Inquiry Search
Rec-ID | Code | Recommendation |
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REC002-4002 | 19 - Offences | Where safety-lamps are necessary - gas being present for (say) one month after being found in dangerous quantity - they should be securely locked by a man duly appointed, and tampering with them must be punishable by a simple and inexpensive process of law. |
REC002-4012 | 38 - Agency/Department Reporting | Complete sets of daily-report books should be provided, and kept in the mine or office, to be overlooked by the Inspector during his periodical visits. |
REC002-4001 | 35 - Business and Industry in relation to industry | The Commission consider that in all mines where gas exists the course of the air should be directed to sweep along the working-faces; in mines worked by Pillar and Stall, bratticing must be resorted to to carry the gas from the face as it issues, and so prevent any accumulation of explosive gases or of gases inimical to life. In cases where gas exists it would be better that no bords should be broken off the back or return heading or supplied with air fouled by dangerous gases. The panel system of working by confining and localising districts, or some modification thereof, might be pursued with advantage. |
REC002-4010 | 35 - Business and Industry in relation to industry | The Commission do not approve of removing any responsibility from the management by increasing the power or number of the Inspectors. The visits of these officials should, so far as possible, be visits of surprise. |
REC002-4008 | 35 - Business and Industry in relation to industry | Where dust exists in quantity, and under conditions favourable for ignition, it should be periodically and sufficiently dampened by water |
REC002-4004 | 35 - Business and Industry in relation to industry | Where safety-lamps are used, and the obligation is laid upon the men to cleanse the same, all examinations, tests, and repairs to these should be done by the owners. |
REC002-4003 | 35 - Business and Industry in relation to industry | Where gas exists, and no provisions are made for its constant removal, no shots should be fired, and, where permitted in a gassy mine, shots should be fired only by a man specially appointed, and at such hours when the miners are not within the mine. All shots should be tamped by stone well damped, and only copper or wooden tools should be employed. As far as possible the use of explosives should be discouraged, and skilful mining encouraged. Danger-boards should be placed further from the faces whence gas issues (say), where practicable, 50 yards. |
REC002-4013 | 19 - Offences | Infringement of the regulations by either party should be followed by a summary form of justice, instituted before two Magistrates. |
Rec-ID | Code | Recommendation |
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REC292-2380 | 24 - Govt responsibility | I recommend that the New South Wales Police Force, in conjunction with NSW Health, establish a Fixated Threat Assessment Centre to identify and gather information about fixated persons, assess the risks they pose, and attempt to mitigate such risks through early intervention. |
REC292-2342 | 13 - Mapping and data quality | The development of an integrated intelligence system that allows police officers secure access to all information platforms should also provide for the recording of all command decisions, the reasons for them, and the dissemination of those decisions. |
REC292-2379 | 24 - Govt responsibility | I recommend that the Premier of New South Wales consider whether the Privacy and Personal Information Protection Act 1998 and the Health Records and Information Privacy Act 2002 should be amended to ensure that there is appropriate access to health related information available to ASIO (consistent with recommendation 12 of the report of the Martin Place Siege Joint Commonwealth—New South Wales review) |
REC292-2339 | 19 - Offences | I recommend that the Law, Crime and Community Safety Council develop a mechanism to ensure that all information on criminal history (including bail) that is relevant to the investigation and prosecution of criminal offences is readily accessible to police and prosecutors across all Australian jurisdictions. |
REC292-2378 | 21 - Role of Commonwealth Government | I recommend that: the Commonwealth Attorney-General and ASIO confer with the Australian Psychological Society regarding the restrictions in clause A 5 2 of the Code of Ethics (2007) with respect to radicalisation, terrorism and politically motivated violence; and the Australian Psychological Society consider amending clause A 5 2 of the Code of Ethics (2007) to enable psychologists to report risks of a terrorist nature. |
REC292-2377 | 21 - Role of Commonwealth Government | I recommend that the Commonwealth Attorney-General liaise with ASIO to develop a policy to ensure that where correspondence is received by a government agency, minister or public office holder, from a non government entity, and that correspondence is relevant to the security assessments of the author, the correspondence be referred to: ASIO; and a Fixated Threat Assessment Centre. |
REC292-2370 | 25 - Inquiry, audit, lessons management and after action review | I recommend that the New South Wales Police Force undertake a formal assessment of alternatives to the TOU’s current soft-point ammunition to determine whether a more appropriate form of ammunition is reasonably available. |
REC292-2381 | 21 - Role of Commonwealth Government | I recommend that ASIO liaise with the Fixated Threat Assessment Centre with a view to both agencies cooperating in the identification, assessment and management of fixated, radicalised individuals. |
REC292-2369 | 26 - Research | I recommend that the New South Wales Police Force evaluate whether the use of noise-attenuation devices should be mandated when explosive distraction devices are used. |
Rec-ID | Code | Recommendation |
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REC208-0527 | 35 - Business and Industry in relation to industry | That the Office of Environment and Heritage require Orica to engage and fund appropriate independent experts to oversee any modifications to the plant in the next major maintenance overhaul of the plant in 2016 and in any upgrades to the plant prior to that date. |
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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REC169-2992 | 24 - Govt responsibility | The Department of Premier and Cabinet should identify risks arising from the joined-up nature of the approach to protecting essential services and critical infrastructure, and to assist departments and agencies to develop associated risk management arrangements at the whole-of-government level. |
REC169-2998 | 38 - Agency/Department Reporting | Reports on the training exercises should be retained in an appropriately secured central repository so that consolidated results of the exercises can be drawn together effectively. |
REC169-2991 | 24 - Govt responsibility | The Department of Premier and Cabinet should provide definitive guidance on identifying essential services for declaration to better inform relevant departments in discharging their responsibilities under Part 6 of the Act. |
REC169-2997 | 38 - Agency/Department Reporting | The Department of Premier and Cabinet and Victoria Police, in consultation with departments, should standardise reporting on training exercises conducted under Part 6 of the Act and the CIP framework to promote greater consistency and to enable better identification of lessons learned and continuous improvement. |
REC169-2990 | 24 - Govt responsibility | The Department of Premier and Cabinet should clarify the roles and responsibilities of departments and agencies under Part 6 of the Act and CIP framework to reduce confusion and gaps. |
REC169-2995 | 24 - Govt responsibility | The Department of Premier and Cabinet, in consultation with Victoria Police, should develop clear guidance to distinguish between declared essential services and critical infrastructure to assist departments, Victoria Police and industry in implementing Part 6 of the Act and the CIP framework more effectively. |
REC169-2989 | 38 - Agency/Department Reporting | The Department of Premier and Cabinet should lead the development of a performance management framework for measuring, monitoring and reporting on the implementation of Part 6 of the Act and the CIP framework. The framework should include key indicators, targets and reporting arrangements for assessing the extent to which departments, agencies and industry have fulfilled their obligations, as well as measures for monitoring achievement of joint objectives. |
REC169-2994 | 24 - Govt responsibility | Representatives of lead departments should obtain necessary security clearances so appropriate officers can access information relevant to their sectors. |
REC169-2993 | 24 - Govt responsibility | The Department of Premier and Cabinet should clarify the requirements in relation to establishing Security and Continuity Networks in designated sectors, so that there is a shared understanding of those requirements. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC158-3429 | 38 - Agency/Department Reporting | That the nominated marine safety authority is required to ensure that incident notification and data recording requirements for Victorian commercial ports are consistent and adhered to. |
REC158-3428 | 38 - Agency/Department Reporting | That the nominated marine safety authority, in consultation with the Emergency Services Commissioner and senior emergency services personnel, is responsible for monitoring the implementation and auditing against appropriate performance standards, risk management guidelines and good practice guidelines. |
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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC156-3493 | 35 - Business and Industry in relation to industry | The electricity distribution businesses and retailers work with the Department of Human Services and hospitals to review the registration, notification and removal process for those on life support machinery. |
REC156-3516 | 28 - Personal responsibility | All Victorians should: |
REC156-3492 | 22 - Role of local Gvt | The review of the municipal emergency management planning guidelines being led by the Office of the Emergency Services Commissioner clarify local governments’ role in community information about emergencies. |
REC156-3514 | 24 - Govt responsibility | The State Government endorse the establishment of the Victorian Emergency Information Line and it is developed with appropriate protocols to ensure linkages and information flows to the energy sector. |
REC156-3490 | 24 - Govt responsibility | The Department of Human Services improve its communication with councils to enhance delivery of recovery services. |
REC156-3506 | 26 - Research | The Office of the Emergency Services Commissioner facilitate further research into technologies that will reduce the need for the public to speak to an operator during an emergency as a component of the proposed emergency warning and alert system and Victorian Emergency Information Line. |
REC156-3486 | 24 - Govt responsibility | The emergency management arrangements include the development of partnerships between the public and private sectors, in particular the involvement of government departments and essential services. |
REC156-3502 | 35 - Business and Industry in relation to industry | The Emergency Services Telecommunications Authority in partnership with Telstra should develop testing regimes that will ensure the integrity of the call queue arrangements and correct configuration of the Recorded Voice Announcements. |
REC156-3518 | 24 - Govt responsibility | The Department of Premier and Cabinet, the Office of the Emergency Services Commissioner and other relevant departments conduct further work to determine the need for a power to appoint a coordinator of essential services restoration. |
REC156-3496 | 21 - Role of Commonwealth Government | The Bureau of Meteorology contact list for severe weather warning be strategically managed in consultation with Emergency Service Organisations, to identify critical contacts. The Bureau of Meteorology must ensure the detail for these critical contacts remains up to date. |
REC156-3517 | 9 - Community education | The Victoria State Emergency Service work with the electricity distribution businesses, Department of Primary Industries and Energy Safe Victoria to develop and implement a joint community education program for public safety during and after storms and power outages. |
Rec-ID | Code | Recommendation |
---|---|---|
REC154-3461 | 24 - Govt responsibility | DPI should develop an Memorandum of Understanding (MOU) with the Department of Human Services that capitalises on and strengthens the current good working relationship to support joint forward planning and risk management and mitigates against relationship failure in the event of leadership change. The MOU should clarify: |
REC154-3459 | 41 - Emergency Management exercises | To improve response preparedness, DPI should clearly link the selection of simulation exercises to the risk management framework to target coverage of high risks. |
REC154-3463 | 13 - Mapping and data quality | Biosecurity Victoria should enhance controls to provide assurance regarding data integrity. This process should include: |
REC154-3462 | 41 - Emergency Management exercises | DPI should formalise the approach and framework for evaluating simulation exercises and response to Emergency Animal Disease incidents with guidelines to define the nature of the review process. This should include: |
Rec-ID | Code | Recommendation |
---|---|---|
REC129-3620 | 35 - Business and Industry in relation to industry | We recommend that NSW Health continue with its good work and conclude agreements with private health providers specifying roles, and expectations in the case of an infectious disease pandemic. |
REC129-3628 | 41 - Emergency Management exercises | We recommend that NSW Health continue with its good work and continue to develop and test the capability of its contact tracing system to deal with a public health emergency. |
REC129-3627 | 41 - Emergency Management exercises | We recommend that NSW Health continue with its good work and continue to develop and test its surveillance systems for early detection of infectious diseases. |
REC129-3625 | 38 - Agency/Department Reporting | We recommend that NSW Health continue with its good work and establish a performance management framework with targets and indicators to assess progress in preparing for infectious disease emergencies. |
REC129-3624 | 41 - Emergency Management exercises | We recommend that NSW Health continue with its good work and formally establish and oversight a comprehensive program of training, testing and evaluation of plans at the state, area and facility level. |
REC129-3623 | 41 - Emergency Management exercises | We recommend that NSW Health continue with its good work and apply the lessons learnt from Exercise Cumpston to further improve preparedness for major infectious disease emergencies. |
Rec-ID | Code | Recommendation |
---|---|---|
REC128-3602 | 38 - Agency/Department Reporting | That the Department’s performance against tactical and strategic benchmarks be regularly reported in annual reports or animal and plant health emergency evaluation reports and compared to other jurisdictions where possible. |
REC128-3619 | 38 - Agency/Department Reporting | That the Department of Primary Industries should ensure the roles and capacities of Rural Lands Protection Boards and industry are effectively monitored to enable assessment of the effectiveness of animal health programs. |
REC128-3601 | 38 - Agency/Department Reporting | That, as a matter of principle, the NSW Government provide public reports on the lessons learned from emergency exercises which it manages or in which it participates. If necessary, such reports should exclude material which might jeopardise security. |
REC128-3615 | 9 - Community education | That the Department of Primary Industries should continue to raise awareness among producers of OJD risks and the operation of Sheep Health Statements. |
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. |
REC128-3613 | 9 - Community education | That the Department of Primary Industries and Rural Lands Protection Boards employ outreach activities to alert these small producers to their responsibilities and improve their awareness of animal and plant pests and diseases. |
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. |
REC128-3605 | 38 - Agency/Department Reporting | That the Department of Primary Industries make every effort to meet its targets for the TSE program and encourage public and private sector veterinarians across the State to submit samples. The Department should include reports on its performance against these targets in annual reports. |
Rec-ID | Code | Recommendation |
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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. |
REC121-3753 | 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. |
REC121-3691 | 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. |
REC121-3712 | 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. |
REC121-3768 | 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. |
REC121-3723 | 38 - Agency/Department Reporting | All ATSB accident investigation reports should be made public. |
REC121-3742 | 19 - Offences | The risk of abuse of internal passenger emergency door releases should be further reduced by introducing significant penalties for any improper use of such an emergency facility. It should be a criminal offence for anyone to use or tamper improperly with an emergency escape facility in a train. |
REC121-3678 | 35 - Business and Industry in relation to industry | All railway owners and operators should have a quality assurance program for the design and construction of rolling stock and regular review of construction to ensure that the rolling stock satisfies the original functional performance specifications. |
REC121-3767 | 24 - Govt responsibility | All accredited rail organisations should be required to re-apply every three years to ITSRR for accreditation. |
REC121-3704 | 28 - Personal responsibility | RailCorp should continue its system of voluntary self-identification and rehabilitation of employees with alcohol or drug related problems. |
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. |
REC121-3729 | 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. |
REC121-3673 | 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. |
REC121-3765 | 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. |
REC121-3697 | 38 - Agency/Department Reporting | All train drivers’ defects reports should be entered by RailCorp into a computerised record and tracked to finalisation. |
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. |
REC121-3776 | 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. |
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. |
REC121-3758 | 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. |
REC121-3694 | 25 - Inquiry, audit, lessons management and after action review | The ITSRR should conduct random audits of accredited rail organisations for compliance with communications protocols. |
REC121-3720 | 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. |
REC121-3775 | 38 - Agency/Department Reporting | The Minister for Transport Services must table in Parliament, each such quarterly report by ITSRR. |
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. |
REC121-3757 | 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. |
REC121-3693 | 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. |
REC121-3713 | 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. |
REC121-3774 | 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: |
Rec-ID | Code | Recommendation |
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REC112-3929 | 35 - Business and Industry in relation to industry | That DPI develops a comprehensive strategy for communicating to industry their rights and responsibilities in relation to threats, incursions, outbreaks and post-outbreak; and also for communicating internally. |
REC112-3918 | 35 - Business and Industry in relation to industry | That DPI effectively communicates to all sectors of the industry their responsibilities to report new threats, and how to report them. |
REC112-3928 | 3 - Biodiversity | That DPI formalises agreements within the Regional Services and Agriculture Division to ensure that plant health information is included in extension programs. |
REC112-3913 | 35 - Business and Industry in relation to industry | That DPI works with industry to develop a training module on the certification and verification system for inclusion in industry quality assurance programs. |
REC112-3926 | 13 - Mapping and data quality | That DPI upgrades the Crop Health Services diagnostic database so that it alerts PSB and PIRVIC to the receipt of samples from nearby areas with similar symptoms and can be linked to other PIRVIC diagnostic databases. |
REC112-3912 | 25 - Inquiry, audit, lessons management and after action review | That DPI, as part of the development of the Victorian plant biosecurity strategy, undertake a strategic review of its plant health planning framework so that: • corporate and business unit plans at all levels of the department align to each other and to government policy so that staff have a coherent frame of reference to guide their work • performance indicators are developed, used, reported against and evaluated regularly • all plans (including service agreements with other parts of DPI) are communicated to staff and implemented in their day-to-day activities and responsibilities. |
REC112-3925 | 13 - Mapping and data quality | That DPI establishes a system to ensure the security of all samples at all times, but particularly during their handling and transport. |
REC112-3911 | 3 - Biodiversity | That DPI develops a consistent process to identify, assess and prioritise potential plant pest and disease threats, and aligns it with prioritisation processes used at the national level by Plant Health Australia. |
REC112-3922 | 25 - Inquiry, audit, lessons management and after action review | That DPI maintains ISO 9000 accreditation for at least one laboratory and seeks NATA accreditation for key diagnostic tests. This should be done in combination with Plant Health Australia’s laboratory accreditation project. |
REC112-3932 | 25 - Inquiry, audit, lessons management and after action review | That DPI conducts and documents debriefs after all incursions, and adopts any improvements that are identified through debriefs. |
REC112-3907 | 25 - Inquiry, audit, lessons management and after action review | That Department of Primary Industries (DPI), in partnership with the Department of Sustainability and Environment, reviews all legislation relating to plant biosecurity with a view to streamlining the legislative framework. |
REC112-3919 | 25 - Inquiry, audit, lessons management and after action review | That the model for state funding be reviewed to ensure that DPI can confidently build and maintain a core level of diagnostic expertise and research capability. |
Rec-ID | Code | Recommendation |
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REC004-3998 | 19 - Offences | That a by-law be made forbidding, under a heavy penalty, any persons travelling in such trains to throw lighted tobacco, cigars, cigarettes, pipe ashes, matches, or other inflammable matter on the railway line or right-of-way, or in any part of a railway carriage except the receptacles duly provided for the purpose. |