its system(s), and update the approach, standards and procedures for the collection, storage and use of the data. |
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 |
---|---|---|
REC162-3015 | 35 - Business and Industry in relation to industry | ESWG recommends National Gas Emergency Response Advisory Committee maintain its industry, jurisdiction and consumer representation noting the importance of input from each of these groups in developing its advice. |
REC162-3020 | 35 - Business and Industry in relation to industry | ESWG recommends that as far as reasonably practical, arrangements for load shedding be as transparent as possible to give consumers confidence in the process. |
REC162-3014 | 35 - Business and Industry in relation to industry | ESWG recommends consideration be given to leveraging AEMO’s expanded responsibilities in gas markets by undertaking the role of the National Gas Emergency Response Advisory Committee (NGERAC) Secretariat while the Commonwealth continue as Chair, with the Chair’s position to be reviewed once the short term trading market (STTM) commences in June 2010. ESWG also recommends that the review be undertaken by NGERAC jurisdictional members. |
REC162-3019 | 35 - Business and Industry in relation to industry | ESWG recommends consideration be given to the spokesperson role AEMO can undertake during an electricity and/or gas supply shortfall in its covered markets and relevant jurisdictional emergencies, noting that AEMO has clear responsibility for the bulk supply of electricity as outlined in the Power System Emergency Management Plan and the Victorian wholesale gas market, and that for multi-jurisdiction gas supply emergencies, any AEMO spokesperson role would be to reflect NGERAC’s advice. |
REC162-3013 | 35 - Business and Industry in relation to industry | ESWG recommends consideration be given to consolidating gas and electricity network status and emergency information on one webpage for central communication. |
REC162-3018 | 35 - Business and Industry in relation to industry | ESWG recommends consideration of a review of communication protocols with the aim of achieving high level policy consistency of communication across jurisdictions to the maximum extent possible. |
REC162-3012 | 35 - Business and Industry in relation to industry | ESWG recommends reviewing AEMO’s Gas Bulletin Board (GBB) to ensure it is effectively communicating all publicly available information to market participants to assist in monitoring daily gas supplies, and any changes to the GBB rules required to improve information and awareness of any potential shortages that will assist the market to make the necessary investments and/or adjustments in maintenance. |
REC162-3017 | 35 - Business and Industry in relation to industry | ESWG notes NGERAC already informally advises ministers on the possible effects of gas emergencies on electricity supplies. ESWG recommends formalising this role by acknowledging it in NGERAC’s MOU. ESWG also recommends an editorial review of NGERAC’s MOU to ensure accuracy and consistency. |
REC162-3022 | 35 - Business and Industry in relation to industry | ESWG recommends consideration of how to ensure good communication and flow of information between the liquid fuels and other energy sectors. One approach that may be considered is that: |
REC162-3011 | 35 - Business and Industry in relation to industry | ESWG recommends consideration be given to expanding the role of AEMO in providing market information on gas by: |
REC162-3016 | 37 - Funding | ESWG recommends investigation of options to fund NGERAC’s on-going activities including through AEMO’s funding model. |
REC162-3021 | 35 - Business and Industry in relation to industry | ESWG notes that existing and future contracts and the impending introduction of the Short Term Trading Market will be the primary mechanisms for addressing future gas supply shortfalls. |
REC162-3010 | 35 - Business and Industry in relation to industry | Energy Security Working Group (ESWG) recommends consideration be given to government and industry working together to understand that investment opportunities in the energy sector are realised in a timely fashion to better manage potential longer term supply shortfalls. |
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. |
REC161-3034 | 12 - EM agency and authority | That National Offshore Petroleum Safety Authority critically review its regulatory manning levels based on its current workload and the recommendations for additional areas of focus and increased auditing presented in this Report. To meet these requirements, we estimate that National Offshore Petroleum Safety Authority requires up to 50 inspectors in total plus associated support staff to bring overall staffing from about 55 to 75. RET should help facilitate the necessary ongoing levy funding in consultation with industry. |
REC161-3039 | 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. |
REC161-3028 | 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. |
REC161-3038 | 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. |
REC161-3024 | 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 |
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. |
REC161-3037 | 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. |
REC161-3023 | 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. |
REC161-3026 | 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. |
REC161-3036 | 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. |
REC161-3025 | 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. |
REC161-3035 | 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. |
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: |
REC160-3043 | 21 - Role of Commonwealth Government | The ANAO recommends that Centrelink develop and promulgate a business continuity plan (BCP) template and require business units to develop BCPs that identify: |
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: |
REC160-3041 | 21 - Role of Commonwealth Government | To improve the governance arrangements for business continuity management (BCM) in Centrelink ,the Australian National Audit Office (ANAO) |
Rec-ID | Code | Recommendation |
---|---|---|
REC159-3061 | 32 - Doctrine, standards, and reform | ACTAS should develop and implement policies and guidance to staff on how complaints should be assessed and actioned, including timeliness targets. |
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. |
REC159-3055 | 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. |
REC159-3060 | 32 - Doctrine, standards, and reform | ACTAS should develop a policy that provides direction on what type of feedback it will seek, from whom it will seek the feedback, and how this feedback will be used to improve the patient care experience. |
REC159-3049 | 12 - EM agency and authority | ACTAS should enhance its approach to demand modelling in order to better guide current and future ambulance resourcing by: |
REC159-3054 | 12 - EM agency and authority | ACTAS should improve systems to manage its non-emergency transport services, provide training and guidance to staff on use of these systems, and implement a quality assurance process. |
REC159-3059 | 38 - Agency/Department Reporting | ACTAS should establish a clinical information database that: |
REC159-3048 | 12 - EM agency and authority | ACTAS should enhance its approach to risk management by: |
REC159-3053 | 32 - Doctrine, standards, and reform | ACTAS should develop policies and guidelines to assist ambulance officers’ decisions on whether or not to transport a patient to hospital. This guidance might include appropriate responses when a mentally impaired patient declines transport or treatment, and when to call on management or clinical guidance. |
REC159-3058 | 25 - Inquiry, audit, lessons management and after action review | ACTAS should improve patient care processes by: |
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. |
REC159-3052 | 12 - EM agency and authority | ACTAS should develop and implement as a matter of priority, appropriate strategies to address declining response times. |
REC159-3057 | 32 - Doctrine, standards, and reform | ACTAS should conduct formal reviews of its clinical procedures manuals in consultation with its Clinical Advisory Committee, and develop guidance to oversight these reviews. |
REC159-3046 | 12 - EM agency and authority | ACT Ambulance Service (ACTAS) should revise its Business Plan to address key priorities and activities for each key service delivery function. This would include clearer expected outputs to be delivered annually and their prioritisation. |
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. |
REC159-3051 | 32 - Doctrine, standards, and reform | ACTAS should: |
REC159-3056 | 32 - Doctrine, standards, and reform | ACTAS should specify and document the role of each of its various clinical governance processes, how they relate to each other, and how these will be managed, measured and monitored within an overarching clinical framework. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC149-3131 | 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. |
REC149-3136 | 16 - Training and behaviour | There is a need for industry in consultation with NOPSA to establish a priority programme of accredited education modules in the Safety Case regime targeting stakeholders in the regime at their respective levels to improve the understanding of the Safety Case and correspondent responsibilities. |
REC149-3142 | 19 - Offences | NOPSA should use encouragement as the primary tool of enforcing compliance provided willingness to improve is exhibited by the players. |
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. |
REC149-3147 | 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. |
REC149-3135 | 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. |
REC149-3141 | 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. |
REC149-3129 | 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. |
REC149-3146 | 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. |
REC149-3134 | 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. |
REC149-3140 | 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. |
REC149-3128 | 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. |
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. |
REC149-3138 | 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. |
REC149-3144 | 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. |
REC149-3132 | 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. |
REC149-3137 | 16 - Training and behaviour | As professional competency is one of the key pillars of any Safety Case, commitment to training for current and future needs remains a fundamental requirement for achieving best practice outcomes in safety. Industry should be encouraged to build on its training commitment now being made to achieve a competent and fully accredited workforce over the next five years. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC147-3190 | 32 - Doctrine, standards, and reform | The ANAO recommends that, to facilitate EMA’s response to requests for assistance in overseas emergency management situations, a statement of the broad principles, responsibilities and performance expectations to apply when EMA is involved in overseas operations be developed and agreed between EMA, DFAT, AusAID and other relevant stakeholders. |
REC148-3189 | 37 - Funding | The ANAO recommends that, to ensure that grant conditions are satisfied, EMA enhance procedures to monitor the progress of projects and follow up those behind schedule or not fulfilling funding agreement requirements. |
REC147-3188 | 12 - EM agency and authority | The ANAO recommends that EMA maintain the Internet site to ensure that material is appropriate, current and readily accessible for users. |
REC147-3187 | 16 - Training and behaviour | The ANAO recommends that, in order to maximise the benefit of emergency management training activities, EMA review periodically its approach to delivering individual training courses, to ensure the most appropriate delivery mechanism is used commensurate with training objectives. |
Rec-ID | Code | Recommendation |
---|---|---|
REC146-3191 | 21 - Role of Commonwealth Government | The committee recommends the Australian Government strengthen CASA's governance framework and administrative capability by: |
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. |
REC146-3192 | 32 - Doctrine, standards, and reform | The committee recommends, in accordance with the findings of the Hawke Taskforce, that CASA's Regulatory Reform Program be brought to a conclusion as quickly as possible to provide certainty to industry and to ensure CASA and industry are ready to address future safety challenges. |
Rec-ID | Code | Recommendation |
---|---|---|
REC145-3200 | 37 - Funding | The Committee recommends that the Australian Government: |
REC145-3234 | 9 - Community education | The Committee recommends that the Australian Government nominate 2012 as the Year of the Coast, to further build community awareness about the issues facing the coastal zone. The Australian Government should work with coastal stakeholders, volunteer groups and the general community in determining key activities as part of this initiative. |
REC145-3220 | 3 - Biodiversity | The Committee recommends that, in seeking to expand the area protected within Australia’s National Reserve System (NRS) under the Caring for our Country program, the Australian Government focus on high biodiversity coastal habitat, including more effective off-reserve coastal zone conservation and expanded coastal reserves that provide larger buffer zones. In undertaking this initiative, the Australian Government should continue to work with state/territory and local governments, Indigenous groups, conservation organisations, private landholders and other stakeholders to ensure that these protected areas are added to the NRS in a timely manner. |
REC145-3240 | 32 - Doctrine, standards, and reform | The Committee recommends that proposals for a National Oceans and Coast Act and a statutory Coastal Council be the subject of ongoing consideration once the Intergovernmental Coastal Zone Agreement is determined. |
REC145-3226 | 24 - Govt responsibility | The Committee recommends that the Australian Government: |
REC145-3199 | 16 - Training and behaviour | The Committee recommends that the Australian Government continue funding under the Climate Change Adaptation Skills for Professionals Program. In addition, the Australian Government should liaise with tertiary institutions to ensure an adequate supply of appropriately skilled coastal planners and engineers. |
REC145-3233 | 9 - Community education | The Committee recommends that the Australian Government undertake an awareness campaign to alert coastal communities to the key challenges facing the coastal zone and the value of community engagement in addressing these challenges. The campaign should aim to build understanding and awareness of coastal management issues to encourage the continued membership and support of volunteer networks in the coastal zone. |
REC145-3219 | 24 - Govt responsibility | The Committee recommends that the Australian Government: |
REC145-3239 | 24 - Govt responsibility | The Committee recommends that the Australian Government establish a National Coastal Advisory Council to: |
REC145-3225 | 3 - Biodiversity | The Committee recommends that the Australian Government: |
REC145-3197 | 32 - Doctrine, standards, and reform | The Committee recommends that the coastal zone component of the National Climate Change Science Framework and proposed National Climate Change Science strategy be clearly identified by the proposed high level coordination group and involve key coastal stakeholders. |
REC145-3232 | 37 - Funding | The Committee recommends that the Australian Government give consideration to establishing a separate funding program for infrastructure enhancement in coastal areas vulnerable to climate change. Such funding should be provided according to a formula requiring contributions, either financial or in-kind, from state governments and relevant local government authorities. |
REC145-3217 | 24 - Govt responsibility | The Committee recommends that the Australian Government, through the Council of Australian Governments process, examine the establishment of a system of national coastal zone environmental accounts, employing the model developed by the South East Queensland Healthy Waterways Partnership. |
REC145-3238 | 32 - Doctrine, standards, and reform | The Committee recommends that the Australian Government: |
REC145-3224 | 24 - Govt responsibility | The Committee recommends that the Australian Government: |
REC145-3195 | 21 - Role of Commonwealth Government | The Committee notes the importance of mitigation measures in addressing climate change impacts and accordingly recommends that the Australian Government continue to take urgent action to ensure that Australia can best contribute to a reduction in global greenhouse gas emissions. |
REC145-3231 | 22 - Role of local Gvt | The Committee recommends that the Australian Government request that the Centre for Excellence for Local Government ensure a particular focus on capacity building for coastal local councils. Capacity building should focus on addressing issues relating to: |
REC145-3208 | 32 - Doctrine, standards, and reform | The Committee recommends that the Australian Government, through the Ministerial Council for Police and Emergency Management, recognise the extensive Surf Life Saving Australia network and take appropriate steps to integrate this network into emergency services preparedness, planning, and response systems and activities. |
REC145-3237 | 24 - Govt responsibility | The Committee recommends that the Australian Government, in cooperation with state, territory and local governments, and in consultation with coastal stakeholders, develop an Intergovernmental Agreement on the Coastal Zone to be endorsed by the Council of Australian Governments. The intergovernmental agreement should: |
REC145-3223 | 24 - Govt responsibility | The Committee recommends that the Australian Government urgently commission a detailed climate change vulnerability assessment for Kakadu National Park, in consultation with the park’s traditional owners and other stakeholders and drawing on the results of the ‘first pass’ National Coastal Vulnerability Assessment of the park. This assessment should specifically focus on the vulnerability of Kakadu’s freshwater wetland systems to saltwater intrusion. A key outcome of the assessment should be the development of a Climate Change Action Plan for Kakadu National Park, with coordinated input from the Australian Government and Northern Territory Government, Indigenous land owners, researchers and other stakeholders. |
REC145-3230 | 24 - Govt responsibility | The Committee recommends that the Australian Government: |
REC145-3207 | 37 - Funding | To further enhance Australia’s disaster mitigation, preparedness, response and recovery arrangements in the event of possible major coastal disasters, the Committee recommends that the Australian Government establish a grants program, the Coastal Natural Disaster Mitigation Program, to fund natural disaster mitigation projects in the Australian coastal zone. |
REC145-3236 | 37 - Funding | The Committee recommends that the Australian Government provide funding support for the ongoing activities of the Australian Coastal Alliance in providing a national information and communication interface between research organisations and local government authorities and other coastal stakeholders. |
REC145-3221 | 24 - Govt responsibility | The Committee recommends that the Australian Government, in considering its response to the Independent Review of the Environment Protection and Biodiversity Conservation Act 1999 (EPBC Act), take into account concerns about the EPBC Act and coastal zone management raised as part of this inquiry—in particular, the need to address the cumulative impacts of coastal development. This could be achieved by numerous means, including: |
REC145-3228 | 42 - Culture and Heritage | The Committee recommends that the Australian Government, in consultation with Indigenous Australians and other coastal stakeholders, commission work to provide a national repository identifying Indigenous and non-Indigenous cultural heritage sites in vulnerable coastal areas. |
Rec-ID | Code | Recommendation |
---|---|---|
REC144-3392 | 32 - Doctrine, standards, and reform | The Committee recommends that the ACT Government finalise Version 2 of the Strategic Bushfire Management Plan as required under the Emergencies Act. |
REC144-3399 | 9 - Community education | The Committee recommends that the Emergency Services Agency post all its publications, which are not internal working documents or otherwise confidential, on its website. |
REC144-3383 | 32 - Doctrine, standards, and reform | The Committee recommends that, if the Bushfire Council is to have an advisory role generally in emergency management, it should be renamed to reflect a general emergency role rather than a role specifically in relation to bushfires. |
REC144-3391 | 32 - Doctrine, standards, and reform | The Committee recommends that the ACT Government explain its reasons to the Legislative Assembly for not proceeding with the release of Version 2 of the Strategic Bushfire Management Plan in July 2005. |
REC144-3398 | 9 - Community education | The Committee recommends that the Emergency Services Agency update its website to accommodate, at a minimum, a publications menu item and a search function. |
REC144-3382 | 24 - Govt responsibility | The Committee recommends that responsibility for oversighting the progress of the implementation of agreed recommendations of the Coroner be undertaken by a truly independent body and not by the Bushfire Council. |
REC144-3390 | 24 - Govt responsibility | If the ACT Government decides to proceed with the site as the emergency services headquarters, that it accord a high priority to the finalisation of the site preparations for the ESA at Fairbairn as a matter of urgency. |
REC144-3397 | 9 - Community education | The Committee recommends that the ACT Government investigate the Victorian Community Fireguard model with a view to implementing a similar scheme in the ACT to enhance community preparedness for and ability to respond to bushfire emergencies. |
REC144-3381 | 32 - Doctrine, standards, and reform | The Committee recommends that the Bushfire Council consultative requirements under the Emergencies Act 2004 be reviewed, with a view to removing the requirement to consult with the Bushfire Council on operational matters, such as staff appointments and matters prescribed by regulation. |
REC144-3389 | 24 - Govt responsibility | If the Auditor-General does not undertake a review in the near future, the Committee recommends that the ACT Government make a public announcement about the future accommodation plans for the Emergency Services Agency and its component parts so that both the ESA and the ACT public are informed about current proposals and timeframes. |
REC144-3396 | 9 - Community education | The Committee recommends that information in relation to proposed fuel load activity and controlled burning should be disseminated to the community and in an accessible format. |
REC144-3380 | 32 - Doctrine, standards, and reform | The Committee recommends that the ACT Government develop and publish an operational policy document which spells out the command and control structures and procedures should an emergency event arise. |
REC144-3388 | 24 - Govt responsibility | If the Auditor-General does not undertake a review in the near future, the Committee recommends that the ACT Government re-investigate the suitability of the Fairbairn site as a proposed centralised accommodation facility for emergency services. |
REC144-3394 | 32 - Doctrine, standards, and reform | The Committee recommends that the ACT Government develops a joint strategic bushfire management plan with the NSW Government and the NSW Rural Fire Service in relation to those areas which have the potential to impact on both jurisdictions. |
REC144-3400 | 12 - EM agency and authority | The Committee recommends that each element of the Emergency Services Agency publish organisation charts showing names, positions and contact details on the individual webpages. |
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. |
REC144-3386 | 24 - Govt responsibility | The Committee considers that the ACT Government should table in the ACT Legislative Assembly the cost-benefit analysis and business plan for Fairbairn as a central site for emergency services in the ACT. |
Rec-ID | Code | Recommendation |
---|---|---|
REC140-3569 | 12 - EM agency and authority | A senior Tasmanian NETS representative be confirmed on the Tasmanian Medical Retrieval Services Committee. |
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. |
REC140-3555 | 16 - Training and behaviour | The Tasmanian Ambulance Service Clinical Advisory Committee review helicopter and fixed wing Flight Paramedic training and consider extending the scope of practice to embrace the role of retrieval paramedic in the Doctor/Paramedic retrieval team setting. |
REC140-3568 | 37 - Funding | The State Medical Retrieval Cost Centre (TMRS and NETS) be formed and be supported by the appropriate administrative and resource accountant expertise. This cost centre should be placed with those responsible for its management. |
REC140-3574 | 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. |
REC140-3554 | 37 - Funding | DHHS fund the equivalent of 2 FTE Consultant positions for retrieval duties (1.5 FTE existing, 0.5 FTE new) |
REC140-3567 | 37 - Funding | A uniform retrieval charge to the region of referral should be considered. This should be independent of the mode of transport used. |
REC140-3572 | 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. |
REC140-3553 | 37 - Funding | RHH Neonatal Emergency Transport Service receive DHHS funding for a Senior Registrar to assume the responsibilities of retrieval staffing, quality assurance, data collection and reporting demands. |
REC140-3566 | 12 - EM agency and authority | Launceston General and Burnie Hospital’s Emergency Departments require sufficient equipment, monitors and human resources to provide occasional safe local retrieval in their region. |
REC140-3571 | 12 - EM agency and authority | A senior, experienced, clinically trained ambulance officer to be based in TAS Communications in Hobart for at least 14 hours a day. |
REC140-3552 | 37 - Funding | Department of Health and Human Services (DHHS) to fund 3 Full-Time Equivalent (FTE) Senior Registrar positions at the Royal Hobart Hospital (RHH) for the Tasmanian Medical Retrieval Service (TMRS). One registrar in the Anaesthesia Department, one in the Intensive Care Unit and one in Emergency Department is proposed. |
REC140-3562 | 12 - EM agency and authority | A rapidly responsive helicopter and road retrieval capability to be developed out of RHH. |
REC140-3570 | 12 - EM agency and authority | The fragmentation and duplication of fixed wing and helicopter clinical coordination should be eliminated through centralisation to TAS Communications. |
REC140-3557 | 12 - EM agency and authority | Royal Flying Doctor Service fixed wing to remain in Launceston for the duration of the current contract. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC121-3682 | 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. |
REC121-3702 | 29 - Operational Health and Safety | Random alcohol testing should be continued. |
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. |
REC121-3738 | 29 - Operational Health and Safety | All passenger trains must be fitted with an internal passenger emergency door release. |
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. |
REC121-3771 | 32 - Doctrine, standards, and reform | RailCorp should establish an integrated safety management system which includes the following: |
REC121-3669 | 16 - Training and behaviour | All operational rail staff should be trained by RailCorp in the action check list relevant to each. |
REC121-3690 | 32 - Doctrine, standards, and reform | All communications protocols must be strictly enforced by all accredited rail organisations. |
REC121-3708 | 12 - EM agency and authority | RailCorp should employ a Chief Safety Information Officer to manage the collection, collation, and dissemination of safety information within RailCorp. |
REC121-3727 | 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. |
REC121-3743 | 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”. |
REC121-3760 | 32 - Doctrine, standards, and reform | The Advisory Board established under the Transport Legislation Amendment (Safety and Reliability) Act 2003 must be abolished. |
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. |
REC121-3675 | 16 - Training and behaviour | All rail employees should be trained by their employer to commence any emergency communication with the words “Emergency, emergency, emergency”, thereafter to identify themselves, the train, its location, what has occurred, the approximate passenger load and whether death or injuries have occurred. |
REC121-3696 | 32 - Doctrine, standards, and reform | Defects reporting, recording and rectification should be integrated with the RailCorp regimes for train maintenance. |
REC121-3714 | 16 - Training and behaviour | RailCorp should use its simulators in an interactive manner. |
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. |
REC121-3749 | 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”. |
REC121-3765 | 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. |
REC121-3659 | 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. |
REC121-3681 | 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. |
REC121-3701 | 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. |
REC121-3719 | 16 - Training and behaviour | The position of team leader should be created by RailCorp to be responsible for a group of approximately 30 train drivers, with responsibility to ensure that each train driver’s training needs are being met and that any safety concerns of train drivers are being properly addressed. The team leaders are to have direct access to the Chief Executive of RailCorp if any safety concerns they have are not addressed. |
REC121-3737 | 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. |
REC121-3754 | 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. |
REC121-3770 | 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 |
REC121-3668 | 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. |
REC121-3689 | 12 - EM agency and authority | All RMC communications related staff should be selected upon the basis of the ability to convey information clearly, accurately and concisely and to follow strict communications protocols. |
REC121-3707 | 29 - Operational Health and Safety | The safety document management system should provide for the distribution of electronic versions of safety documentation to relevant staff. |
REC121-3726 | 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. |
REC121-3742 | 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. |
REC121-3759 | 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: |
REC121-3775 | 38 - Agency/Department Reporting | The Minister for Transport Services must table in Parliament, each such quarterly report by ITSRR. |
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. |
REC121-3694 | 25 - Inquiry, audit, lessons management and after action review | The ITSRR should conduct random audits of accredited rail organisations for compliance with communications protocols. |
REC121-3713 | 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. |
REC121-3731 | 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: |
REC121-3748 | 29 - Operational Health and Safety | All new rail cars must have appropriate signage and lighting identifying escape routes in the case of emergency. |
REC121-3764 | 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. |
REC121-3658 | 12 - EM agency and authority | All emergency services stations should be provided with access keys to, and maps showing, all gates providing access to RailCorp tracks within their geographic area of responsibility. |
REC121-3680 | 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. |
REC121-3700 | 12 - EM agency and authority | The RailCorp defects unit should be combined with the passenger fleet maintenance division of RailCorp. |
REC121-3718 | 16 - Training and behaviour | Training should be based upon a needs analysis, to determine what skills a particular person will require to carry out the tasks of any position safely and efficiently, and instruction and practice, to acquire and demonstrate those skills. |
REC121-3736 | 32 - Doctrine, standards, and reform | The RailCorp passenger containment policy must be abandoned. |
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. |
REC121-3769 | 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. |
REC121-3667 | 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. |
REC121-3688 | 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. |
REC121-3706 | 29 - Operational Health and Safety | RailCorp should establish a comprehensive safety document management system. |
REC121-3723 | 38 - Agency/Department Reporting | All ATSB accident investigation reports should be made public. |
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. |
REC121-3758 | 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. |
REC121-3774 | 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: |
REC121-3672 | 16 - Training and behaviour | All emergency response personnel should be specifically trained in the features of railways which are relevant to their work, such as the location and means of operation of all emergency door releases on trains, the location and use of signal telephones, the methods by which electrical power can be isolated and the means by which they can readily identify and obtain information from the on-site rail commander. |
REC121-3693 | 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. |
REC121-3712 | 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. |
REC121-3730 | 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. |
REC121-3747 | 29 - Operational Health and Safety | All trains should have windows available through which passengers can escape. |
REC121-3763 | 32 - Doctrine, standards, and reform | The ITSRR should publish guidelines to be followed by accredited organisations. |
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. |
REC121-3679 | 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. |
REC121-3717 | 16 - Training and behaviour | RailCorp must establish a task analysis for particular categories of employees, to identify the specific skills and responsibility of those employees or groups of employees, and thereafter undertake a training needs analysis, to develop the skills required in particular areas. |
REC121-3735 | 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. |
REC121-3752 | 12 - EM agency and authority | RailCorp should establish clear safety accountability statements and reporting lines for all management positions. |
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. |
REC121-3662 | 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. |
REC121-3686 | 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: |
REC121-3722 | 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. |
REC121-3740 | 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. |
REC121-3757 | 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. |
REC121-3773 | 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. |
REC121-3671 | 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. |
REC121-3692 | 32 - Doctrine, standards, and reform | Communications protocols and procedures should be standardised and mandated by regulations making them a condition of accreditation. |
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. |
REC121-3729 | 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. |
REC121-3746 | 16 - Training and behaviour | All emergency services personnel should be trained in the location and operation of emergency door release mechanisms on all rail cars. |
REC121-3762 | 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. |
REC121-3654 | 16 - Training and behaviour | All train guards should be trained by RailCorp in the use of the Metronet radio and instructed to use it in any emergency. |
REC121-3678 | 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. |
REC121-3716 | 16 - Training and behaviour | Train driver and guard training should encourage teamwork and discourage authority gradients. |
REC121-3734 | 29 - Operational Health and Safety | RailCorp should integrate its management of occupational health and safety into its overall safety management. |
REC121-3751 | 16 - Training and behaviour | RailCorp should make it a condition of employment that all level 2 managers have or obtain a formal qualification in system safety management. |
REC121-3767 | 24 - Govt responsibility | All accredited rail organisations should be required to re-apply every three years to ITSRR for accreditation. |
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. |
REC121-3685 | 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. |
REC121-3721 | 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. |
REC121-3739 | 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. |
REC121-3756 | 16 - Training and behaviour | RailCorp should ensure that where the safety competency of any manager is deficient such manager is required to undertake professional development courses to raise his or her safety competency level to an adequate standard. |
REC121-3772 | 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. |
REC121-3670 | 16 - Training and behaviour | The RailCorp emergency response plan should be provided to all emergency response agencies. The officers of each emergency service should be trained in any rail specific features of the plan, so as to better ensure inter-agency co-ordination in the circumstances of an emergency. |
REC121-3691 | 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. |
REC121-3709 | 29 - Operational Health and Safety | RailCorp should provide access to electronic versions of safety documentation for all operational staff at their workplace. |
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. |
REC121-3744 | 16 - Training and behaviour | All RailCorp operational personnel should be trained in the location and operation of external emergency door release mechanisms. |
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. |
REC121-3650 | 16 - Training and behaviour | Staff at the Rail Management Centre (RMC) should receive training from RailCorp to enable them to quickly and accurately assess that an emergency has occurred and to provide precise and reliable information to emergency response personnel about the location of the emergency, the available access to the site and the resources necessary. |
REC121-3677 | 16 - Training and behaviour | A training centre for emergency services personnel should be established by RailCorp. The emergency services personnel should be required to undertake training at such a centre, which should be equipped with features replicating railway infrastructure and rolling stock. |
REC121-3697 | 38 - Agency/Department Reporting | All train drivers’ defects reports should be entered by RailCorp into a computerised record and tracked to finalisation. |
REC121-3715 | 16 - Training and behaviour | RailCorp should use its simulators to train drivers and guards in methods of dealing with degraded operations on the rail network. |
REC121-3733 | 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. |
REC121-3750 | 32 - Doctrine, standards, and reform | ITSRR should initiate and/or participate in the development of a national standard for crashworthiness of all passenger trains. |
REC121-3766 | 12 - EM agency and authority | Staffing arrangements for ITSRR should be reviewed by it to ensure that adequate staff are employed in field positions, actively monitoring the safety of rail operations and compliance with conditions of accreditation. |
Rec-ID | Code | Recommendation |
---|---|---|
REC119-3649 | 25 - Inquiry, audit, lessons management and after action review | It is recommended that the Board: |
REC119-3648 | 38 - Agency/Department Reporting | It is recommended that providers supply data to the Board: |
REC119-3647 | 32 - Doctrine, standards, and reform | It is recommended that the Board: |
REC119-3646 | 32 - Doctrine, standards, and reform | It is recommended that the Board develop response time standards for metropolitan and rural rescue services to guide committees in determining the number, type and location of rescue units (page 25). |
REC119-3645 | 32 - Doctrine, standards, and reform | It is recommended that the Board: |
Rec-ID | Code | Recommendation |
---|---|---|
REC116-2111 | 9 - Community education | The Working Group recommends that the national forum mentioned in recommendation 13 consider the ongoing need for dissemination of information on a national basis both during and following a catastrophic disaster and also identify strategies to ensure the ability of this to be facilitated. |
REC116-2124 | 32 - Doctrine, standards, and reform | The whole of government disaster plan should also be written in such a way as to manage continuity of national government, ensure delivery of key services for which the Australian Government has responsibility and establish (or document existing) command and control mechanisms. |
REC116-2102 | 35 - Business and Industry in relation to industry | The Working Group recommends that jurisdictions identify appropriate commercial organisations/bodies able to ensure maintenance of supply of food items and packaged water to commercial outlets in times of disaster. |
REC116-2110 | 9 - Community education | The Working Group recommends that EMA convene a national forum to explore community information and warning needs in catastrophic disasters, to review existing information and warning systems, and to identify possible technologies and techniques that might be used to enhance community needs in disasters. |
REC116-2123 | 24 - Govt responsibility | The Working Group recommends that the Australian Government consider developing an overarching whole of government disaster plan that clearly articulates authority, roles and responsibilities of agencies, inter-departmental committees and key officials, to link the range of existing Australian Government disaster plans. |
REC116-2101 | 35 - Business and Industry in relation to industry | The Working Group recommends that each jurisdiction; |
REC116-2109 | 24 - Govt responsibility | The Working Group recommends that participants in the exercises designed to test continuity of executive government plans and procedures should be the office holders themselves. |
REC116-2121 | 35 - Business and Industry in relation to industry | The Working Group recommends that the Australian Government investigate, in consultation with the finance and banking sector, the development of arrangements to ensure that essential transactions can continue in the event of a catastrophic failure of the banking system that includes access to cash. |
REC116-2100 | 32 - Doctrine, standards, and reform | The Working Group recommends that agreed national protocols be developed to manage the integration of overseas workers and international aid into an affected jurisdiction. |
REC116-2128 | 32 - Doctrine, standards, and reform | The Working Group recommends that jurisdictions review their emergency management arrangements (plans, legislation, etc) to ensure that they are able to mitigate, respond to and recover from disasters, and maximise the duration of self reliance that can be achieved. |
REC116-2108 | 24 - Govt responsibility | The Working Group recommends that all States/Territories and the Australian Government should regularly (annually) test their continuity of executive government plans and contingencies. |
REC116-2118 | 24 - Govt responsibility | The Working Group recommends that State/Territory Recovery Committees review their membership to ensure that it is reflective of community needs, including representation from the Insurance Disaster Response Organisation. |
REC116-2099 | 32 - Doctrine, standards, and reform | The Working Group recommends that a review of the operation of the Commonwealth Mutual Recognition Act 1992 be conducted and that agreed national protocols be developed to manage the integration of |
REC116-2126 | 24 - Govt responsibility | The Working Group recommends the Australian Emergency Management Committee note that: |
REC116-2106 | 16 - Training and behaviour | The Working Group recommends that appropriate building/surveyor peak bodies be identified, and that discussions be held between the emergency management sector and those peak bodies at State/Territory and national level with a view to: |
REC116-2114 | 21 - Role of Commonwealth Government | Related to recommendation 16, the Working Group recommends that the likelihood and consequences be systematically assessed by appropriate agencies that would include Geoscience Australia, the Bureau of Meteorology, CSIRO and the Department of Agriculture, Fisheries and Forestry among others. The range of hazards to be considered should include but not be limited to; |
REC116-2125 | 24 - Govt responsibility | The Working group recommends that the Australian Government take a leadership role with regard to addressing the national capability issues identified within this review. Further, that the States/Territories recognise and accept the collaborative nature of developing national capability and commit through engagement and consultation to assisting the Australian Government in this task. |
REC116-2105 | 24 - Govt responsibility | The Working Group recommends that the adequacy of existing national mortuary capability to meet the likely demands of a catastrophic disaster be assessed by State/Territory Coroners. This assessment should also consider the need for a mobile mortuary capability and involve discussions with the Australian Federal Police. |
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. |
REC008-3990 | 16 - Training and behaviour | The Commission recommends that more than one means of exit should be provided in every mine from every level of it to the surface; and that the miners should be kept informed where they are situated. |
REC008-3988 | 40 - Equipment and consumables | The Commission recommends that buckets of sand or other apparatus for extinguishing fire be kept in any chamber where high powered electricity is used. |
REC008-3984 | 16 - Training and behaviour | The Commission recommends that the live parts of resistances should be fixed so that no unprotected combustible material is within 6ins of the frames or cases containing them or within 24ins measured vertically above. |