Inquiry Search
Rec-ID | Code | Recommendation |
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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. |
Rec-ID | Code | Recommendation |
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REC252-2574 | 32 - Doctrine, standards, and reform | St John Ambulance should ensure the positive gains in clinical governance achieved since the Inquiry become embedded throughout the whole organisation. |
REC252-2570 | 25 - Inquiry, audit, lessons management and after action review | Western Australia Health should carry out targeted clinical audits in volunteer country sub-centres until longer term solutions are in place |
REC252-2570 | 25 - Inquiry, audit, lessons management and after action review | Western Australia Health should carry out targeted clinical audits in volunteer country sub-centres until longer term solutions are in place |
REC252-2569 | 32 - Doctrine, standards, and reform | Western Australia Health should consider publishing information on St John Ambulance’s complaints processes to assist Western Australia Health staff. |
Rec-ID | Code | Recommendation |
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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. |
REC237-0822 | 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. |
REC237-0821 | 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. |
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. |
Rec-ID | Code | Recommendation |
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REC227-2857 | 21 - Role of Commonwealth Government | I recommend that the Commonwealth ensure that there is a mooring buoy which will enable the mooring of SIEVs to take place and free up the Christmas Island response vessel for ongoing surveillance duties. |
REC227-2855 | 32 - Doctrine, standards, and reform | I recommend that arrangements be put in place which would remove the requirements for Masters of Volunteer Marine Rescue vessels to hold a commercial certificate of competency. Operators could then be qualified through the FESA Volunteer Marine Rescue Training pathway as skippers and crew. This would increase the number of available skippers in the event of a search and rescue incident and would make appropriate training easier to arrange. |
REC227-2853 | 21 - Role of Commonwealth Government | I recommend that the Commonwealth liaise closely with representatives of the Christmas Island VMRS prior to purchasing or replacing any vessels for the VMRS in the future. |
REC227-2852 | 21 - Role of Commonwealth Government | I recommend that the Commonwealth and the Shire of Christmas Island take steps to ensure that the Ethel Beach boat ramp is significantly upgraded, that it should be provided with shelter in the form of a rock groyne or similar buffer and that provision should be made so that a person can walk beside the ramp on a stable footing; or If this is not considered likely to be effective in providing an appropriate means of deploying a rescue vessel in adverse conditions, such other action be taken as is necessary to ensure that there is a means of deploying a rescue vessel in adverse conditions. |
Rec-ID | Code | Recommendation |
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REC222-1864 | 32 - Doctrine, standards, and reform | The Chief Executive Officer of the Fire and Emergency Services Authority request the Australasian Fire and Emergency Services Authorities Council to include a new module in the Australasian Inter-service Incident Management System to guide the provision of welfare services for emergency service workers during a disaster. |
REC222-1862 | 25 - Inquiry, audit, lessons management and after action review | The Minister for Emergency Services request the State Emergency Management Committee to review by June 2013 the sharing of data between the State’s emergency response agencies using the WebEOC software and any further enhancements that can be made to this process. |
REC222-1847 | 25 - Inquiry, audit, lessons management and after action review | The Ministers for Emergency Services, Environment and Police ensure their departments undertake a formal review by 30 June 2013 of the welfare services addressing stress and trauma provided to both their career and volunteer members. |
REC222-1869 | 25 - Inquiry, audit, lessons management and after action review | The Ministers for Emergency Services, Environment and Police ensure their departments include provisions for regular external audits of invoices for payment in their next round of Employee Assistance Program contract negotiations. |
Rec-ID | Code | Recommendation |
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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. |
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. |
Rec-ID | Code | Recommendation |
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REC170-0060 | 32 - Doctrine, standards, and reform | Agencies should: update out-of-date Westplans and support plans as a matter of urgency |
REC170-0056 | 32 - Doctrine, standards, and reform | SEMC and EM WA should: define key roles within the emergency management framework |
REC170-0064 | 32 - Doctrine, standards, and reform | Agencies should: ensure their internal emergency management arrangements are up-to-date and regularly reviewed |
REC170-0053 | 32 - Doctrine, standards, and reform | SEMC and EM WA should: submit outstanding legislative changes to Parliament as a matter of priority |
REC170-0063 | 32 - Doctrine, standards, and reform | Agencies should: ensure their Westplans and support plans have supporting local arrangements in place |
REC170-0052 | 32 - Doctrine, standards, and reform | SEMC and EM WA should: ensure agencies fulfil their obligations under the Act |
REC170-0062 | 25 - Inquiry, audit, lessons management and after action review | Agencies should: annually assess their capability to respond to emergencies and take measures to address any shortfalls |
REC170-0051 | 32 - Doctrine, standards, and reform | SEMC and EM WA should: review procedures for plan preparation and approval so that agencies can prepare their plans in a more timely way |
REC170-0061 | 32 - Doctrine, standards, and reform | Agencies should: identify overlaps between Westplans and develop written procedures for these circumstances |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC159-3061 | 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. |
REC159-3051 | 32 - Doctrine, standards, and reform | ACTAS should: |
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. |
REC159-3058 | 25 - Inquiry, audit, lessons management and after action review | ACTAS should improve patient care processes by: |
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. |
REC159-3056 | 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 |
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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. |
REC144-3394 | 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. |
REC144-3379 | 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. |
REC144-3392 | 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. |
REC144-3391 | 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. |
REC144-3383 | 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. |
REC144-3397 | 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. |
REC144-3396 | 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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC143-3578 | 32 - Doctrine, standards, and reform | That Fire and Emergency Services Authority of Western Australia (FESA), in consultation with local governments, develop and make broadly available Western Australian Natural Disaster Relief Arrangements (WANDRA) guidelines with a view to improving pre-disaster awareness of assistance measures and application processes. |
REC143-3584 | 32 - Doctrine, standards, and reform | That the guidelines of WANDRA be revised to provide for the inclusion of the cost of materials expended in the repair of boundary fences. |
REC143-3579 | 9 - Community education | That FESA develop comprehensive internet-based information including but not limited to detail of WANDRA objectives, assistance measures, administering agencies, eligibility criteria (where applicable) and application forms. |
Rec-ID | Code | Recommendation |
---|---|---|
REC121-3692 | 32 - Doctrine, standards, and reform | Communications protocols and procedures should be standardised and mandated by regulations making them a condition of accreditation. |
REC121-3757 | 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. |
REC121-3662 | 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. |
REC121-3699 | 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. |
REC121-3763 | 32 - Doctrine, standards, and reform | The ITSRR should publish guidelines to be followed by accredited organisations. |
REC121-3771 | 32 - Doctrine, standards, and reform | RailCorp should establish an integrated safety management system which includes the following: |
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. |
REC121-3727 | 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. |
REC121-3691 | 25 - Inquiry, audit, lessons management and after action review | The ITSRR should audit the RMC to ensure communications protocols are being followed. The sanction for non-compliance with communications protocols should be identical to that in the aviation industry and involve immediate removal from duty. Any RailCorp employee not following communications protocols should be required to undertake further training. If, following return to duties after such training, the officer continues to fail to comply with communications protocols, that officer is not to be employed in communications related work. |
REC121-3753 | 25 - Inquiry, audit, lessons management and after action review | The RailCorp Board should establish independent external safety auditing processes to regularly audit and report to the Board on the implementation of an integrated safety management system by RailCorp and on safety performance generally. |
REC121-3661 | 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. |
REC121-3698 | 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. |
REC121-3762 | 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. |
REC121-3770 | 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 |
REC121-3674 | 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. |
REC121-3726 | 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. |
REC121-3690 | 32 - Doctrine, standards, and reform | All communications protocols must be strictly enforced by all accredited rail organisations. |
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. |
REC121-3660 | 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. |
REC121-3696 | 32 - Doctrine, standards, and reform | Defects reporting, recording and rectification should be integrated with the RailCorp regimes for train maintenance. |
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. |
REC121-3671 | 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. |
REC121-3713 | 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. |
REC121-3769 | 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. |
REC121-3688 | 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. |
REC121-3736 | 32 - Doctrine, standards, and reform | The RailCorp passenger containment policy must be abandoned. |
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. |
REC121-3694 | 25 - Inquiry, audit, lessons management and after action review | The ITSRR should conduct random audits of accredited rail organisations for compliance with communications protocols. |
REC121-3760 | 32 - Doctrine, standards, and reform | The Advisory Board established under the Transport Legislation Amendment (Safety and Reliability) Act 2003 must be abolished. |
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. |
REC121-3705 | 32 - Doctrine, standards, and reform | The ITSRR should develop standards for periodic medical examinations which include the following: |
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. |
REC121-3773 | 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. |
REC121-3686 | 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. |
REC121-3730 | 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. |
REC121-3655 | 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. |
REC121-3693 | 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. |
REC121-3758 | 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. |
REC121-3667 | 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. |
REC121-3701 | 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. |
REC121-3765 | 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. |
REC121-3772 | 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. |
REC121-3685 | 32 - Doctrine, standards, and reform | The ITSRR should impose a standard in relation to the collection and use of data from data loggers. |
REC121-3728 | 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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC119-3649 | 25 - Inquiry, audit, lessons management and after action review | It is recommended that 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: |