Inquiry Search
Rec-ID | Code | Recommendation |
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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 |
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REC286-2015 | 1 - Land-use and building regs | Build flood capable infrastructure. |
REC286-2065 | 16 - Training and behaviour | Deliver human influenza pandemic training and exercises in THS and other key organisations. |
REC286-2073 | 16 - Training and behaviour | Ensure people designing and certifying buildings are appropriately trained and qualified. |
REC286-1435 | 1 - Land-use and building regs | Monitor effectiveness of new Land Use Planning and Building System reforms to evaluate effectiveness of delivering desired outcomes. |
REC286-2037 | 1 - Land-use and building regs | Make property level information on landslide hazards publicly available |
REC286-1453 | 1 - Land-use and building regs | Review building controls to ensure they are adaptive to changing coastal inundation risks. |
REC286-2050 | 1 - Land-use and building regs | Ensure landuse planning and building systems, including appeal mechanisms, are transparent, equitable and integrated at the municipal, State and national levels. |
REC286-2013 | 16 - Training and behaviour | State to develop a Swift Water rescue capability. |
REC286-2063 | 24 - Govt responsibility | Review Tas Govt interoperability arrangements. |
REC286-1434 | 16 - Training and behaviour | Improve the strategic resource-to-risk skills mix (recruitment, retention, capacity), including investigating difference models of volunteering within the TFS Brigade Network. |
REC286-2036 | 16 - Training and behaviour | Provide information on landslide hazards and risks to decision makers. |
REC286-2070 | 25 - Inquiry, audit, lessons management and after action review | Test the Biosecurity Act 2015. |
REC286-1451 | 1 - Land-use and building regs | Include consideration of coastal inundation in land use planning for new developments and uses. |
REC286-2046 | 1 - Land-use and building regs | Incentivising safer sites (charge people less rates and discounts for defensive actions by land managers). |
REC286-1477 | 16 - Training and behaviour | Develop and deliver flood incident response management training to SES personnel. |
REC286-2059 | 24 - Govt responsibility | Enhance business continuity planning by the Tasmanian Health Service. |
REC286-2033 | 24 - Govt responsibility | Incorporate heatwave surge response planning into business continuity planning. |
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. |
REC286-2044 | 1 - Land-use and building regs | Develop linkages between landslide risk assessors and building engineers/structural works. |
REC286-1474 | 1 - Land-use and building regs | Raised access routes. |
REC286-2058 | 24 - Govt responsibility | Clarify the relationship between the DHHS and THS in the establishment of flu services. |
REC286-2023 | 1 - Land-use and building regs | Locate and design new public infrastructure so that it can continue to operate during flood events. |
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. |
REC286-2040 | 1 - Land-use and building regs | Further development of Landslide Hazard Banding of the State (MRT). |
REC286-1471 | 1 - Land-use and building regs | Promote the use of Water Sensitive Urban Design in stormwater systems. |
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. |
REC286-2019 | 24 - Govt responsibility | Assess water supply resilience in the case of an interruption. |
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. |
REC286-2038 | 1 - Land-use and building regs | Monitor effectiveness of new Land Use Planning reforms to evaluate effectiveness of delivering desired outcomes. |
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. |
REC286-2051 | 1 - Land-use and building regs | Establish arrangements to enable the buy-back of specified landslip prone land. |
Rec-ID | Code | Recommendation |
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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 |
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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 |
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REC263-1097 | 16 - Training and behaviour | CFA should: improve Brigade Operational Skills Profiles to reflect volunteer activity and availability |
Rec-ID | Code | Recommendation |
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REC248-2587 | 16 - Training and behaviour | Victoria Police should adequately train all frontline police managers to handle complex personal matters involving staff. |
Rec-ID | Code | Recommendation |
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REC245-2598 | 24 - Govt responsibility | That government considers the establishment of a separate unit to implement and operate a Whole of Government network if existing stakeholders fail to make significant progress toward an agreed Whole of Government solution. |
REC245-2596 | 24 - Govt responsibility | That the Whole of Government project’s objectives should include meeting entity requirements and the consultant be asked to reevaluate the revised set of objectives. |
Rec-ID | Code | Recommendation |
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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. |
Rec-ID | Code | Recommendation |
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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 |
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REC179-2983 | 24 - Govt responsibility | The Department of Human Services should work with the State Emergency Recovery Planning Committee, regions, and other partners to facilitate understanding and ownership of roles and responsibilities for common recovery services. |
REC179-2980 | 24 - Govt responsibility | The Department of Human Services should work with regions and partner agencies at the state level to create consistent, streamlined impact assessment processes and systems. |
REC179-2979 | 24 - Govt responsibility | The Department of Human Services should communicate strategic priorities to achieve state and regional level alignment in building recovery capacity and capability. |
REC179-2978 | 16 - Training and behaviour | The Department of Human Services should make sure relevant senior staff complete recovery training. |
Rec-ID | Code | Recommendation |
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REC159-3058 | 25 - Inquiry, audit, lessons management and after action review | ACTAS should improve patient care processes by: |
Rec-ID | Code | Recommendation |
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REC158-3454 | 24 - Govt responsibility | That the Department of Transport ensures that key stakeholders are engaged during the implementation of the approved Review recommendations. |
REC158-3452 | 25 - Inquiry, audit, lessons management and after action review | That the nominated marine safety authority undertakes a further assessment to determine the recommendations from this Review that may also be applicable to State waters outside commercial port waters. |
REC158-3448 | 24 - Govt responsibility | That the Director of Marine Safety works with the Australian Maritime Safety Authority to ensure that State and port emergency arrangements interface appropriately with the National Maritime Emergency Response Arrangements. |
REC158-3433 | 24 - Govt responsibility | That Harbour Masters are employed by a government body and remain geographically located at the port. |
Rec-ID | Code | Recommendation |
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REC144-3379 | 25 - Inquiry, audit, lessons management and after action review | The Committee recommends that a thorough review be undertaken of the communications and coordination between the separate agencies which make up the Emergency Services Agency, to assess the extent to which cultural factors are detrimental to the effective operation of the ESA. |
REC144-3390 | 24 - Govt responsibility | If the ACT Government decides to proceed with the site as the emergency services headquarters, that it accord a high priority to the finalisation of the site preparations for the ESA at Fairbairn as a matter of urgency. |
REC144-3389 | 24 - Govt responsibility | If the Auditor-General does not undertake a review in the near future, the Committee recommends that the ACT Government make a public announcement about the future accommodation plans for the Emergency Services Agency and its component parts so that both the ESA and the ACT public are informed about current proposals and timeframes. |
REC144-3388 | 24 - Govt responsibility | If the Auditor-General does not undertake a review in the near future, the Committee recommends that the ACT Government re-investigate the suitability of the Fairbairn site as a proposed centralised accommodation facility for emergency services. |
REC144-3386 | 24 - Govt responsibility | The Committee considers that the ACT Government should table in the ACT Legislative Assembly the cost-benefit analysis and business plan for Fairbairn as a central site for emergency services in the ACT. |
REC144-3382 | 24 - Govt responsibility | The Committee recommends that responsibility for oversighting the progress of the implementation of agreed recommendations of the Coroner be undertaken by a truly independent body and not by the Bushfire Council. |
REC144-3393 | 1 - Land-use and building regs | The Committee recommends that the responsibility for land management issues lie within a single portfolio, specifically the Minister for Territory and Municipal Services. |
Rec-ID | Code | Recommendation |
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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. |
Rec-ID | Code | Recommendation |
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REC123-3877 | 25 - Inquiry, audit, lessons management and after action review | All agencies review formal and informal incident notification processes to ensure they support the earliest possible reporting of emergencies to all stakeholders involved in the Airport Emergency Plan and in so doing, ensure early access to specialist advice and support. |
Rec-ID | Code | Recommendation |
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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. |
REC121-3753 | 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. |
REC121-3715 | 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. |
REC121-3767 | 24 - Govt responsibility | All accredited rail organisations should be required to re-apply every three years to ITSRR for accreditation. |
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. |
REC121-3720 | 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. |
REC121-3751 | 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. |
REC121-3714 | 16 - Training and behaviour | RailCorp should use its simulators in an interactive manner. |
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. |
REC121-3650 | 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. |
REC121-3719 | 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. |
REC121-3746 | 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. |
REC121-3713 | 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. |
REC121-3758 | 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. |
REC121-3718 | 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. |
REC121-3672 | 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. |
REC121-3744 | 16 - Training and behaviour | All RailCorp operational personnel should be trained in the location and operation of external emergency door release mechanisms. |
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. |
REC121-3757 | 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. |
REC121-3717 | 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. |
REC121-3670 | 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. |
REC121-3726 | 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. |
REC121-3693 | 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. |
REC121-3756 | 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. |
REC121-3716 | 16 - Training and behaviour | Train driver and guard training should encourage teamwork and discourage authority gradients. |
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. |
Rec-ID | Code | Recommendation |
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REC119-3649 | 25 - Inquiry, audit, lessons management and after action review | It is recommended that the Board: |
Rec-ID | Code | Recommendation |
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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. |
REC008-3984 | 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. |