Inquiry Search
Rec-ID | Code | Recommendation |
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REC258-2534 | 16 - Training and behaviour | The Civil Aviation Safety Authority develops a staff exchange program with industry. |
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. |
REC258-2530 | 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. |
REC258-2528 | 25 - Inquiry, audit, lessons management and after action review | The Australian Transport Safety Bureau investigates as many fatal accidents in the sport and recreational aviation sector as its resources will allow. |
REC258-2549 | 25 - Inquiry, audit, lessons management and after action review | The Civil Aviation Safety Authority provides full disclosure of audit findings at audit exit briefings in accordance with international best practice. |
REC258-2526 | 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. |
REC258-2542 | 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. |
REC258-2561 | 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. |
REC258-2541 | 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: |
REC258-2556 | 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 |
---|---|---|
REC256-1561 | 24 - Govt responsibility | State and territory governments should be required to report on the following accountability requirements: |
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: |
REC256-1571 | 24 - Govt responsibility | State and territory taxes and levies on general insurance should be phased out and replaced with less distortionary taxes. |
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. |
REC256-1567 | 24 - Govt responsibility | State and territory governments should: |
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. |
REC256-1575 | 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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC244-2605 | 39 - Disaster Risk Management | A thorough consultative process be developed and implemented between the CFS and local government. This will determine how bushfire management planning can enable improved process and practice to mitigate bushfire risk, and ensure that fire permits are issued and complied with. |
REC244-2601 | 25 - Inquiry, audit, lessons management and after action review | That an independent review of the operational and geographic boundaries of the ESOs be conducted recognising the limitations of the current governance structures to adequately address such issues. Such a review needs to be performed periodically, but not less than every 8 years. |
REC244-2600 | 25 - Inquiry, audit, lessons management and after action review | An external audit of shared services performed by SAFECOM and services now provided by the three ESOs which have the potential to be shared, be undertaken to determine the most efficient and cost effective way such services can be delivered to the sector. The three ESO Chiefs need to have input into this process. |
REC244-2631 | 25 - Inquiry, audit, lessons management and after action review | Review Section 134 to ensure that it is not a deterrent to a group of farm fire units operating at an incident. |
REC244-2620 | 25 - Inquiry, audit, lessons management and after action review | Review employment conditions under the F&ES Act to align with those under the Public Sector Act unless there is a compelling reason to the contrary. |
REC244-2617 | 25 - Inquiry, audit, lessons management and after action review | When judging major incidents in the future, consideration be given to Eburn and Dover’s proposal to establish processes with a statutory basis that sufficiently balance the community’s interests in ensuring that true lessons, including lessons of error or neglect, are identified, whilst also protecting members of the emergency services. Processes need to be developed for emergency services such as those used in aviation and medicine, to facilitate open and honest disclosure of errors. |
Rec-ID | Code | Recommendation |
---|---|---|
REC239-2660 | 24 - Govt responsibility | That Queensland Corrective Services be transferred to the Department of Justice and Attorney-General by a machinery-of-Government change as soon as is practicable. |
REC239-2700 | 24 - Govt responsibility | That the position of Inspector General Emergency Management (in addition to some of the responsibilities of the chief executive officer under the current Disaster Management Act 2003) will: |
REC239-2749 | 24 - Govt responsibility | That the Prostitution Licensing Authority be moved to the Department of Justice and Attorney General Office of Fair Trading. |
REC239-2674 | 38 - Agency/Department Reporting | That Queensland Corrective Service continues to develop its proposed recidivism index as a priority, including place and program based measures. |
REC239-2721 | 24 - Govt responsibility | That the Chief Executive Officer Portfolio Business collaborate with the two portfolio Commissioners to: |
REC239-2759 | 24 - Govt responsibility | That the new Chief Executive Officer Portfolio Business be accountable for delivering the reformed Communications Centre arrangement by the 2017–18 financial year in time for the Commonwealth Games of 2018. |
REC239-2686 | 24 - Govt responsibility | That primacy of control should rest with the State Disaster Coordinator. This position should, by default, be the Deputy Commissioner, Regional Operations, Queensland Police Service. |
REC239-2729 | 16 - Training and behaviour | That the Queensland Fire and Rescue Service work to change the culture of entitlement so that firefighters recognise firefighting is only one of a range of skills they bring to their core role of emergency management. |
REC239-2772 | 38 - Agency/Department Reporting | That the roll-out of the mobile service program business case mentioned earlier |
REC239-2657 | 24 - Govt responsibility | That negotiation takes place between Queensland Health and the Queensland Ambulance Service to determine the broad governance requirements of any such arrangements. |
REC239-2699 | 24 - Govt responsibility | That the Minister establish a public sector office to be headed by an Inspector General of Emergency Management. The Inspector General of Emergency Management will be responsible for most of the functions listed under part 16A of the current Disaster Management Act 2003. |
REC239-2748 | 20 - Role of police | That the Queensland Police Service considers adopting the broader use of ANPR in line with other Australian jurisdictions in consultation with the Privacy Commissioner. |
REC239-2782 | 24 - Govt responsibility | That transparency of the Ministerial direction be achieved through publishing and monitoring for effectiveness. |
REC239-2673 | 38 - Agency/Department Reporting | That Queensland Corrective Service, in consultation with key partners in the criminal justice and social services sectors, develops specific performance indicators focused on efficiencies and customer/stakeholder outcomes across the criminal justice system. |
REC239-2712 | 24 - Govt responsibility | That Emergency Management Queensland be integrated with the current Queensland Fire and Rescue to become the Department of Fire and Emergency Services. |
REC239-2758 | 25 - Inquiry, audit, lessons management and after action review | That the Chief Executive Officer Portfolio Business leads an efficiency review of portfolio agencies beginning with the Queensland Police Service. |
REC239-2685 | 24 - Govt responsibility | That primacy of control for disaster operations remains with the Queensland Police Service and be reinforced. |
REC239-2727 | 25 - Inquiry, audit, lessons management and after action review | That as part of its efficiency review, the Queensland Fire and Rescue Service instigate an independent review of commercial operations in terms of statutory obligations and current ‘full cost pricing’ methodology to ensure: |
REC239-2771 | 38 - Agency/Department Reporting | That the Queensland Police Service Commissioner addresses the situation regarding statistical reporting. The Commissioner, in collaboration with the Chief Executive Officer Portfolio Business and the Queensland Fire and Rescue Service Commissioner should also examine the opportunity to acquire the services of a qualified and experienced Chief Information Officer or Chief Digital Officer in line with other Queensland and Australian government agencies. |
REC239-2655 | 24 - Govt responsibility | That the Queensland Ambulance Service is transferred to Queensland Health by a machinery-of-Government change as soon as is practicable and that the Commissioner report directly to the Director General Queensland Health. |
REC239-2692 | 39 - Disaster Risk Management | That the Queensland Police Service Disaster Management Unit is to be permanently located at the State Disaster Coordination Centre to work on a day to day basis with the proposed new Department of Fire and Emergency Services. |
REC239-2747 | 20 - Role of police | That as the Queensland Police Service moves to a digital platform the strategy around effective targeting and alternative automated number plate recognition models should form part of the design architecture. |
REC239-2777 | 25 - Inquiry, audit, lessons management and after action review | That the review of this Queensland Fire and Rescue Services business unit be done in conjunction with the efficiency review proposed for the Queensland Police Service. |
REC239-2671 | 16 - Training and behaviour | That all Queensland Corrective Service provision of training should be contestable. |
REC239-2711 | 39 - Disaster Risk Management | That the Inspector General Emergency Management be empowered to provide an assurance to Government that the disaster management system is both appropriate and capable of dealing with complex events. |
REC239-2757 | 20 - Role of police | That the Queensland Police Service executive team reassesses its preparedness to collaborate with other agencies to deliver a whole of Government approach to delivering community safety. |
REC239-2684 | 38 - Agency/Department Reporting | The Chief Executive Officer Portfolio Business establishes a set of performance indicators to provide a transparent process for government to monitor its performance. |
REC239-2726 | 20 - Role of police | That the Queensland Fire and Rescue Service enters into discussion with the Queensland Police Service regarding the possibility for the Queensland Police Service to assist with prosecutions that may arise out of fire safety matters. |
REC239-2767 | 38 - Agency/Department Reporting | Recommendation: That the CEO Portfolio Business collaborates with the two portfolio Commissioners to: |
REC239-2691 | 39 - Disaster Risk Management | That the Commissioners of Police and the Queensland Fire and Rescue Service review the current district disaster boundaries as a matter of urgency in-line with the findings and recommendations of the Auditor–General’s report into the Queensland disaster management system. |
REC239-2741 | 16 - Training and behaviour | That the annual training calendar identify course, training location and the coordinating authority. |
REC239-2776 | 25 - Inquiry, audit, lessons management and after action review | That the proposed efficiency review of the Queensland Police Service examine whether: |
REC239-2662 | 24 - Govt responsibility | That responsibility for prisoner transport and non-managerial roles within the larger watch-houses is transferred to Queensland Corrective Service. |
REC239-2708 | 24 - Govt responsibility | That the role of the Inspector General Emergency Management not extend to conducting reviews on behalf of agencies and that the role consider the effectiveness of all agencies and how their work contributes to a whole of Government response. |
REC239-2752 | 20 - Role of police | That the roll-out of the Queensland Police Service digital technology should take into consideration adopting and facilitating new processes including the police response to domestic violence. |
REC239-2679 | 24 - Govt responsibility | To remove the Queensland Ambulance Service and Queensland Corrective Services from the Department of Community Safety—we recommend that it be renamed the Department of Fire and Emergency Services and be led by a Commissioner. |
REC239-2725 | 25 - Inquiry, audit, lessons management and after action review | That the Queensland Fire and Rescue Service community safety operations be joined in the efficiency review of the Queensland Police Service focussing on both the community safety outcomes achieved and the extent to which they support the Government’s economic priorities. |
REC239-2764 | 25 - Inquiry, audit, lessons management and after action review | That the proposed efficiency review consider whether special service functions are core business, whether this practice is sustainable, and other options such as the use of casual employees. |
REC239-2689 | 20 - Role of police | That, where appropriate, the Commissioner of Police appoints appropriately trained and experienced public service officers to appropriate roles in the disaster management system to support District Disaster Coordinators in their vital roles. |
REC239-2740 | 16 - Training and behaviour | That impediments to the publication of an annual training calendar of core skills be removed. |
REC239-2774 | 39 - Disaster Risk Management | Those final determinations of disaster management districts include consultation with the Local Government Association Queensland, the Queensland Fire and Rescue Service and other Government departments. |
REC239-2661 | 24 - Govt responsibility | That Queensland Corrective Service remains a separate program within the Department of Justice and Attorney-General so that while opportunities for improved services and efficacy can be realised, there is a clear separation from the youth justice services. |
REC239-2701 | 24 - Govt responsibility | That the Inspector General Emergency Management provide continuing advice to Government on the level of interoperability in disaster management arrangements, as well as the level of interoperability being achieved within the new portfolio. |
REC239-2750 | 20 - Role of police | That the Queensland Police Service: |
REC239-2678 | 24 - Govt responsibility | That probation and parole should continue to work together with the Queensland Police Service to reduce the risk of reoffending and reduce crime. |
REC239-2724 | 25 - Inquiry, audit, lessons management and after action review | That the Queensland Fire and Rescue Service undertake a review of all standing orders, incident directives and guidelines regarding response protocols with a view to reducing risk to staff and other road users associated with urgent duty driving. |
REC239-2763 | 25 - Inquiry, audit, lessons management and after action review | That the proposed efficiency review includes a focus on the rank structure of both the Queensland Police Service and the proposed Fire and Emergency Services. |
REC239-2687 | 24 - Govt responsibility | That funding, staffing and responsibility associated with administration of the NDRP be transferred from Emergency Management Queensland to the Department of Local Government, Community Recovery and Resilience. |
REC239-2732 | 24 - Govt responsibility | There be a formation of an Office of Portfolio Business, providing support and governance across a range of corporate functions, which are essential to the delivery of frontline services. The Review team considers that the functions of the Operations Business and Strategy Directorate should become part of that Office and that any exception should be carefully considered by those charged with implementation of approved recommendations. |
REC239-2773 | 38 - Agency/Department Reporting | That should the Mobile Strategy in its current form be approved by government the CEO Portfolio Business and the Deputy Commissioner Operations: |
Rec-ID | Code | Recommendation |
---|---|---|
REC207-2882 | 39 - Disaster Risk Management | Review disaster recovery and business continuity plans. |
Rec-ID | Code | Recommendation |
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REC205-1902 | 25 - Inquiry, audit, lessons management and after action review | The Council of Australian Governments should commission an independent public inquiry to develop an appropriate response to managing the risks of climate change to existing settlements. The inquiry should: |
REC205-1899 | 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. |
REC205-1896 | 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: |
REC205-1904 | 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. |
REC205-1903 | 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: |
Rec-ID | Code | Recommendation |
---|---|---|
REC177-3291 | 39 - Disaster Risk Management | Removal of a barrier must be the subject of consultation between licensees and rig operators prior to removal. A proper risk assessment should be carried out and agreed upon, and documented in writing before removal. Joint written certification as to the appropriateness of removal should take place before removal. Senior onshore representatives of stakeholder entities should be involved in that certification process. |
REC177-3344 | 25 - Inquiry, audit, lessons management and after action review | There should be a review to determine whether it is appropriate to introduce a rigorous civil penalty regime and/or substantially increase some or all of the penalties that can be imposed for breaches of legislative requirements relating to well integrity and safety. |
REC144-3387 | 25 - Inquiry, audit, lessons management and after action review | In order that the ACT public can be reassured about the project management and financial planning in relation to the Fairbairn site as a proposed centralised accommodation facility for emergency services, the Auditor-General undertake a review of the project from a financial probity and project management perspective. |
REC177-3290 | 38 - Agency/Department Reporting | The successful installation of every barrier should be the subject of written verification within and between licensees and rig operators; and should be the subject of explicit reporting to the relevant regulator(s). |
REC177-3333 | 16 - Training and behaviour | Licensees and rig operators (and third party contractors involved in well control operations) should specifically assess, and document, the nature and extent of knowledge/skills of relevant personnel in relation to well control (including familiarity of personnel with agency‐specific requirements and procedures). Training needs and opportunities should be identified. This process should take place on engagement and at appropriate intervals. |
REC177-3378 | 25 - Inquiry, audit, lessons management and after action review | In view of the numerous well integrity problems in all of the Montara Oilfield wells, the Minister should commission a detailed audit of all the other offshore wells operated by PTTEPAA to determine whether they too may suffer from well integrity problems. |
REC177-3289 | 39 - Disaster Risk Management | The use/type of barriers (including any change requests relating thereto) must be the subject of consultation between licensees and rig operators prior to installation. A proper risk assessment should be carried out, agreed upon, and documented in writing before installation. Joint written certification as to the appropriateness of the use of particular barriers should take place before installation. Senior onshore representatives of stakeholder entities should be involved in that certification process. |
REC177-3332 | 16 - Training and behaviour | A specific focus on well control training should be mandatory for key personnel involved in well control operations (including both on‐rig personnel and onshore personnel in supervisory capacities). |
REC177-3374 | 25 - Inquiry, audit, lessons management and after action review | The Minister should, as the JA for the offshore area of the Territory of Ashmore and Cartier Islands, undertake a review of PTTEPAA’s permit and licence to operate at the Montara Oilfield. |
REC177-3287 | 38 - Agency/Department Reporting | Licensees should be subject to an express obligation to inform regulators of problems which arise in the course of installing barriers, even if they consider that well integrity is not thereby compromised. The information should be provided by way of special report, rather than included in a standard reporting document (such as a DDR). The information provided should include risk assessment details. |
REC177-3331 | 16 - Training and behaviour | Existing well control training programs should be reviewed by the industry, regulators and training providers, with a focus on well control accidents that have occurred (in Australia and overseas). |
REC177-3360 | 42 - Culture and Heritage | DEWHA should participate in training programs and exercises relevant to an oil spill in the marine environment. |
REC177-3286 | 39 - Disaster Risk Management | Problems which arise in the course of installing barriers must be the subject of consultation between licensees, rig operators, and contractors (if used). A proper risk assessment should then be carried out and remedial steps (including further testing/verification) should be agreed upon, and documented in writing before the performance of remedial work whenever practicable. Joint written certification as to resolution of the problem should take place before resumption of drilling operations. Senior onshore representatives of stakeholder entities should be involved in that certification process. |
REC177-3330 | 39 - Disaster Risk Management | Decision‐making about well control issues should be professionalised. Industry participants must recognise that decision‐makers owe independent duties to the public, not just their employer or principal, in relation to well control. Risk management in the context of well control needs to be understood as an ethical/professional duty. Self‐regulation contemplates self‐regulation by the industry, not just by individual licensees and operators. |
REC177-3356 | 39 - Disaster Risk Management | The regulator should pre‐assess and review in a generic sense, and in conjunction with the offshore petroleum industry, available options for well control in the event of a blowout. Being ‘match fit’ in this sense will enable a quicker and more effective response in terms of safety assessment, and will ensure that expectations of both operator and regulator are more readily aligned. |
REC177-3285 | 39 - Disaster Risk Management | Pre‐drilling assessments should include a risk assessment of the worst‐case blowout scenario. |
Rec-ID | Code | Recommendation |
---|---|---|
REC165-0098 | 24 - Govt responsibility | The SDMG take into account key improvement initiatives and change processes suggested when deciding on an effective implementation strategy for agreed recommendations. |
REC165-0097 | 24 - Govt responsibility | Revised governance arrangements be implemented involving Disaster Management Groups at the three levels supported by EMQ as outlined in this report to achieve continuous improvement in the Disaster Management arrangements in the State. A new provision in Section 5 emphasise the discretion available to all involved in the Disaster Management system to take action to prevent impending loss of life even if contrary to the agreed arrangements. |
REC165-0085 | 20 - Role of police | The Commissioner of Police, through a dedicated Assistant Commissioner (supported by a cohort of Assistant Commissioners to ensure adequate coverage), be assigned responsibility for overall control of each natural Disaster Management event in Queensland as the preferred arrangement. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC161-3030 | 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. |
REC161-3028 | 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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC151-3095 | 24 - Govt responsibility | SAFECOM re-evaluate and determine a more meaningful definition of fire districts. |
REC151-3071 | 24 - Govt responsibility | The comprehensive prevention, preparedness, response and recovery (PPRR) approach to the management of bushfires as recommended by the Ministerial Review of Bushfire Management in South Australia is supported: its implementation should consider issues raised by councils and should also be considerate of the recommendations of the Wangary Coronial Inquest. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC149-3139 | 39 - Disaster Risk Management | The industry should develop in conjunction with the Regulator a process for addressing the need to maintain the risk profile of a facility moving into extended life operation at the same risk profile as when it was within design life. |
REC149-3138 | 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. |
REC149-3137 | 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. |
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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC140-3575 | 24 - Govt responsibility | The preferred model for the Tasmanian Medical Retrieval Services is to have TMRS and NETS staff based in RHH. The fixed wing would remain based in Launceston (for the present) with the helicopter to remain based in Hobart. |
REC140-3574 | 38 - Agency/Department Reporting | Formation of a subcommittee of the DHHS Tasmanian Medical Retrieval Services Committee to identify risk exposures, system problems and potential solutions. The subcommittee should review data, problem cases, system issues and generate a risk register. Meetings should occur at least quarterly. |
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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC121-3710 | 39 - Disaster Risk Management | The ITSRR should have permanent access to the RailCorp intranet. |
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. |
REC121-3716 | 16 - Training and behaviour | Train driver and guard training should encourage teamwork and discourage authority gradients. |
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. |
REC121-3670 | 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. |
REC121-3684 | 39 - Disaster Risk Management | The ITSRR should conduct its own risk assessment in relation to the risk of any such high consequence, low probability accident and, if necessary, direct RailCorp to conduct a further risk assessment to reduce the level of residual risk to a level ITSRR regards as acceptable. |
REC121-3721 | 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. |
REC121-3775 | 38 - Agency/Department Reporting | The Minister for Transport Services must table in Parliament, each such quarterly report by ITSRR. |
REC121-3700 | 39 - Disaster Risk Management | Maintenance plans on all trains should be revised annually. |
REC121-3744 | 16 - Training and behaviour | All RailCorp operational personnel should be trained in the location and operation of external emergency door release mechanisms. |
REC121-3715 | 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. |
REC121-3757 | 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. |
REC121-3669 | 16 - Training and behaviour | All operational rail staff should be trained by RailCorp in the action check list relevant to each. |
REC121-3683 | 39 - Disaster Risk Management | RailCorp should undertake risk assessments of each of its activities as follows: |
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. |
REC121-3774 | 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: |
REC121-3697 | 38 - Agency/Department Reporting | All train drivers’ defects reports should be entered by RailCorp into a computerised record and tracked to finalisation. |
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. |
REC121-3714 | 16 - Training and behaviour | RailCorp should use its simulators in an interactive manner. |
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. |
REC121-3664 | 20 - Role of police | The location of the command post for site control at the scene of any rail accident should be identified by NSW Police by a distinctive flashing light. |
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. |
REC121-3719 | 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. |
REC121-3768 | 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. |
REC121-3694 | 25 - Inquiry, audit, lessons management and after action review | The ITSRR should conduct random audits of accredited rail organisations for compliance with communications protocols. |
REC121-3726 | 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. |
REC121-3713 | 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. |
REC121-3753 | 25 - Inquiry, audit, lessons management and after action review | The RailCorp Board should establish independent external safety auditing processes to regularly audit and report to the Board on the implementation of an integrated safety management system by RailCorp and on safety performance generally. |
REC121-3654 | 16 - Training and behaviour | All train guards should be trained by RailCorp in the use of the Metronet radio and instructed to use it in any emergency. |
REC121-3718 | 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. |
REC121-3767 | 24 - Govt responsibility | All accredited rail organisations should be required to re-apply every three years to ITSRR for accreditation. |
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. |
REC121-3693 | 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. |
REC121-3723 | 38 - Agency/Department Reporting | All ATSB accident investigation reports should be made public. |
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. |
REC121-3751 | 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. |
REC121-3650 | 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. |
REC121-3717 | 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. |
REC121-3765 | 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. |
REC121-3672 | 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. |
REC121-3691 | 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. |
REC121-3722 | 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. |
REC121-3776 | 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. |