Inquiry Search
Rec-ID | Code | Recommendation |
---|---|---|
REC314-3263 | 4 - Fire season preparation | Clarify and streamline processes and educate the community about their roles and responsibilities in managing native vegetation to improve hazard reduction on both public and private land. Provide additional resources to manage fuel in a shorter off fire season and develop a risk reduction target linked to prioritised objectives. |
REC314-3262 | 10 - Infrastructure | Invest in upgrading and integrating ICT platforms to eliminate manual data transfers, and ensure IT and radio communication interoperability across the agencies, together with a dedicated focus on the development of a coordinated risk intelligence capability to provide all stakeholders with a common operating picture and rapid damage assessments. |
REC314-3260 | 32 - Doctrine, standards, and reform | Align risk assessment tools and processes to Risk Management Standard ISO 31000 and the National Emergency Risk Assessment Guidelines (NERAG) and communicate these on public-facing platforms. Make Bushfire Management Area Plans (BMAP) accountable for managing and reporting on region-specific risk and identifying critical infrastructure such as mobile phone towers as key risks. |
REC314-3259 | 32 - Doctrine, standards, and reform | Implement previous review recommendations for bushfire management including those relating to the 2009 amendments to the Fire and Emergency Services Act 2005, State Bushfire Coordination Committee operation, State Bushfire Management Plan, as well as urgent completion of Codes of Practice for fuel hazard reduction on all land tenures, and redevelopment of Bushfire Management Area Plans accompanied by effective community engagement to build an understanding of risk. |
REC314-3272 | 10 - Infrastructure | Clarify business continuity and restoration of critical infrastructure in the planning and response phases to facilitate water replenishment, fireground remediation and access to businesses (including farming properties). |
REC314-3269 | 32 - Doctrine, standards, and reform | Develop and practice procedures for the CFS, DEW and local governments to access and deploy heavy plant and machinery for fuel reduction operations both before and during bushfires. |
Rec-ID | Code | Recommendation |
---|---|---|
REC302-2395 | 32 - Doctrine, standards, and reform | Remove those policies, guidelines, memoranda of understanding and committees that are made redundant as a result of adopting recommendation #2 while updating any remaining policies that are considered to still be relevant |
Rec-ID | Code | Recommendation |
---|---|---|
REC273-1128 | 32 - Doctrine, standards, and reform | Incorporate in operational doctrine the ability for the State Controller to determine the operational readiness levels of the state or regions based on either the predicted and/or actual risk and/or activity to some or all of the regions. |
REC273-1145 | 32 - Doctrine, standards, and reform | Review relevant Legislation associated Acts and Plans to establish a consistent approach to fire and emergency management to minimise duplication and risk of contradiction. That the Hazard and Functional area plans be amalgamated and establish a SA Bushfire Plan, under the SEMP, which clearly define role of SACFS. |
REC273-1143 | 32 - Doctrine, standards, and reform | That SACFS in consultation with SAMFS consider adopting common terminology and capability requirements for strike teams being ‘4-5 appliances and a group officer’ in line with other jurisdictions. |
REC273-1133 | 32 - Doctrine, standards, and reform | That a complete review of current naming conventions of personnel and centres, in accordance with the outcomes of the Victorian Bushfire Royal Commission is undertaken, to ensure clarity around command, control and coordination within SA. |
REC273-1129 | 32 - Doctrine, standards, and reform | Incorporating ‘triggers’ within Chief Officers Standing Orders No. 17, which requires the escalation of the State Controller role to the rank of Assistant Chief Officer or greater, depending on the increased risk or activity. |
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. |
REC244-2626 | 32 - Doctrine, standards, and reform | Section 70 (5) be amended to preclude a person from being elected as a group officer, brigade captain or brigade lieutenant if he or she is an employee of the CFS. |
REC244-2611 | 32 - Doctrine, standards, and reform | Review the format and necessity for Schedules 9 and 10 of the Regulations |
REC244-2631 | 25 - Inquiry, audit, lessons management and after action review | Review Section 134 to ensure that it is not a deterrent to a group of farm fire units operating at an incident. |
REC244-2617 | 25 - Inquiry, audit, lessons management and after action review | When judging major incidents in the future, consideration be given to Eburn and Dover’s proposal to establish processes with a statutory basis that sufficiently balance the community’s interests in ensuring that true lessons, including lessons of error or neglect, are identified, whilst also protecting members of the emergency services. Processes need to be developed for emergency services such as those used in aviation and medicine, to facilitate open and honest disclosure of errors. |
REC244-2603 | 32 - Doctrine, standards, and reform | Should the State Bushfire Coordination Committee continue to exist under the F&ES Act, then Section 71 of the Act be amended to provide for the appointment of an independent presiding member of the committee. |
REC244-2625 | 32 - Doctrine, standards, and reform | Sections 42 and 97 be amended to provide greater flexibility in the engagement of contractors by Senior MFS and CFS Officers. Consideration be given to providing similar powers in Section 118 to enable the SES to engage contractors. |
REC244-2610 | 32 - Doctrine, standards, and reform | Amend Regulation 33 (6) and (8) to include respectively ‘notice given’ and ‘permit application’ using the online medium. |
REC244-2630 | 32 - Doctrine, standards, and reform | Clarify that Section 128 of the F&ES Act is not compromised by any other legislation. |
REC244-2615 | 32 - Doctrine, standards, and reform | In consultation with stakeholders including CFA, develop a Forest Industry Brigade standard for inclusion in the Fire and Emergency Services Regulations. |
REC244-2636 | 32 - Doctrine, standards, and reform | Amend the F&ES Act to provide for the operation of interstate fire and emergency service workers in South Australia. The issue of liability may need to be considered. |
REC244-2602 | 32 - Doctrine, standards, and reform | That South Australia’s Hazard Leader Plan for Rural Fire, prepared in accordance with the State Emergency Management Plan, replace the F&ES Act requirement for a separate State Bushfire Management Plan. |
REC244-2624 | 32 - Doctrine, standards, and reform | The F&ES Act be amended to clarify the meaning of ‘closure’ in Section 38 and that provisions relating to the extension and rescission of closure orders be reviewed. |
REC244-2609 | 32 - Doctrine, standards, and reform | That the proposed ‘Permit Information Management System’ (PIMS) be implemented as soon as possible and incorporated into the Call Receipt and Dispatch process. Following implementation, amend Regulation 33 (5) (d) and (10) (c) in line with the automated notification process. |
REC244-2629 | 32 - Doctrine, standards, and reform | The power of the Chief Officer to appoint officers from the staff of the SES as well as appoint volunteer officers of the SES be clarified. A command structure section (similar to Section 70) be incorporated into the Act and include the power to register, appoint, disqualify and terminate volunteer members. |
REC244-2614 | 32 - Doctrine, standards, and reform | Consider the amendment of Section 82 (2) to include the power to order the cessation of harvesting or any other actions (including the lighting of fires authorised under Section 81) that because of the weather conditions, may cause a fire, if ignited, to get out of control. |
REC244-2635 | 32 - Doctrine, standards, and reform | The requirement to consult with members of the unit and the SESVA before an SES Unit is dissolved should remain but the need for public meetings be removed from the regulations. |
REC244-2601 | 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. |
REC244-2623 | 32 - Doctrine, standards, and reform | That the F&ES Act be amended to enable fire safety inspections in and outside fire districts. |
REC244-2608 | 32 - Doctrine, standards, and reform | Consider whether Regulation 71 be amended to extend the range of offences for which expiation fees apply to include a breach of any permit condition imposed by an authorised officer. |
REC244-2628 | 32 - Doctrine, standards, and reform | Amend the F&ES Act to reflect the SES expanded responsibilities as Hazard Leader for ‘Extreme Weather’ including their community education role. |
REC244-2613 | 32 - Doctrine, standards, and reform | Should the State Bushfire Coordination Committee continue to exist under the F&ES Act amend Section 94 (4) (c) to refer to the ‘State Bushfire Coordination Committee’. |
REC244-2633 | 32 - Doctrine, standards, and reform | Amend Section 143 to strengthen the capacity of the ESOs to recover outstanding debts (e.g. penalty for late payment provisions). |
REC244-2600 | 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. |
REC244-2622 | 32 - Doctrine, standards, and reform | Amend Sections 28, 61 and 110 to provide the Chief Officers greater flexibility over organisational structure. |
REC244-2607 | 32 - Doctrine, standards, and reform | Amend Regulation 41 to exempt the use of prescribed appliances when a Hot Work Permit compliant with AS1674.1 has been issued. |
REC244-2627 | 4 - Fire season preparation | Government in conjunction with the CFS identify the ownership of disused railway corridors which may pose a significant fire risk and ensure the agency or individual responsible for the land complies with legislative requirements. |
REC244-2612 | 32 - Doctrine, standards, and reform | Develop a code of practice which is referenced by the F&ES Act for burning off including the option to issue seasonal permits for relevant purposes throughout the State. |
REC244-2632 | 32 - Doctrine, standards, and reform | Section 142 be amended to include the SES |
REC244-2599 | 32 - Doctrine, standards, and reform | That the MFS, CFS and SES be incorporated into a departmental structure under the direction of a Chief Executive based on interstate developments over the past two decades, which establishes this arrangement as the benchmark for the governance of Emergency Services in Australia. The MFS, CFS and SES would operate as separate units under the ultimate direction of the CEO. |
REC244-2620 | 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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC237-0825 | 1 - Land-use and building regs | That the NSW Rural Fire Service hold discussions with the Department of Planning and Infrastructure and Local Government NSW on ways to improve compliance with development consents under section 76A of the Environmental Planning and Assessment Act 1979. |
REC237-0819 | 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. |
REC237-0832 | 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. |
REC237-0818 | 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. |
REC237-0831 | 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 |
REC237-0817 | 32 - Doctrine, standards, and reform | That section 3(c) of the Rural Fires Act 1997, which sets out the objects of the Act, be extended to include protecting infrastructure, environmental, economic, cultural, agricultural and social assets from damage. |
REC237-0822 | 32 - Doctrine, standards, and reform | That section 74 of the Rural Fires Act 1997 be amended to require public authorities to report to the Commissioner of the NSW Rural Fire Service within one month of the end of the financial year on activities undertaken to reduce bush fire hazards on managed land during the preceding financial year. |
REC237-0827 | 32 - Doctrine, standards, and reform | The Panel notes and endorses the NSW bush fire management system based on a multi-agency, tenure blind approach using locally focused Bush Fire Management Committees, Bush Fire Management Plans and the Bush Fire Environmental Assessment Code as best practice. |
REC237-0821 | 32 - Doctrine, standards, and reform | That the definition of “bush fire hazard reduction work” in the Dictionary of the Rural Fires Act 1997 be amended to include the establishment or maintenance of fire trails. |
REC237-0826 | 32 - Doctrine, standards, and reform | That the NSW Rural Fire Service hold discussions with the Commonwealth Department of Sustainability, Environment, Water, Population and Communities about hazard reduction and roadside vegetation, including potential changes to the NSW Bush Fire Environmental Assessment Code. |
REC237-0820 | 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 |
---|---|---|
REC151-3072 | 32 - Doctrine, standards, and reform | Provisions in the FES Act relating to, “land management principles” be reviewed in consultation with appropriate agencies and having due regard to the recommendations of the Wangary Coronial Inquest. |
REC151-3094 | 32 - Doctrine, standards, and reform | Where in the FES Act reference is made to ‘South Australian Volunteer Fire-Brigades Association’ this be removed and replaced with, ‘Country Fire Service Volunteers Association’. |
REC151-3081 | 32 - Doctrine, standards, and reform | So as to increase the pool of volunteers from which the Minister can appoint Advisory Board members, Section 18(3)(c) and (d) be amended to include nominations from the Group Committee (SACFS) and Unit Managers Advisory Group (SASES). |
REC151-3101 | 32 - Doctrine, standards, and reform | Divisions and Subdivisions and Regulations 22 and 62 headings relating to conduct and discipline be changed to have similar wording and should include, “Conduct, Discipline and Grievance Procedures for Members”. |
REC151-3063 | 32 - Doctrine, standards, and reform | The preamble of the Fire and Emergency Services (FES) Act be amended to include a stronger emphasis on the strategic and policy purposes of the Commission, highlighting its key role in the governance of the emergency services sector. |
REC151-3087 | 32 - Doctrine, standards, and reform | Section 90 – provisions relating to smoking, and throwing burning material be removed from the principal FES Act and placed in the Regulations. |
REC151-3106 | 32 - Doctrine, standards, and reform | A schedule for revocation of permits be included in the Regulations. |
REC151-3070 | 32 - Doctrine, standards, and reform | Crown law opinion be obtained to determine whether additional functions now undertaken by the Commission following the devolvement of the functions of the Security and Emergency Management Office (SEMO) require an amendment to the FES Act. |
REC151-3093 | 32 - Doctrine, standards, and reform | Where in the FES Act reference is made to, ‘an officer of the National Parks and Wildlife Service’ this be removed and replaced with, ‘an officer of the Department for Environment and Heritage’. |
REC151-3076 | 32 - Doctrine, standards, and reform | Provisions in Section 11(1)(e)(i) and (ii) relating to appointments of volunteer associations to the SAFECOM Board be removed. |
REC151-3100 | 32 - Doctrine, standards, and reform | Section 70(12) (relating to disciplinary action) be amended to include, where the officer is an employee of a government agency, the Chief Officer shall advise an appropriate representative of the agency prior to any disciplinary action being taken. |
REC151-3086 | 32 - Doctrine, standards, and reform | Section 88 – requirement to carry fire extinguishers in a caravan be removed from the principal FES Act and placed in the Regulations. |
REC151-3105 | 32 - Doctrine, standards, and reform | With the implementation of the Ministerial Review of Bushfire Management in South Australia, the provisions in Sections 84 and 85 be reviewed in terms of enforcing hazard reduction on council or Crown land. |
REC151-3069 | 32 - Doctrine, standards, and reform | Consistent with the requirement for Emergency Service Organisations, the FES Act be amended to require South Australian Fire and Emergency Commission (SAFECOM) to submit a workforce plan to the Board. |
REC151-3091 | 32 - Doctrine, standards, and reform | Regulation 48 regarding prescribed offences be amended to include Section 79(2)(e) or its equivalent under the amendment proposed in Recommendation 22 above. |
REC151-3075 | 32 - Doctrine, standards, and reform | Section 92 include the facility to issue a warrant for the relevant authority to break into land or buildings for the purposes of determining what measures have been taken for the prevention, control or suppression of fire or for the prevention of, or for dealing with, the escape of hazardous materials; and that costs and expenses in doing so are recoverable. |
REC151-3097 | 32 - Doctrine, standards, and reform | Regulation 8(4)(b) be amended to allow persons of or above 16 years of age to register as fire-fighters. |
REC151-3085 | 32 - Doctrine, standards, and reform | With the implementation of the Ministerial Review of Bushfire Management in South Australia, consideration should be given to provisions within Part 4, Division 7 of the principal FES Act which would be more appropriately placed in the Regulations. |
REC151-3104 | 32 - Doctrine, standards, and reform | SAFECOM in consultation with SAMFS consider the merits of amending Sections 49- 51 to replace the right to appeal from the District Court to the South Australian Industrial Relations Commission. |
REC151-3068 | 32 - Doctrine, standards, and reform | The FES Act be amended so as to allow the Chief Executive (CE) to manage the Commission (SAFECOM) Office by removing provisions relative to the SAFECOM Board’s managerial and administrative oversight of the Commission. |
REC151-3090 | 32 - Doctrine, standards, and reform | Following the amendment to Section 79 as proposed above in Recommendation 22, a definition of, ‘properly constructed fire place’ and ‘properly constructed incinerator’ be included in the new Regulation. |
REC151-3074 | 32 - Doctrine, standards, and reform | Sections 56 and 83 (amended as suggested above) include the facility to issue a warrant for the relevant authority to break into land or buildings to carry out requirements regarding flammable undergrowth or material; and that costs and expenses in doing so are recoverable. |
REC151-3096 | 32 - Doctrine, standards, and reform | All Regulations relating to constitutions be deleted; the FES Act be amended to allow the Chief Officers to prescribe the constitution; and the process for the management of a SACFS brigade/group and a SASES unit to be in the form of an administrative instruction. |
REC151-3084 | 32 - Doctrine, standards, and reform | Section 79(1) – provisions relating to lighting or maintaining a fire in the open air during the fire danger season be retained in the principal FES Act; Section 79(2) be amended to provide that a fire may be lit or maintained in accordance with the Regulations; provisions specifying the conditions under which a fire can be lit or maintained, and currently under Section 79(2), be placed in the Regulations. |
REC151-3103 | 32 - Doctrine, standards, and reform | Provisions be included in the Regulations for mediation in appropriate circumstances. |
REC151-3065 | 32 - Doctrine, standards, and reform | The FES Act be amended to create the position which currently has the working title of ‘Commissioner of Fire and Emergencies’ to replace the position of CE and that the FES Act be amended in places where this position is mentioned. |
REC151-3089 | 32 - Doctrine, standards, and reform | The definition of ‘officer’ in Section 3 be amended to include reference to the designation being made by the Chief Officer. |
REC151-3111 | 32 - Doctrine, standards, and reform | Crown law opinion be obtained as to what amendments, if necessary or appropriate, are required to satisfy Recommendation 29.9(7) of the Wangary Coronial Inquest, that a dedicated bushfire prevention officer be appointed. |
REC151-3073 | 32 - Doctrine, standards, and reform | Sections 56 and 83 be repealed and replaced with a single section which unifies their provisions. |
REC151-3094 | 32 - Doctrine, standards, and reform | Where in the FES Act reference is made to ‘South Australian Volunteer Fire-Brigades Association’ this be removed and replaced with, ‘Country Fire Service Volunteers Association’. |
REC151-3082 | 32 - Doctrine, standards, and reform | The Regulations be amended to include appropriate references to the Unit Managers Advisory Group (SASES) consistent with those of the Group Committee (SACFS). |
REC151-3102 | 32 - Doctrine, standards, and reform | Regulations 22 and 62 be reviewed to ensure reports regarding conduct must be relevant to the enquiry. |
REC151-3064 | 32 - Doctrine, standards, and reform | The FES Act be amended to include a definition of ‘operations’ and/or ‘operational’. |
REC151-3088 | 32 - Doctrine, standards, and reform | Sections 68 and 116 – provisions relating to the establishment/dissolution of SACFS Brigades and SASES Units be amended so as to retain the head of power in the principal FES Act and that the procedural provisions within each of these sections be placed in the Regulations. |
REC151-3110 | 32 - Doctrine, standards, and reform | Further to Recommendations 11 and 12 above concerning the joining of Sections 56 and 83 of the FES Act, that these existing provisions be examined to determine whether they provide sufficient authority to address Recommendation 29.9(4) of the Wangary Coronial Inquest so as to require the owners or occupiers of rural land to create fire breaks and/or the removal of flammable materials from the land, as measures for preventing the outbreak of a bushfire, or for preventing the spread or extension of a bushfire. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC121-3700 | 39 - Disaster Risk Management | Maintenance plans on all trains should be revised annually. |
REC121-3760 | 32 - Doctrine, standards, and reform | The Advisory Board established under the Transport Legislation Amendment (Safety and Reliability) Act 2003 must be abolished. |
REC121-3655 | 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. |
REC121-3687 | 10 - Infrastructure | There must be compatibility of communications systems throughout the rail network. It is essential that all train drivers, train controllers, signallers, train guards and supervisors of trackside work gangs in New South Wales be able to communicate using the same technology. |
REC121-3724 | 13 - Mapping and data quality | The ITSRR should establish a data and information management system, containing all data and information that it requires, to continually monitor the safety of the New South Wales rail system. |
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. |
REC121-3662 | 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. |
REC121-3693 | 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. |
REC121-3730 | 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. |
REC121-3674 | 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. |
REC121-3699 | 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. |
REC121-3758 | 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. |
REC121-3653 | 10 - Infrastructure | The RMC should be equipped by RailCorp with a transcriber system, or mimic board, or such other system as is necessary to enable identification of the precise location at any time of any train on the RailCorp network. |
REC121-3686 | 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. |
REC121-3713 | 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. |
REC121-3765 | 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. |
REC121-3661 | 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. |
REC121-3692 | 32 - Doctrine, standards, and reform | Communications protocols and procedures should be standardised and mandated by regulations making them a condition of accreditation. |
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. |
REC121-3673 | 41 - Emergency Management exercises | Regular field training exercises should be conducted by RailCorp with the emergency services to ensure that the incident command system and rail displan are able to be fully implemented as quickly as possible and are reviewed and improved. |
REC121-3698 | 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. |
REC121-3757 | 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. |
REC121-3651 | 10 - Infrastructure | A dedicated telephone line should be established by RailCorp between the RMC and any Emergency Services Control Centre for use during any emergency. |
REC121-3685 | 32 - Doctrine, standards, and reform | The ITSRR should impose a standard in relation to the collection and use of data from data loggers. |
REC121-3710 | 39 - Disaster Risk Management | The ITSRR should have permanent access to the RailCorp intranet. |
REC121-3763 | 32 - Doctrine, standards, and reform | The ITSRR should publish guidelines to be followed by accredited organisations. |
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. |
REC121-3691 | 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. |
REC121-3727 | 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. |
REC121-3771 | 32 - Doctrine, standards, and reform | RailCorp should establish an integrated safety management system which includes the following: |
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. |
REC121-3696 | 32 - Doctrine, standards, and reform | Defects reporting, recording and rectification should be integrated with the RailCorp regimes for train maintenance. |
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. |
REC121-3684 | 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. |
REC121-3705 | 32 - Doctrine, standards, and reform | The ITSRR should develop standards for periodic medical examinations which include the following: |
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. |
REC121-3659 | 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. |
REC121-3690 | 32 - Doctrine, standards, and reform | All communications protocols must be strictly enforced by all accredited rail organisations. |
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. |
REC121-3770 | 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. |
REC121-3695 | 10 - Infrastructure | There should be interoperability of communications equipment between all trains operating on the New South Wales rail network. |
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. |
REC121-3683 | 39 - Disaster Risk Management | RailCorp should undertake risk assessments of each of its activities as follows: |
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. |
REC121-3761 | 32 - Doctrine, standards, and reform | Legislative changes should be enacted to ensure the complete independence of ITSRR from the Minister for Transport Services. |
REC121-3657 | 10 - Infrastructure | All signal telephones must be maintained by RailCorp in proper working order. |
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. |
REC121-3725 | 13 - Mapping and data quality | The data and information management system should be compatible with any data and information management system established by the ATSB for the designated interstate rail network, provided that the establishment of a compatible system does not reduce the amount or quality of the information obtained by ITSRR below the optimum levels which it needs to conduct trend analysis, and otherwise properly manage the safety of rail operations in New South Wales. |
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. |
REC121-3694 | 25 - Inquiry, audit, lessons management and after action review | The ITSRR should conduct random audits of accredited rail organisations for compliance with communications protocols. |
REC121-3736 | 32 - Doctrine, standards, and reform | The RailCorp passenger containment policy must be abandoned. |