Inquiry Search
Rec-ID | Code | Recommendation |
---|---|---|
REC002-4006 | 17 - Assets and technology | The Commisison would not insist upon a barometer being provided at each mine. Experience has proved that this is a tardy index to atmospheric conditions. Serious changes in the atmospheric pressure occur and are felt before they are indicated by a barometer. |
REC002-4009 | 16 - Training and behaviour | In gassy mines the Manager should be specially competent, and one possessing a thorough knowledge of the principles and practice of mining, the properties of gases, and systems of ventilation; and, above all, he must be prudent and cautious, yet resolute, possessing sound judgement. He must have absolute and supreme control over the whole operations, and of the men within the mine, to maintain rigid discipline, and be perfectly free and untrammelled by any outside influences. The competency of a manager should be certified by an examination before a specially-appointed Board. The Commission consider that better results may be obtained if such examinations be oral, and probably assume a more practical form than those hitherto conducted in Great Britain for the same object. |
Rec-ID | Code | Recommendation |
---|---|---|
REC286-1477 | 16 - Training and behaviour | Develop and deliver flood incident response management training to SES personnel. |
REC286-2067 | 24 - Govt responsibility | Improve integration of health information systems. |
REC286-1438 | 25 - Inquiry, audit, lessons management and after action review | Consider outcomes of national review of warnings and review resilience of warning systems’ infrastructure. |
REC286-2024 | 26 - Research | Improve knowledge and understanding of the effect heatwaves coinciding with other hazard events have on the effectiveness and capability of response and recovery capabilities |
REC286-2078 | 15 - Inter-service cooperation | Review interagency information sharing arrangements. |
REC286-1458 | 13 - Mapping and data quality | Make coastal mapping available to public. |
REC286-2048 | 26 - Research | Conduct research into changes of owners’ and occupiers stated and revealed risk tolerance and preference for treatment measures before and after natural hazard events. |
REC286-2092 | 37 - Funding | Ensure sufficient investment in controls across the PPRR spectrum with a focus on Prevention and Mitigation. |
REC286-1473 | 13 - Mapping and data quality | Develop a statewide flood hazard map for use within the Tasmanian Planning System. |
REC286-2065 | 16 - Training and behaviour | Deliver human influenza pandemic training and exercises in THS and other key organisations. |
REC286-2019 | 24 - Govt responsibility | Assess water supply resilience in the case of an interruption. |
REC286-2073 | 16 - Training and behaviour | Ensure people designing and certifying buildings are appropriately trained and qualified. |
REC286-1434 | 16 - Training and behaviour | Improve the strategic resource-to-risk skills mix (recruitment, retention, capacity), including investigating difference models of volunteering within the TFS Brigade Network. |
REC286-1457 | 26 - Research | Improve understanding of how coastal inundation events interact with riverine flood events. |
REC286-2045 | 26 - Research | Investigate the potential effectiveness of economic and financial mechanisms to manage the risk appetites of land owners. |
REC286-2092 | 26 - Research | Investigate usefulness of satellite data for PPRR (prevention, preparedness, response, recovery) planning. |
REC286-1467 | 15 - Inter-service cooperation | Review the allocation of responsibilities for earthquake risk management. |
REC286-2063 | 24 - Govt responsibility | Review Tas Govt interoperability arrangements. |
REC286-2097 | 13 - Mapping and data quality | Extend current tsunami maritime hazard modelling project to deliver coastal inundation modelling. |
REC286-2014 | 15 - Inter-service cooperation | Integrate non-government entities into emergency response and recovery arrangements. |
REC286-2070 | 25 - Inquiry, audit, lessons management and after action review | Test the Biosecurity Act 2015. |
REC286-1456 | 26 - Research | Improve understanding of the weather systems that cause storm surge events to improve predictability and warnings. |
REC286-2036 | 16 - Training and behaviour | Provide information on landslide hazards and risks to decision makers. |
REC286-2091 | 37 - Funding | Investigate the costs and benefits in enhancing the current Tsunami detection buoy network. |
REC286-1465 | 15 - Inter-service cooperation | Improve the coordination and delivery of the National seismic monitoring program. |
REC286-2059 | 24 - Govt responsibility | Enhance business continuity planning by the Tasmanian Health Service. |
REC286-2095 | 37 - Funding | Investigate the costs and benefits of delivering a public education and awareness program. |
REC286-2013 | 16 - Training and behaviour | State to develop a Swift Water rescue capability. |
REC286-2069 | 24 - Govt responsibility | Implement a database management approach for notifiable disease record systems. |
REC286-1444 | 16 - Training and behaviour | Maintain adequate seasonal fire crew resources across the fire agencies. |
REC286-2033 | 24 - Govt responsibility | Incorporate heatwave surge response planning into business continuity planning. |
REC286-2090 | 26 - Research | Increase understanding of the Puysegur Trench dynamics to improve certainty around the likelihood and magnitude of future Tsunamis. |
REC286-1460 | 25 - Inquiry, audit, lessons management and after action review | Review seismic monitoring network alert systems to ensure emergency managers are on the contact lists. |
REC286-2058 | 24 - Govt responsibility | Clarify the relationship between the DHHS and THS in the establishment of flu services. |
REC286-2094 | 13 - Mapping and data quality | Deliver updated inundation mapping. |
REC286-1480 | 26 - Research | Deliver Flood Studies. |
REC286-2068 | 24 - Govt responsibility | Develop a disaster client record system. |
REC286-1442 | 25 - Inquiry, audit, lessons management and after action review | Review legislation relating to Fuel Stove only areas, Fire Permit System and Total Fire Bans to ensure appropriate incentives to modify individuals’ behaviour. |
REC286-2032 | 26 - Research | Quantify the effect of heatwaves on vulnerable people. |
REC286-2079 | 26 - Research | Develop capacity to utilise the new high-resolution satellite products now available. |
REC286-1459 | 13 - Mapping and data quality | Improve beach morphology mapping to understand coastal inundation, including post-event surveys. |
REC286-2057 | 16 - Training and behaviour | Provide training sessions to GPs to improve their understanding of their roles, options and obligations relating to human influenza pandemic. |
REC286-2093 | 37 - Funding | Investigate the costs and benefits in enhancing the current Tsunami warning arrangements with signage and audible warning systems at key exposed locations (e.g. Port Arthur and Kingston Beach). |
Rec-ID | Code | Recommendation |
---|---|---|
REC285-2524 | 25 - Inquiry, audit, lessons management and after action review | The report recommends that Ambulance Tasmania investigate why the level of multiple responses had increased. |
REC285-2520 | 25 - Inquiry, audit, lessons management and after action review | The report recommends that Ambulance Tasmania investigate whether the additional resources in the North and North West regions were effective in reducing average response times. |
Rec-ID | Code | Recommendation |
---|---|---|
REC279-1232 | 16 - Training and behaviour | Volunteer Charter: by December 2014, agree a charter with volunteers that clarifies roles and expectations including commitments by: a) SES to support volunteers to prepare for and respond to emergencies b) SES to make the best use of volunteers’ time by introducing user-friendly systems and reducing the administrative burden on them c) volunteers to turn-out when called to respond to emergencies. |
REC279-1231 | 16 - Training and behaviour | Training Strategy: By April 2015, develop a training strategy that identifies volunteer training priorities and provides for ongoing review to ensure operational currency, flexibility of delivery and evaluation |
Rec-ID | Code | Recommendation |
---|---|---|
REC245-2595 | 17 - Assets and technology | That stakeholders involved with the Whole of Government radio project re-engage positively to ensure a solution to the current impasse is achieved in the best interests of the stakeholders and the State as a whole. |
REC245-2594 | 17 - Assets and technology | That the network managers produce business cases for all major upgrades. |
REC245-2593 | 17 - Assets and technology | That network managers develop and document strategic plans for the management of their radio networks. |
REC245-2598 | 24 - Govt responsibility | That government considers the establishment of a separate unit to implement and operate a Whole of Government network if existing stakeholders fail to make significant progress toward an agreed Whole of Government solution. |
REC245-2592 | 37 - Funding | That duplication of infrastructure be costed and taken into account when considering whether to proceed with the Whole of Government network. |
REC245-2597 | 17 - Assets and technology | That the project team become independent from any of the entities involved in the Whole of Government network. |
REC245-2591 | 17 - Assets and technology | That until the outcome of the Whole of Government project is complete (and interoperability is achieved), emergency services should investigate and implement methods for further improving interoperability. |
REC245-2596 | 24 - Govt responsibility | That the Whole of Government project’s objectives should include meeting entity requirements and the consultant be asked to reevaluate the revised set of objectives. |
Rec-ID | Code | Recommendation |
---|---|---|
REC237-0833 | 37 - Funding | That the NSW Rural Fire Service and the NSW Treasury explore ways to ensure that unspent hazard reduction funds be carried over to the next financial year in a timely manner and to ensure that hazard reduction funding has a seamless transition from one financial year to the next. |
REC237-0834 | 37 - Funding | That the NSW Rural Fire Service apply for funding from the NSW Treasury for the development of a multi-agency business case for a BRIMS replacement that includes internal management, risk communication, community engagement capability and publishing activities on websites. |
Rec-ID | Code | Recommendation |
---|---|---|
REC208-0526 | 25 - Inquiry, audit, lessons management and after action review | That OEH’s testing procedures for determining the impact of pollution incidents incorporate additional requirements for the checking and verification of results before those results are released. |
Rec-ID | Code | Recommendation |
---|---|---|
REC140-3561 | 17 - Assets and technology | Development of a helipad at Mersey Hospital. |
REC140-3568 | 37 - Funding | The State Medical Retrieval Cost Centre (TMRS and NETS) be formed and be supported by the appropriate administrative and resource accountant expertise. This cost centre should be placed with those responsible for its management. |
REC140-3553 | 37 - Funding | RHH Neonatal Emergency Transport Service receive DHHS funding for a Senior Registrar to assume the responsibilities of retrieval staffing, quality assurance, data collection and reporting demands. |
REC140-3560 | 17 - Assets and technology | RHH requires a helipad. Plans to rebuild RHH must include a helipad at its earliest stage of conception. |
REC140-3567 | 37 - Funding | A uniform retrieval charge to the region of referral should be considered. This should be independent of the mode of transport used. |
REC140-3552 | 37 - Funding | Department of Health and Human Services (DHHS) to fund 3 Full-Time Equivalent (FTE) Senior Registrar positions at the Royal Hobart Hospital (RHH) for the Tasmanian Medical Retrieval Service (TMRS). One registrar in the Anaesthesia Department, one in the Intensive Care Unit and one in Emergency Department is proposed. |
REC140-3559 | 17 - Assets and technology | A service level agreement is negotiated with the Police department that will cover access, tasking, price, equipment and staffing. This will enable a more strategic use of the helicopter. |
REC140-3565 | 17 - Assets and technology | The TMRS medical equipment inventory requires an overhaul. The TMRS medical equipment should be located with the TMRS team. |
REC140-3556 | 17 - Assets and technology | The use of hospital transport vehicles to support retrieval operations be investigated. |
REC140-3564 | 17 - Assets and technology | The medical equipment used in retrieval and air ambulance duties undertaken by helicopter and fixed wing must be standardised. |
REC140-3575 | 24 - Govt responsibility | The preferred model for the Tasmanian Medical Retrieval Services is to have TMRS and NETS staff based in RHH. The fixed wing would remain based in Launceston (for the present) with the helicopter to remain based in Hobart. |
REC140-3555 | 16 - Training and behaviour | The Tasmanian Ambulance Service Clinical Advisory Committee review helicopter and fixed wing Flight Paramedic training and consider extending the scope of practice to embrace the role of retrieval paramedic in the Doctor/Paramedic retrieval team setting. |
REC140-3563 | 17 - Assets and technology | An additional secure emergency oxygen supply source to be located in the BK 117 helicopter. An internal supply is preferred. |
REC140-3573 | 13 - Mapping and data quality | Databases with a common minimum data set complete with incident monitoring should be established for TAS Air Ambulance, TMRS and NETS missions. |
REC140-3554 | 37 - Funding | DHHS fund the equivalent of 2 FTE Consultant positions for retrieval duties (1.5 FTE existing, 0.5 FTE new) |
Rec-ID | Code | Recommendation |
---|---|---|
REC128-3616 | 37 - Funding | That the Department of Primary Industries continue to pursue improvements to consultation with industry and accountability mechanisms to further build trust between industry and government, thereby enhancing the effectiveness of the OJD Program. |
REC128-3604 | 37 - Funding | That the Department of Primary Industries restore the level of discretionary testing funds provided to District Veterinarians to previous levels and maintain these in the future in real terms. |
REC128-3614 | 37 - Funding | The Committee encourages the Department and the Rural Land Protection Boards to discuss the need for funding of poultry surveillance activities in the context of reviewing the Memorandum of Understanding between the two parties. |
REC128-3603 | 37 - Funding | That the Department of Primary Industries consider applying discretion to the use of user charging policies for testing in times when farm incomes are affected by external circumstances such as widespread drought. |
REC128-3609 | 16 - Training and behaviour | That the Department of Primary Industries be conscious of its responsibilities in maintaining the continued enthusiasm of Industry Liaison Officers and offer training and refresher training as required. |
REC128-3598 | 25 - Inquiry, audit, lessons management and after action review | That the Department of Primary Industries incorporates reviews of plans and operating procedures as a result of emergency incidents and exercises and ensures that there is adequate commitment from all participants in the review process. |
REC128-3608 | 16 - Training and behaviour | That emergency animal health training be included in induction programs for newly recruited District Veterinarians and all District Veterinarians be encouraged to maintain their skills by attending regular refresher training as appropriate. |
REC128-3607 | 16 - Training and behaviour | That the Department of Primary Industries should continue efforts to develop the skills of private sector veterinarians to increase the level of resources available in emergency responses. |
REC128-3617 | 37 - Funding | That the Department of Primary Industries should provide specific information on levies to contributing producers through a separate document, rather than rely on standard audit documents and annual reporting requirements. |
REC128-3606 | 24 - Govt responsibility | That the Department of Primary Industries address the forthcoming potential shortage of veterinary pathologists and agronomists within its testing facilities by positive recruitment actions over the next five years such as offering scholarships or training existing professional staff to develop skills in pathology. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC121-3758 | 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. |
REC121-3656 | 17 - Assets and technology | Satellite telephones should be provided by RailCorp to all rail commanders at any emergency. |
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. |
REC121-3677 | 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. |
REC121-3744 | 16 - Training and behaviour | All RailCorp operational personnel should be trained in the location and operation of external emergency door release mechanisms. |
REC121-3714 | 16 - Training and behaviour | RailCorp should use its simulators in an interactive manner. |
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. |
REC121-3654 | 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. |
REC121-3719 | 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. |
REC121-3675 | 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. |
REC121-3726 | 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. |
REC121-3756 | 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. |
REC121-3650 | 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. |
REC121-3718 | 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. |
REC121-3768 | 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. |
REC121-3672 | 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. |
REC121-3725 | 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. |
REC121-3694 | 25 - Inquiry, audit, lessons management and after action review | The ITSRR should conduct random audits of accredited rail organisations for compliance with communications protocols. |
REC121-3753 | 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. |
REC121-3717 | 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. |
REC121-3767 | 24 - Govt responsibility | All accredited rail organisations should be required to re-apply every three years to ITSRR for accreditation. |
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. |
REC121-3724 | 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. |
REC121-3693 | 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. |
REC121-3751 | 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. |
REC121-3716 | 16 - Training and behaviour | Train driver and guard training should encourage teamwork and discourage authority gradients. |
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. |
REC121-3669 | 16 - Training and behaviour | All operational rail staff should be trained by RailCorp in the action check list relevant to each. |
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. |
REC121-3691 | 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. |
REC121-3746 | 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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC119-3649 | 25 - Inquiry, audit, lessons management and after action review | It is recommended that the Board: |
Rec-ID | Code | Recommendation |
---|---|---|
REC008-3985 | 17 - Assets and technology | The Commission recommends that conductors carrying currents at medium pressure should not be encased in wood in damp places. |
REC008-3984 | 16 - Training and behaviour | The Commission recommends that the live parts of resistances should be fixed so that no unprotected combustible material is within 6ins of the frames or cases containing them or within 24ins measured vertically above. |
REC008-3990 | 16 - Training and behaviour | The Commission recommends that more than one means of exit should be provided in every mine from every level of it to the surface; and that the miners should be kept informed where they are situated. |
REC008-3989 | 17 - Assets and technology | The Commission recommends that there be continuous supervision of every chamber in which electrical machinery is worked by currents of medium pressure. |
REC008-3987 | 17 - Assets and technology | The Commission recommends that systematic tests be made and recorded of apparatus and circuits as a precaution against fire and so that any gradual deterioration of the system may be detected. |
REC008-3986 | 17 - Assets and technology | The Commission recommends that every precaution be taken to keep water off electrical machinery. |