Inquiry Search
Rec-ID | Code | Recommendation |
---|---|---|
REC325-4325 | 32 - Doctrine, standards, and reform | The Inspector-General of Emergency Management recommends Queensland Fire and Emergency Services review and implement State Emergency Service (SES) protocol by 1 November 2023 outlining procedures to be undertaken to ensure persons uplifted from places of immediate danger or risk are transferred to a place of safety. |
REC325-4334 | 32 - Doctrine, standards, and reform | The Inspector-General of Emergency Management recommends Queensland Fire and Emergency Services develop and publish an operationally based quick reference guide that complements the training offered (as per Recommendation 5) by 1 November 2022. The guide will identify key and critical aspects of the Emergency Alert system in relation to the development, composition, request for and authorising of Emergency Alerts and will include a template and an example of ‘good’ messaging using concise, minimal language and Clear Explicit Translatable Language (CETL). |
REC325-4321 | 25 - Inquiry, audit, lessons management and after action review | The Inspector-General of Emergency Management recommends this report be returned to the Office of the Inspector-General of Emergency Management to monitor, evaluate, and report on progress and implementation of the recommendations that are accepted in whole or in part by government. |
REC325-4324 | 32 - Doctrine, standards, and reform | The Inspector-General of Emergency Management recommends Queensland Fire and Emergency Services review the tasking protocols used to manage State Emergency Service (SES) tasks undertaken in the response phase of a disaster to enable more complete recording of details for all ‘jobs of opportunity’ (including the personal details of those assisted and/or rescued) to enable better coordination of tasks and reflect outcomes of activities by 1 November 2023. |
Rec-ID | Code | Recommendation |
---|---|---|
REC324-4301 | 32 - Doctrine, standards, and reform | Floodplains as assets: That, to establish the capacity and maximise the economic, social and environmental potential and consequently unlock the value of NSW floodplains, Government adopt the following guiding principles for floodplain management: |
REC324-4302 | 32 - Doctrine, standards, and reform | Disaster adaptation plans for all towns: That, to establish realistic expectations of safe spaces to live and deliver much needed housing quickly, Government through NSWRA working with local government: |
REC324-4317 | 32 - Doctrine, standards, and reform | Flood rescue capability: That, to help improve the protection of life across NSW in flood events: |
Rec-ID | Code | Recommendation |
---|---|---|
REC311-2505 | 25 - Inquiry, audit, lessons management and after action review | This report be returned to the InspectorGeneral Emergency Management to monitor, evaluate and report on progress and implementation of the recommendation(s) that are accepted in whole or in part by government. |
REC311-2504 | 25 - Inquiry, audit, lessons management and after action review | To enable entities in the sector to proactively work to achieve better results for the community, the recommendations and lessons of this review should be evaluated through the lessons management processes of entities involved in dam safety for their value and relevance. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC002-4001 | 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. |
REC002-4011 | 32 - Doctrine, standards, and reform | The Commission feel that the 4th clause in the present Act, relating to the spacing of cut-throughs, should be amended to admit of any convenient or safe system of mining being pursued. This is a matter of detail that would be better out of the Act. The Commission would advise that the word should not occur at all, and that, if bratticing be used, or the air by some other satisfactory device be conveyed to the face, scope would be given to Managers to introduce systems of mining adapted to the circumstance of each particular coal-seam, with advantage to all concerned. |
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 |
Rec-ID | Code | Recommendation |
---|---|---|
REC297-1259 | 25 - Inquiry, audit, lessons management and after action review | That DPIPWE examines the Forest Practice Code 2015 for relevance of its concepts to farming and other business activities near rivers, streams and naturally occurring dams and makes recommendations to Government accordingly. |
REC297-1258 | 25 - Inquiry, audit, lessons management and after action review | That DPIPWE examines the WMAwater report along with its own, analyses the differences, consults with the Forest Practices Authority and Environment Protection Authority, and proposes an appropriate course of action to Government. |
REC297-1273 | 25 - Inquiry, audit, lessons management and after action review | That the State Emergency Management Committee allocates resources to reviewing all findings and recommendations in the Productivity Commission Report No. 74 relevant to Tasmania and, for those identified as relevant, actions taken and, if none, why not. |
REC297-1257 | 35 - Business and Industry in relation to industry | That in the event that Hydro Tasmania decides to start cloud seeding again, water managers, represented by DPIPWE, work with Hydro Tasmania to ensure appropriate, best practice application of the guidelines issued by the Agricultural and Resource Management Council of Australia and New Zealand. |
REC297-1269 | 35 - Business and Industry in relation to industry | That Government engages with non-government organisations that may provide services during emergency events to clarify the terms and conditions for support through a written arrangement (MOU or similar). |
REC297-1264 | 25 - Inquiry, audit, lessons management and after action review | That the Flood Warning Consultative Committee reviews flood classification levels in the Service Level Specifications with BoM specifically relating to flood level triggers on gauges. |
REC297-1260 | 32 - Doctrine, standards, and reform | That DPIPWE clarifies responsibility for river restoration and riparian management and, having done so, communicates this to councils, landowners and other owners of relevant infrastructure. |
Rec-ID | Code | Recommendation |
---|---|---|
REC271-1531 | 32 - Doctrine, standards, and reform | Banana Shire Council completes business continuity planning as a matter of priority, including documentation and testing of the plan. |
REC271-1532 | 32 - Doctrine, standards, and reform | The evacuation sub-plan component of the Local Disaster Managment Plan should be reviewed, including any identified triggers for activation. Ideally, the plan should be tested in a live, multi-agency exercise prior to next summer. |
Rec-ID | Code | Recommendation |
---|---|---|
REC258-2556 | 25 - Inquiry, audit, lessons management and after action review | The Civil Aviation Safety Authority structures all regulations not yet made with the three-tier approach, and subsequently reviews all other Civil Aviation Safety Regulation Parts (in consultation with industry) to determine if they should be remade using the three-tier structure. |
REC258-2533 | 32 - Doctrine, standards, and reform | The Civil Aviation Safety Authority: |
REC258-2539 | 35 - Business and Industry in relation to industry | The Civil Aviation Safety Authority changes its regulatory philosophy and, together with industry, builds an effective collaborative relationship on a foundation of mutual understanding and respect. |
REC258-2555 | 32 - Doctrine, standards, and reform | The Civil Aviation Safety Authority changes the current two-tier regulatory framework (act and regulations) to a three-tier structure (act, regulations and standards), with: |
REC258-2531 | 32 - Doctrine, standards, and reform | The Civil Aviation Safety Authority’s Board exercises full governance control. The nonexecutive directors should possess a range of appropriate skills and backgrounds in aviation, safety, management, risk, regulation, governance and government. |
REC258-2538 | 32 - Doctrine, standards, and reform | The Department of Infrastructure and Regional Development and Department of Defence (and appropriate agencies) establish an agreed policy position on safety oversight of civil operations into joint user and military airports. |
REC258-2554 | 32 - Doctrine, standards, and reform | Recreational Aviation Administration Organisations, in coordination with the Civil Aviation Safety Authority, develop mechanisms to ensure all aircraft to be regulated under CASR Part 149 are registered. |
REC258-2529 | 32 - Doctrine, standards, and reform | The Australian Transport Safety Bureau and the Civil Aviation Safety Authority utilise the provision in their bilateral Memorandum of Understanding to accredit CASA observers to ATSB investigations. |
REC258-2537 | 32 - Doctrine, standards, and reform | The Civil Aviation Safety Authority delegates responsibility for the day-to-day operational management of airspace to Airservices Australia, including the designation of air routes, short term designations of temporary Restricted Areas, and temporary changes to the classification of airspace for operational reasons. |
REC258-2552 | 25 - Inquiry, audit, lessons management and after action review | The Civil Aviation Safety Authority implements a system of using third-party commercial audits as a supplementary tool to its surveillance system. |
REC258-2528 | 25 - Inquiry, audit, lessons management and after action review | The Australian Transport Safety Bureau investigates as many fatal accidents in the sport and recreational aviation sector as its resources will allow. |
REC258-2562 | 32 - Doctrine, standards, and reform | The Civil Aviation Safety Authority amends the current Terms of Reference of the Industry Complaints Commissioner so that: |
REC258-2536 | 32 - Doctrine, standards, and reform | The Australian Transport Safety Bureau and the Civil Aviation Safety Authority amend the wording of their existing Memorandum of Understanding to make it more definitive about interaction, coordination, and cooperation. |
REC258-2551 | 25 - Inquiry, audit, lessons management and after action review | The Civil Aviation Safety Authority assures consistency of audits across all regions, and delivers audit reports within an agreed timeframe. |
REC258-2527 | 32 - Doctrine, standards, and reform | The Department of Infrastructure and Regional Development plays a stronger policy role in the State Safety Program. |
REC258-2560 | 29 - Operational Health and Safety | The Civil Aviation Safety Authority devolve to Designated Aviation Medical Examiners the ability to renew aviation medical certificates (for Classes 1, 2, and 3) where the applicant meets the required standard at the time of the medical examination. |
REC258-2535 | 32 - Doctrine, standards, and reform | Airservices Australia, in conjunction with the Department of Infrastructure and Regional Development and the Civil Aviation Safety Authority, reconsiders the policy on ‘Assessment of Priorities’ that stipulates that air traffic controllers sequence arriving aircraft based on category of operation, rather than on the accepted international practice of ‘first come, first served’. |
REC258-2549 | 25 - Inquiry, audit, lessons management and after action review | The Civil Aviation Safety Authority provides full disclosure of audit findings at audit exit briefings in accordance with international best practice. |
Rec-ID | Code | Recommendation |
---|---|---|
REC250-0796 | 25 - Inquiry, audit, lessons management and after action review | The Department of Premier and Cabinet should lead: x the development of an evaluation framework, based on work undertaken to date by the Department of Human Services, to be used in assessing the impact of relief and recovery programs in the recent floods and in future disaster events x an evaluation of the impact of relief and recovery programs in the recent floods, using this framework. |
REC250-0790 | 25 - Inquiry, audit, lessons management and after action review | The Department of Justice should review the current model for rapid impact assessment to improve the quality of the information collected. |
Rec-ID | Code | Recommendation |
---|---|---|
REC238-0797 | 32 - Doctrine, standards, and reform | Determine the appropriateness and the steps required to allow the reduction of full supply level by up to five metres and/or the implementation of alternative gate operation at Warragamba Dam for the mitigation of minor to moderate flood events in the short-term. |
REC238-0803 | 32 - Doctrine, standards, and reform | Ensure effective flood gauging arrangements in the Hawkesbury-Nepean Valley |
REC238-0802 | 25 - Inquiry, audit, lessons management and after action review | Review the NSW state-wide governance arrangements for flood risk management so that broader issues identified by this Review can be most effectively addressed. |
REC238-0798 | 32 - Doctrine, standards, and reform | Optimise the configuration of a raised Warragamba Dam for flood mitigation of the full range of flood events and water supply, with due consideration of upstream impacts. |
Rec-ID | Code | Recommendation |
---|---|---|
REC236-2804 | 32 - Doctrine, standards, and reform | The committee recommends that Airservices Australia discuss the safety case for providing a hazard alert service with Fijian and New Zealand ATC (and any other relevant jurisdictions) and encourage them to adopt this practice. |
REC236-2786 | 32 - Doctrine, standards, and reform | The committee recommends that the ATSB be required to document investigative avenues that were explored and then discarded, providing detailed explanations as to why. |
REC236-2795 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that a short inquiry be conducted by the Senate Standing Committee on Rural and Regional Affairs and Transport into the current status of aviation regulatory reform to assess the direction, progress and resources expended to date to ensure greater visibility of the processes. |
REC236-2803 | 32 - Doctrine, standards, and reform | The committee recommends that the government consider setting a time limit for agencies to implement or reject recommendations, beyond which ministerial oversight is required where the agencies concerned must report to the minister why the recommendation has not been implemented or that, with ministerial approval, it has been formally rejected. |
REC236-2785 | 32 - Doctrine, standards, and reform | The committee recommends that the ATSB move away from its current approach of forecasting the probability of future events and focus on the analysis of factors which allowed the accident under investigation to occur. This would enable the industry to identify, assess and implement lessons relevant to their own operations. |
REC236-2794 | 32 - Doctrine, standards, and reform | The committee recommends that CASA, in consultation with an Emergency Medical Services industry representative group (eg. Royal Flying Doctor Service, air ambulance operators, rotary wing rescue providers) consider the merit, form and standards of a new category of operations for Emergency Medical Services. The minister should require CASA to approve the industry plan unless there is a clear safety case not to. Scope for industry to assist as part of an audit team should also be investigated where standardisation is an issue. This should be completed within 12 months and the outcome reported publicly. |
REC236-2802 | 32 - Doctrine, standards, and reform | The committee recommends that where the consideration and implementation of an ATSB recommendation may be protracted, the requirement for regular updates (for example 6 monthly) should be included in the TSI Act. |
REC236-2784 | 32 - Doctrine, standards, and reform | The committee recommends that the minister, in issuing a new Statement of Expectations to the ATSB, valid from 1 July 2013, make it clear that safety in aviation operations involving passengers (fare paying or those with no control over the flight they are on, e.g. air ambulance) is to be accorded equal priority irrespective of flight classification. |
REC236-2807 | 32 - Doctrine, standards, and reform | The committee recommends that the Aeronautical Information Package (AIP) En Route Supplement Australia (ERSA) is updated to reflect the need for caution with regard to Norfolk Island forecasts where the actual conditions can change rapidly and vary from forecasts. |
REC236-2793 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that CASA processes in relation to matters highlighted by this investigation be reviewed. This could involve an evaluation benchmarked against a credible peer (such as FAA or CAA) of regulation and audits with respect to: non-RPT passenger carrying operations; approach to audits; and training and standardisation of FOI across regional offices. |
REC236-2801 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that the ATSB review its process to track the implementation of recommendations or safety actions to ensure it is an effective closed loop system. This should be made public, and provided to the Senate Regional and Rural Affairs and Transport Committee prior to each Budget Estimates. |
REC236-2806 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that the relevant agencies investigate appropriate methods to ensure that information about the incidence of, and variable weather conditions at, Norfolk Island is available to assist flight crews and operators managing risk that may result from unforseen weather events. |
REC236-2792 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that the investigation be re-opened by the ATSB with a focus on organisational, oversight and broader systemic issues. |
REC236-2798 | 32 - Doctrine, standards, and reform | The committee recommends that, where relevant, the ATSB include thorough human factors analysis and discussion in future investigation reports. Where human factors are not considered relevant, the ATSB should include a statement explaining why. |
REC236-2805 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that the relevant agencies review whether any equipment or other changes can be made to improve the weather forecasting at Norfolk Island. The review would include whether the Unicom operator should be an approved meteorological observer. |
REC236-2789 | 32 - Doctrine, standards, and reform | The committee recommends that the Transport Safety Investigation Act 2003 be amended to require that the Chief Commissioner of the ATSB be able to demonstrate extensive aviation safety expertise and experience as a prerequisite for the selection process. |
REC236-2796 | 32 - Doctrine, standards, and reform | The committee recommends that the ATSB-CASA Memorandum of Understanding be re-drafted to remove any ambiguity in relation to information that should be shared between the agencies in relation to aviation accident investigations, to require CASA to: |
Rec-ID | Code | Recommendation |
---|---|---|
REC235-2809 | 32 - Doctrine, standards, and reform | The Australian National Audit Office recommends that the Department of Regional Australia, Local Government, Arts and Sport improve the arrangements for conducting value for money reviews of Victorian reconstruction projects by pursuing amendments to the operating protocol with Victoria to require that, at regular intervals, the Taskforce is provided with information on all reconstruction projects being delivered within the scope of the National Partnership Agreement. |
Rec-ID | Code | Recommendation |
---|---|---|
REC234-2811 | 32 - Doctrine, standards, and reform | In order to maximise the envisaged benefits from the Inspectorate’s program of value for money reviews, the Australian National Audit Office (ANAO) recommends that the National Disaster Recovery Taskforce improve the application of the sampling approach to make it more representative of the |
Rec-ID | Code | Recommendation |
---|---|---|
REC232-2828 | 25 - Inquiry, audit, lessons management and after action review | The Australian Government, in consultation with state and territory governments, commission an independent review to assess the case for establishing a national centre for communicable disease control in Australia. The review should outline the role of a national centre and how it might be structured to build on and enhance existing systems. It should examine different models, considering a range of options for location, governance and staffing. The review should incorporate a cost-benefit analysis for each of the models presented. |
REC232-2827 | 25 - Inquiry, audit, lessons management and after action review | The Australian Government, in consultation with state and territory governments, conduct a comprehensive national audit and mapping exercise to: |
REC232-2816 | 32 - Doctrine, standards, and reform | The Australian Department of Health and Ageing work with the states and territories to provide a uniform notifiable diseases list across Australia, with consistent reporting requirements across each state and territory and consistent public health information on infectious diseases disseminated to the public. This work should be a priority of Australian Health Ministers’ Advisory Council (AHMAC). |
REC232-2815 | 25 - Inquiry, audit, lessons management and after action review | The Department of Health and Ageing review the existing evidence base to evaluate the cost-effectiveness of its policy to use heat scanners at ports of entry as a measure to mitigate the risk of infectious disease importation. |
REC232-2814 | 32 - Doctrine, standards, and reform | The relevant government agencies that have a significant role in managing the biosecurity threat develop a coordinated approach which addresses the health threats to Australians and recognises the impact on the economy. |
Rec-ID | Code | Recommendation |
---|---|---|
REC227-2855 | 32 - Doctrine, standards, and reform | I recommend that arrangements be put in place which would remove the requirements for Masters of Volunteer Marine Rescue vessels to hold a commercial certificate of competency. Operators could then be qualified through the FESA Volunteer Marine Rescue Training pathway as skippers and crew. This would increase the number of available skippers in the event of a search and rescue incident and would make appropriate training easier to arrange. |
Rec-ID | Code | Recommendation |
---|---|---|
REC217-1830 | 32 - Doctrine, standards, and reform | The Department of Sustainability and Environment will develop a code of practice on the removal of vegetation around critical public assets, in consultation with councils, CMAs and asset managers. Regional Flood Strategies will support this code of practice as part of shared flood risk management planning. |
REC217-1829 | 32 - Doctrine, standards, and reform | The Department of Sustainability and Environment should develop guidelines for streamlining the permitting system for works on waterways for incorporation in the revised Victoria Flood Management Strategy. An exemption process will be introduced, with particular application to identified reaches of rivers and streams that require ongoing vegetation management and maintenance: |
REC217-1840 | 25 - Inquiry, audit, lessons management and after action review | The state government implement the Victorian Floods Review recommendation 8, to review the flood gauging network. As part of the review, consideration should also be given to the use of portable telemetered river gauges, and to the replacement of manual gauges with telemetered gauges over time and where appropriate. |
REC217-1828 | 32 - Doctrine, standards, and reform | The revised Victoria Flood Management Strategy should clearly articulate the policy guidelines for the management of vegetation and debris in Victorian waterways, for the purposes of flood protection and mitigation, taking into account the localised potential flooding effects of in‐stream vegetation in townships. |
REC217-1838 | 32 - Doctrine, standards, and reform | That statements of obligations, issued under the Water Industry Act 1994 for water authorities, be amended to include a provision whereby managing authorities must: |
REC217-1820 | 32 - Doctrine, standards, and reform | The Department of Sustainability and Environment will develop guidelines for the management of levees in emergencies, during and after a flood event, which can be incorporated into local flood response plans. The department will also provide, as part of these guidelines, a set of criteria for assessing the ongoing viability of ad hoc levees post‐flood. The Emergency Management Act 1986 will be amended to support the implementation of these guidelines. A more effective means for councils to remove illegal levees will also be examined by the Department of Sustainability and Environment. |
REC217-1837 | 32 - Doctrine, standards, and reform | The state government give consideration to enacting legislation to provide protection from legal liability for public authorities conducting works on priority levees in good faith, acting reasonably and responsibly in the public interest, and in accordance with standards agreed to under approved schemes. Public authorities should not be excluded from liability if they have acted negligently. |
REC217-1834 | 32 - Doctrine, standards, and reform | The Department of Sustainability and Environment will develop clear policy for the coordinated management of rural drainage, clarifying the legal framework, and identifying authorities with responsibility for the management and ongoing maintenance of formal schemes, and their development: |
Rec-ID | Code | Recommendation |
---|---|---|
REC210-0750 | 32 - Doctrine, standards, and reform | The assessment of flood mitigation manuals should be completed by a person with appropriate expertise who has had no involvement in its development, at any stage, and who can be seen to be independent of all individuals who were so involved. |
REC210-0712 | 32 - Doctrine, standards, and reform | The Queensland Government should legislate to clarify the purposes for which a transitional environmental program can be granted. In particular, if the government considers the transitional environmental program the appropriate regulatory mechanism to deal with the discharge of water from mines during flood, section 330 of the Environmental Protection Act 1994 should be clarified to make it clear that it extends to that use. |
REC210-0770 | 32 - Doctrine, standards, and reform | The Queensland Government should legislate to oblige each owner of a referable dam to have an emergency action plan approved by the appropriate Queensland Government agency. Such plans should be reviewed periodically |
REC210-0733 | 32 - Doctrine, standards, and reform | Emergency Management Queensland should pursue the execution of the ‘Local Arrangements’ with councils where a Memorandum of Agreement is in place. The contents of the arrangements should be reviewed and updated regularly |
REC210-0749 | 32 - Doctrine, standards, and reform | The Queensland Government should amend the Water Supply (Safety and Reliability) Act 2008 to designate the Minister as the person who must approve a flood mitigation manual. |
REC210-0708 | 35 - Business and Industry in relation to industry | The Queensland Government should work collaboratively with the Commonwealth Government and mine operators to ensure co-ordinated and effective monitoring of salts, metals and other contaminants in marine environments that may be affected by mine discharges. |
REC210-0763 | 35 - Business and Industry in relation to industry | Seqwater should ensure that the Somerset Dam gallery is not susceptible to flooding during overtopping events. |
REC210-0726 | 25 - Inquiry, audit, lessons management and after action review | The Queensland Fire and Rescue Service should require that each region records in writing the results of its risk assessment undertaken as part of its annual review of its special operations functional plan. |
REC210-0743 | 25 - Inquiry, audit, lessons management and after action review | Seqwater should, in creating the new Wivenhoe and North Pine flood mitigation manuals, comprehensively consider: • the amount of discretion that is able to be exercised by the flood engineers and the senior flood engineers, and the description of the circumstances in which such discretion may be exercised • the circumstances in which it might be appropriate to release water in advance of an impending flood on the basis of forecasts from the Bureau of Meteorology • if strategies of the form of strategy W2 and W3 in Revision 7 are included in the revised manual, or any strategy defined as a ‘transition strategy’, when and how those strategies should be implemented • if the concept of ‘urban inundation’ is relevant to the operation of the dam, how it should be defined, and if the definition involves diverse concepts, how those concepts can be related back to the strategies, so that flood engineers can reach a clear understanding of their objectives and primary considerations • if the concept of ‘natural peak flow’ is relevant, how it should be defined. |
REC210-0762 | 25 - Inquiry, audit, lessons management and after action review | Seqwater should consider commissioning an investigation into the extent of cracking below the level of the upper gallery of Somerset Dam and the impact of any such cracking on the dam’s stability and, in turn, its operation. |
REC210-0719 | 32 - Doctrine, standards, and reform | The Queensland Government should amend the Environmental Protection Act 1994 so as to permit an emergency direction to be given orally where it is not practicable to provide the direction in writing, with provision for its subsequent confirmation in writing |
REC210-0738 | 25 - Inquiry, audit, lessons management and after action review | Seqwater should ensure that any future peer review process: • is co-ordinated by someone independent of those who wrote the report • entails the provision of all relevant information to the peer reviewers • permits sufficient time for the review • documents all contact between those whose actions are under review and the reviewers. |
REC210-0760 | 32 - Doctrine, standards, and reform | CS Energy should amend its business procedure to remove any ambiguity as to the establishment of communications with Seqwater and to acknowledge the formal communications protocol regarding releases. |
REC210-0717 | 32 - Doctrine, standards, and reform | The Queensland Government should consider amending the Environmental Protection Act 1994 to provide a definition of the term ‘emergency’ for the purposes of section 468 of that Act. |
REC210-0773 | 25 - Inquiry, audit, lessons management and after action review | The Department of Environment and Resource Management should prioritise dam safety audits according to risk. The risk assessment should be informed by criteria including: • structure and materials used in construction • age of the dam • time since last inspection • occurrence of a flood event since last audit and the size of that flood event • population at risk if the dam were to fail • experience and capability of dam owner • dam owner compliance history • time since last audit. |
REC210-0737 | 25 - Inquiry, audit, lessons management and after action review | The Department of Environment and Resource Management should ensure that an independent and appropriately qualified person immediately starts the task of reviewing the March flood event report to ensure that the review is completed before the start of the 2012/2013 wet season. |
REC210-0759 | 32 - Doctrine, standards, and reform | CS Energy should review its emergency action plan and business procedures to ensure they are wholly consistent and give appropriate consideration to flooding as a possible emergency event. |
REC210-0714 | 32 - Doctrine, standards, and reform | The Queensland Government should consider amending the Environmental Protection Act 1994 so that it allows for the relaxation of environmental authority conditions, by transitional environmental program or otherwise, as to discharge of water: • pre-emptively, in advance of rainfall or flooding events, or • for all mines in a catchment that is flooding. |
REC210-0772 | 25 - Inquiry, audit, lessons management and after action review | Prior to each wet season, the Department of Environment and Resource Management should audit the compliance of each owner of a referable dam with the obligation to have an emergency action plan approved by the Queensland Government. |
REC210-0736 | 25 - Inquiry, audit, lessons management and after action review | Seqwater should ensure that proper support and oversight mechanisms are put in place around both the substantive and procedural aspects of drafting flood event reports. Seqwater should consider engaging consultants with expertise in the production of reports following significant events to advise on these mechanisms. Measures to be considered should include: • ensuring appropriate systems are in place to ensure the recollections of flood engineers and other parties are recorded immediately after the event, perhaps by engaging an external party to interview the flood engineers and other parties • ensuring that a methodology for writing the report is set out clearly in advance, in writing, and that the final report includes a statement of that methodology • putting in place systems to ensure that members of senior management have sufficient understanding of both the methodology and process by which the report is prepared to allow themselves to be satisfied that these are appropriate. |
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. |
REC208-0530 | 32 - Doctrine, standards, and reform | That, if necessary, regulation be amended to require Health to approve any script used by any party concerned, for door knocking or other information dissemination, if Health is not the first source of information to affected residents. |
REC208-0529 | 32 - Doctrine, standards, and reform | That, when developing requirements concerning pollution incident response management plans pursuant to the recent legislative amendments, the Office of Environment and Hertiage include appropriate definitions as to the meaning of ‘immediately’, and when ‘material harm to the environment is caused or threatened’. |
REC208-0528 | 32 - Doctrine, standards, and reform | That, as part of the Pollution Incident Management Response Plan to be developed for Orica’s Kooragang Island site, or by another appropriate mechanism, the Office of Environment and Heritage ensure that Orica’s incident-response procedures address the need to consider all relevant factors when assessing potential impacts, including the height and force of emissions as well as the location of any onsite fallout and whether there are off-site impacts following all serious incidents. |
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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC199-0401 | 25 - Inquiry, audit, lessons management and after action review | the state task the Emergency Services Commissioner with the responsibility to establish an effective audit regime of the total flood warning system. |
REC199-0428 | 25 - Inquiry, audit, lessons management and after action review | the state clarify which agency is responsible for collecting post-flood extent and related data. This should include: • the development of guidelines to ensure consistent standards are applied to post-flood data collection; and • an appropriate process to ensure funding availability for such activities. |
REC199-0427 | 35 - Business and Industry in relation to industry | the state require dam owners and operators provide regular situational reports to the relevant control agency where dam issues may impact incident management. |
REC199-0454 | 32 - Doctrine, standards, and reform | the State Emergency Response Coordinator further develop the Strategic Emergency Management Assurance Team process by involving subject matter experts from relevant emergency management control agencies who are the subject of Strategic Emergency Management Assurance Team focus. |
REC199-0464 | 32 - Doctrine, standards, and reform | the state develop and implement a strategy that maximises the flexibility and united capacity of the Country Fire Authority and Victoria State Emergency Service to respond to emergencies. |
REC199-0487 | 32 - Doctrine, standards, and reform | the state develop and incorporate into emergency management planning regimes plans based on geographic risk, such as sub-regional plans |
REC199-0426 | 35 - Business and Industry in relation to industry | the state require that dam owners and operators inform people situated downstream of water storages if the owners/operators become aware of an immediate threat arising from the dam to the safety of those people. The owner/operators should provide this information as soon as the owner/operators become aware of the threat. |
REC199-0450 | 25 - Inquiry, audit, lessons management and after action review | the state ensure that appropriate record management processes are developed and implemented and that these processes also provide record accountability for multi-agency operations. Agency processes should be standardised to the fullest extent possible |
REC199-0461 | 32 - Doctrine, standards, and reform | the state ensure: • water rescue/swift water rescue definitions, roles and responsibilities are clarified and communicated to all stakeholders to ensure common understanding • appropriate training, equipment and support is provided to those required to perform water rescue/swift water rescue. Common training programs, standards and accreditation should be utilised wherever possible to increase potential for joined up operations and maximised capability • that based upon the experiences of these flood events, an appropriate level of water rescue capacity and capability is established and maintained • flood plans (all levels) and flood emergency response planning incorporate consideration of pre-positioning of appropriate water rescue capability in the event that such services should be required; and • that revised water rescue roles, responsibilities and arrangements are clearly defined in the Emergency Management Manual Victoria and such definitions are replicated in all individual agency planning and operational documents |
REC199-0484 | 32 - Doctrine, standards, and reform | the state: • assess current risk and risk mitigation strategies for essential services, with a focus on ensuring that risks are appropriately identified at all levels of emergency planning; and • ensure that the responsible authority or owner/ operator of essential services put in place appropriate strategies to mitigate any risk to service continuity |
REC199-0425 | 35 - Business and Industry in relation to industry | the state require that dam owners and operators inform the control agency and the Bureau of Meteorology about the management and operation of dams and weirs consistent with the flood warning requirements of the relevant river systems, including providing telemetry at sites as necessary. This may require the state proactively liaising with other states to ensure equivalent obligations are placed on interstate dam operators where the dam may impact Victorian communities. |
REC199-0445 | 25 - Inquiry, audit, lessons management and after action review | the state develop and implement operational performance standards for each state agency involved in emergency management response and recovery and that: • each agency be assessed by the Emergency Services Commissioner periodically against these performance standards for both capability and capacity; and • where performance against these standards for either capability or capacity cannot be demonstrated by any agency – appropriate advice is communicated to the relevant Minister, departmental/agency head and State Emergency Response Coordinator; and – an action plan is developed and implemented to address the relevant capability or capacity deficiency in both the short and longer term. |
REC199-0459 | 32 - Doctrine, standards, and reform | the state undertake a complete review of emergency management legislation. This should include agencyspecific emergency management legislation and should focus on service interoperability and securing an ‘all hazards, all agencies’ capability |
REC199-0482 | 25 - Inquiry, audit, lessons management and after action review | the state task the Emergency Services Commissioner with the responsibility to develop and undertake the regular audit of emergency management plans at all levels. |
REC199-0424 | 35 - Business and Industry in relation to industry | the state require dam owners and operators to review storage operating manuals to incorporate lessons from the 2010–11 floods and make this information publicly available. The manuals should include a clear policy on dam surcharging and pre-release. |
REC199-0443 | 32 - Doctrine, standards, and reform | the state reconfigure the Victorian Emergency Management Council and the supportive committee arrangements to ensure a comprehensive, accountable, effective and integrated approach to the development of emergency management arrangements is in place for Victoria. The process should also include consideration of the Security and Emergencies Committee and Central Government Response Committee roles, functions, reporting arrangements and relationships with other state level emergency management groups. Settled arrangements must be clearly articulated to ensure stakeholder understanding. |
REC199-0457 | 32 - Doctrine, standards, and reform | the state: • revise the Emergency Management Team Practice Note to include a template to ensure an appropriate and consistent approach to Emergency Management Team operations • provide the revised Emergency Management Team Practice Note to all stakeholders to enable familiarisation; and • ensure that there is regular exercising of Emergency Management Teams with an `all hazards’ focus. |
REC199-0469 | 32 - Doctrine, standards, and reform | the state update the current fire specific guidelines and resources for evacuation planning to take an ‘all hazards’ approach |
REC199-0407 | 25 - Inquiry, audit, lessons management and after action review | the state: • undertake a strategic review to identify areas at risk from flash or riverine flooding. Shortcomings in the flood gauging networks identified in the review should then be the focus of remedial action • seek to address as a priority any notable gaps in the total flood warning system as apparent in the 2010–11 floods (including south west Victoria, Wimmera and north central region) by enhancing mapping, gauging and education programs; and • seek a commitment from the Bureau of Meteorology to ensure any new gauges installed are utilised to enhance flood prediction capability and coverage. |
REC199-0442 | 32 - Doctrine, standards, and reform | the state appoint a state emergency controller who is ultimately accountable for all major emergencies. |
REC199-0456 | 32 - Doctrine, standards, and reform | the state: • ensure an ‘all hazards, all agencies’ approach to Incident Action Plan compilation is developed and implemented to enable the timely issue of functional Incident Action Plans. All agency incident action planning processes should be standardised to the fullest extent possible, including consideration of a library of pro-forma Incident Action Plans; and • develop and implement mechanisms to test and ensure that agencies possess satisfactory incident action planning capability and capacity for ‘all hazards’ at all levels of operations. |
REC199-0467 | 32 - Doctrine, standards, and reform | the state review and align all policies and procedures for evacuation, such as the interim evacuation guidelines and the State Health Emergency Response Plan, to ensure consistency and to clarify roles and responsibilities. |
Rec-ID | Code | Recommendation |
---|---|---|
REC189-2914 | 32 - Doctrine, standards, and reform | The review team recommend that: |
REC189-2912 | 29 - Operational Health and Safety | The review team recommend that the safety case system be strengthened by including provisions for a design notification scheme along the lines of that under the British Offshore Safety Case Regulations. |
REC189-2911 | 29 - Operational Health and Safety | The review team recommend that: |
REC189-2909 | 32 - Doctrine, standards, and reform | Equipping the regulator with a wider range of compliance tools under the legislation should continue to be a policy priority. The aim should be to enhance the regulator’s capacity to secure compliance in an appropriately graduated way. The opportunity should be taken to ensure that the regulator and inspectors can, in appropriate cases, bring proceedings that do not require referral to the Commonwealth Director of Public Prosecutions, such as actions for civil penalties or injunctions. |
REC189-2907 | 29 - Operational Health and Safety | a) For the purposes of designing and implementing its regulatory activities, National Offshore Petroleum Safety Authority (NOPSA) should continue to identify priority hazards and risks and their underlying causes, in consultation with the NOPSA Advisory Board and stakeholders (see Theme 9, Stakeholder engagement). |
Rec-ID | Code | Recommendation |
---|---|---|
REC164-0072 | 32 - Doctrine, standards, and reform | SERCon consider that the proposed State Recovery Committee review the recommended considerations arising from |
REC164-0071 | 32 - Doctrine, standards, and reform | SERCon consider the establishment of a body, such as a State Recovery Committee, with responsibility for the |
REC164-0077 | 32 - Doctrine, standards, and reform | SERCon consider the continued development of a State Recovery Sub-Plan (including complementary local and district |
REC164-0076 | 32 - Doctrine, standards, and reform | SERCon consider meeting with the State Emergency Management Committee, Directors General and agency heads to |
REC164-0073 | 25 - Inquiry, audit, lessons management and after action review | SERCon consider that the proposed State Recovery Committee provide an interim report to government on these and |
Rec-ID | Code | Recommendation |
---|---|---|
REC158-3437 | 32 - Doctrine, standards, and reform | That port/channel managers coordinate marine emergency planning for the port and are required to ensure that marine emergency arrangements are integrated with whole of port emergency management plans. |
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. |
REC158-3425 | 32 - Doctrine, standards, and reform | Consequential or complementary amendments to the Emergency Management Act are required to ensure that: |
REC158-3436 | 32 - Doctrine, standards, and reform | That Harbour Masters are the designated principle marine specialists within the port and work directly with emergency services to provide advice and the interface with the marine legislative powers, to manage a marine emergency. |
REC158-3441 | 32 - Doctrine, standards, and reform | That, where practical, risk assessments, emergency planning, training and exercising are integrated to minimise duplication of effort. |
REC158-3424 | 32 - Doctrine, standards, and reform | That legislation is prepared by the Department of Transport to ensure marine emergency management arrangements are clarified and provide: |
REC158-3435 | 32 - Doctrine, standards, and reform | That Harbour Masters have the appropriate powers, authority, accountability, skills, responsibility and indemnity to provide a coordinated response of marine resources in support of emergency services, except where the nominated marine safety authority is the control agency for a marine pollution or marine casualty emergency. |
REC158-3440 | 32 - Doctrine, standards, and reform | That the Water Division Emergency Response Plan is amended, by the Water Division emergency response coordinator, to provide a framework to coordinate a marine response that crosses declared port water boundaries and requires resource coordination and prioritisation. |
REC158-3434 | 32 - Doctrine, standards, and reform | That the accountability relationship between Harbour Masters and the Director of Marine Safety is strengthened in the relevant legislation. |
REC158-3439 | 32 - Doctrine, standards, and reform | That the port marine emergency management arrangements are integrated with the Victorian Water Division Emergency Response Plan. |
REC158-3427 | 32 - Doctrine, standards, and reform | That the standards and guidelines determined by the nominated marine safety authority require port/channel managers to conduct a marine emergency risk assessment using AS/NZ 4360:2004 Risk Management and, in addition, must require port/channel managers to: |
REC158-3438 | 32 - Doctrine, standards, and reform | That the port/channel managers coordinate marine emergency management planning in the port and are required to ensure that individual port stakeholder marine emergency management arrangements plans are integrated with the whole of port marine emergency management arrangements. |
REC158-3453 | 32 - Doctrine, standards, and reform | That, where applicable, consideration is given to legislative amendment that will enable the findings of this report to be applied to areas inside State waters but outside commercial port waters. |
REC158-3426 | 32 - Doctrine, standards, and reform | That the nominated marine safety authority, in consultation with the Emergency Services Commissioner, senior emergency services personnel and relevant port stakeholders, is responsible for establishing appropriate performance standards, risk management guidelines and good practice guidelines for marine emergency management. |
Rec-ID | Code | Recommendation |
---|---|---|
REC154-3458 | 32 - Doctrine, standards, and reform | DPI should develop a surveillance strategy with agreed goals and a comprehensive, integrated approach to surveillance across the livestock value chain. The surveillance strategy should: |
REC154-3457 | 32 - Doctrine, standards, and reform | DPI should develop a strategy to deliver an integrated and coordinated approach to prevention and early detection across the livestock value chain. As part of the strategy DPI should: |
REC154-3456 | 32 - Doctrine, standards, and reform | DPI should more closely align planning and risk management processes to support its decision-making and response to changing priorities, capacity, capability and investment. |
REC154-3455 | 32 - Doctrine, standards, and reform | Department of Primary Industries (DPI) should broaden the focus of its planning for biosecurity to include a longer term horizon and demonstrate closer alignment with national planning frameworks. To support this DPI should: |
REC154-3460 | 32 - Doctrine, standards, and reform | To support increased effectiveness in EAD (Emergency Animal Disease) response management DPI should: |
Rec-ID | Code | Recommendation |
---|---|---|
REC149-3132 | 35 - Business and Industry in relation to industry | Coverage of the regime should be increased to cover the complete hydrocarbons production system from wells through to custody transfer point or reasonable physical/technical system boundary. If NOPSA is also to be responsible for Carbon Capture and Storage it needs to be resourced to ensure that this does not detract from NOPSA's current responsibilities. |
REC149-3141 | 32 - Doctrine, standards, and reform | NOPSA should complete the next revision of Safety Case guidelines in consultation and agreement with stakeholders and continue its program to achieve consistency with a firmer hand from the CEO and management. |
REC149-3131 | 35 - Business and Industry in relation to industry | The exploration/production operator making all major decisions related to petroleum activities (i.e. selection of rig, well design and selection of service companies) should be made responsible for demonstrating to the regulator that drilling operations can be conducted safely. Where the drilling contractor owns the rig and conducts the day-to-day management of safety on the rig, this duty can be described in a rig specific Safety Case that is owned by the drilling contractor. This rig specific Safety Case does not have to be submitted for every well/well operation. |
REC149-3140 | 32 - Doctrine, standards, and reform | The industry should provide advice to NOPSA on where the regulations do not provide sufficient clarity and consider developing broad policy/process guidelines in consultation with the regulator to provide clarity and consistency. Regulators should not take personal views or preferences. |
REC149-3147 | 29 - Operational Health and Safety | As all stakeholders have responsibility for safe outcomes, decisions regarding target subjects for safety promotion need to have the support of all stakeholders including NOPSA and the workforce. Industry, which ultimately has the responsibility for managing risk as well as funding the promotion, should take a leadership role in implementation. |
REC149-3130 | 32 - Doctrine, standards, and reform | The regulations pertaining to vessels of opportunity or their interpretation should be changed to facilitate a risk based approach to regulation. This approach will be consistent with the approach taken in other jurisdictions. |
REC149-3135 | 29 - Operational Health and Safety | The initial acceptance of a new facility Safety Case should be in conjunction with inspection of a facility upon commencement of operations. |
REC149-3146 | 35 - Business and Industry in relation to industry | NOPSA should consider establishing a small forum for consultation consisting of representatives of relevant stakeholders. The representatives should have standing, with authority to participate in decision making and take on commitment on behalf of their stakeholder group. |
REC149-3129 | 32 - Doctrine, standards, and reform | The consequences of the disapplication of the Navigation Act 1912 should be analysed, the actual consequences identified and unintended consequences addressed. |
REC149-3134 | 32 - Doctrine, standards, and reform | Improved and agreed guidelines for Safety Case application and assessment, including suggested structure and content, would alleviate many current problems related to Safety Case processes. |
REC149-3145 | 25 - Inquiry, audit, lessons management and after action review | NOPSA should consider an audit regime that targets Greenfields operations at commencement of operations. |
REC149-3128 | 29 - Operational Health and Safety | National Offshore Petroleum Safety Authority (NOPSA) should develop guidelines in consultation with stakeholders to provide clarity and consistency to the process which ultimately will result in better safety outcomes. |
REC149-3133 | 35 - Business and Industry in relation to industry | Because some issues related to emergency response are beyond any single operator and usually occur outside the title area, there is a need for the representatives of the offshore industry to work together with other governments, interested and involved parties to develop the strategies to be utilised and the emergency planning model that will satisfy the requirements of all parties. |
REC149-3144 | 29 - Operational Health and Safety | The Safety Case proponent should be allowed some flexibility to involve appropriate experience matched with the proposed workforce competencies to enable the Safety Case to be developed with value adding processes. Subsequent to the hiring of the workforce Final Government Response Offshore Petroleum Safety Regulation Inquiry and 2008 Review of NOPSA Operational Activities and preferably before the commencement of operations a review of the Safety Case should take place with the new workforce to ensure they understand the accepted Safety Case, its risks and Safety Management Plan. |
Rec-ID | Code | Recommendation |
---|---|---|
REC148-3153 | 32 - Doctrine, standards, and reform | That premises be used for pre-export quarantine only if they have been approved by the officer responsible for the importation of horses and only if they have adequate biosecurity precautions that are the subject of documented procedures that can be audited. The import conditions for horses shall include a requirement that pre-export quarantine premises have been so approved. |
REC148-3179 | 32 - Doctrine, standards, and reform | That the import conditions for horses include that the nasopharyngeal swabs taken within 24 hours of arrival and five days after the last horse arrives in post-arrival quarantine be divided and the swabs made subject to a quantitative PCR test and a ‘rapid’ immuno-assay test to detect influenza A. The operating procedures should also require that these additional tests be conducted. |
REC148-3158 | 32 - Doctrine, standards, and reform | That the import conditions for horses specify, based on advice from Biosecurity Australia that is reviewed at least annually, the vaccines for equine influenza to be administered to horses before they are exported, taking account of the countries or regions from which the horses are exported. If there are commercially available vaccines that contain representatives of currently circulating strains, the import conditions should specify that the horses be vaccinated using that vaccine or one of those vaccines. Otherwise, the conditions should specify the vaccine or vaccines that may be used, based on the advice of Biosecurity Australia. |
REC148-3171 | 32 - Doctrine, standards, and reform | That the operating procedures require that there be identified a person who has overall responsibility for the various clearance procedures and biosecurity tasks to be performed in the course of unloading horses at an airport and transferring them to a quarantine station. |
REC148-3150 | 32 - Doctrine, standards, and reform | That the position of Inspector General of Horse Importation: |
REC148-3176 | 32 - Doctrine, standards, and reform | That there be prepared operating procedures or a manual that: |
REC148-3157 | 32 - Doctrine, standards, and reform | That the import conditions for horses include that the operations and procedures at the pre-export quarantine premises may from time to time, be inspected and audited by or on behalf of the Australian Government. |
REC148-3170 | 25 - Inquiry, audit, lessons management and after action review | That the officer responsible for the importation of horses arrange for Biosecurity Australia to conduct within six months, an inspection and review of the process of horse importation from the time horses arrive in Australia until the completion of their post-arrival quarantine in order to: |
REC148-3175 | 25 - Inquiry, audit, lessons management and after action review | That the officer responsible for the importation of horses arrange for Biosecurity Australia to review, at least once every two years, the operating procedures to ensure that they adequately identify and manage the risk of entry and spread of equine influenza associated with the importation of horses into Australia. The outcome of each such review should be the subject of a written report and recommendations to the person responsible for the importation of horses and the Executive Director of AQIS. A determination should then be made as to whether any, and if so what, changes should be made to the operating procedures. |
REC148-3156 | 32 - Doctrine, standards, and reform | That the import conditions for horses include that the horse be tested for equine influenza at a time as close as practicable to the end of the pre- export quarantine period. Until more sensitive and specific detection tests become available, an agent test for influenza A—either a quantitative PCR or an antigen-capture ELISA test—should be used. |
REC148-3183 | 32 - Doctrine, standards, and reform | That the Quarantine Act 1908 be reviewed in order to identify amendments necessary to ensure that the Act clearly and adequately confers all relevant powers to ensure the biosecurity of horse importation and quarantine and to give effect to these recommendations. |
REC148-3167 | 25 - Inquiry, audit, lessons management and after action review | That the facilities at Eastern Creek and Spotswood Quarantine Stations be reviewed by AQIS in consultation with experts in biosecurity and interested parties including state and territory governments, import agents, veterinarians, farriers, operators of private quarantine stations, and representatives of horse owners, horse racing organisations and equestrian organisations. There should in any event be constructed without delay, an adequate supply of hygienic, modern showering facilities and places of entry and exit to the stations and the horse sections of them that can be supervised and monitored continually. There should also be provided at those stations as soon as is practicable suitable means of electronic surveillance, including closed-circuit television; a secure place to store chemicals, drugs, instruments and equipment for use by people attending the quarantined horses, and a set of horse stalls and yards separate from the main stalls and yards to enable isolation of horses suffering from contagious or infectious diseases. These reviews should also consider the desirability of separate areas in quarantine stations to hold horses forming part of a single quarantine intake but that have been imported from different regions or have undergone pre-export quarantine in different places. The reviews should be carried out without delay, and the two quarantine stations should be upgraded in accordance with the recommendations of the reviews. |
REC148-3174 | 32 - Doctrine, standards, and reform | That the operating procedures require, as a condition of entry for all non- AQIS personnel to a quarantine station, that each person report any suspected breach (by that or any other person) of quarantine procedures in the quarantine station and that a person may be excluded from entry to a quarantine station in the event of a breach of such procedures by that person or in the event of a failure of that person to report any suspected breach. |
REC148-3155 | 32 - Doctrine, standards, and reform | That the import conditions for horses include that a blood sample be taken while a horse is in pre-export quarantine. Part of the sample is to be retained in the country of export and another part of that sample is to be transported to Australia, preferably with the horse. Both parts are to be retained for at least three months. |
REC148-3182 | 25 - Inquiry, audit, lessons management and after action review | That Biosecurity Australia review that formal import risk analysis at least once every two years to take into account any relevant developments in scientific knowledge—specifically testing methods, vaccines, vaccination procedures and other matters that affect biosecurity. Reports on the reviews should be provided to the officer responsible for the importation of horses and should contain recommendations for any necessary changes to policies for importation. |
REC148-3160 | 32 - Doctrine, standards, and reform | That, before a horse is loaded on to an aircraft or vessel for carriage to Australia, AQIS verify that there exists such certification as is required by its import conditions up to the time the horse arrives at the airport of departure and that the horse complies with those conditions. This could be done by facsimile or electronic communication with AQIS officers in Australia. |
REC148-3173 | 32 - Doctrine, standards, and reform | That the operating procedures require that the duties of any people responsible for maintaining 24 hour security at a quarantine station (whether they be AQIS officers or private contractors) are recorded in writing and that those people have received training in relation to biosecurity risks sufficient to instil an appreciation of such acts or circumstances as might give rise to biosecurity risks. |
REC148-3154 | 25 - Inquiry, audit, lessons management and after action review | That the officer responsible for the importation of horses arrange for Biosecurity Australia or another qualified body to inspect and review the activities and events that occur from the time horses enter pre-export quarantine until the time they arrive at an airport in Australia, in order to identify any biosecurity risks and recommend any necessary changes to import conditions or other requirements. This inspection and review shall be performed without delay for each country or region from which horses are imported to Australia, and it should take account of my other recommendations and comments in this report. |
REC148-3180 | 32 - Doctrine, standards, and reform | That the import conditions for horses include that each horse be tested for equine influenza as close as practicable before the end of the quarantine period and that a negative result for that test be available before the horse may be released from quarantine. Until more sensitive and specific detection tests become available, an agent detection test for influenza A - either a quantitative PCR test or an antigen-capture ELISA test - should be used for that purpose. |
REC148-3159 | 32 - Doctrine, standards, and reform | That the import conditions for horses specify that there be available for inspection at the port of loading and produced on the horse’s arrival in Australia, certification (including in electronic form) that the horse has been vaccinated, has had a blood sample taken during pre-export quarantine, and has passed a suitable detection test, currently either a quantitative PCR or an antigen-capture ELISA test for influenza A. |
REC148-3172 | 32 - Doctrine, standards, and reform | That the operating procedures require that the manager of a quarantine station be responsible for ensuring that a written report on compliance with procedures is prepared and reviewed daily and that any non-compliance and corrective action are recorded. |
Rec-ID | Code | Recommendation |
---|---|---|
REC137-3531 | 32 - Doctrine, standards, and reform | I recommend that CASA consider creating firm guidelines that require consideration of workload, lines of authority, potential conflicts of interest and any other factors that impact upon the ability of “key personnel” to discharge their responsibilities within an aviation organisation when its officers are approving appointments to those positions. |
Rec-ID | Code | Recommendation |
---|---|---|
REC134-3522 | 32 - Doctrine, standards, and reform | To improve the effectiveness of deployment arrangements for the National Medical Stockpile, the ANAO recommends that the Department of Health and Ageing: |
REC134-3521 | 32 - Doctrine, standards, and reform | To improve the management of the National Medical Stockpile, the ANAO recommends that the Department of Health and Ageing develop and implement procedures for: |
REC134-3519 | 32 - Doctrine, standards, and reform | The Australian National Audit Office (ANAO) recommends that the Department of Agriculture, Fisheries and Forestry and Animal Health Australia review: |
Rec-ID | Code | Recommendation |
---|---|---|
REC129-3621 | 32 - Doctrine, standards, and reform | We recommend that NSW Health continue with its good work and establish a time table to finalise all emergency and contingency plans. |
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. |
REC129-3632 | 32 - Doctrine, standards, and reform | We recommend that NSW Health continue with its good work and develop distinct surge capacity plans within each Area Health Service to manage emergency staffing needs, isolation facilities, intensive care units, assisted ventilation services, hospital beds and medical supplies. |
REC129-3631 | 32 - Doctrine, standards, and reform | We recommend that NSW Health continue with its good work and continue to develop plans to respond to the surge in demand for diagnostic tests and for laboratory personnel. |
REC129-3630 | 32 - Doctrine, standards, and reform | We recommend that NSW Health continue with its good work and continue to develop systems to bring all the information relevant to the surge in demand for health resources together in real time. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC128-3618 | 32 - Doctrine, standards, and reform | That the Department of Primary Industries should complete a review of the Memorandum of Understanding and ensure the roles of the Department and Rural Lands Protection Boards are more clearly identified outlined for effective delivery of animal health programs. |
REC128-3610 | 32 - Doctrine, standards, and reform | That the Minister for Primary Industries consider amending the Stock Diseases Act 1923 to ban the supply of waste swill to pig owners by food retailing businesses such as bakeries, restaurants and supermarkets. |
REC128-3599 | 32 - Doctrine, standards, and reform | In order to improve the response to animal health emergencies, that the Department of Primary Industries prioritise the finalisation of Memoranda of Understanding with the four jurisdictions bordering New South Wales. |
Rec-ID | Code | Recommendation |
---|---|---|
REC125-3892 | 35 - Business and Industry in relation to industry | That Melbourne Water ensures stakeholder expectations are fully considered when setting flood risk reduction targets. |
REC125-3898 | 25 - Inquiry, audit, lessons management and after action review | That agencies develop a detailed improvement plan and commit resources to its implementation. |
REC125-3895 | 32 - Doctrine, standards, and reform | That all agencies develop drainage asset management plans, consistent with best practice, and that these incorporate: |
REC125-3893 | 35 - Business and Industry in relation to industry | That Melbourne Water ensures that stakeholders (and especially local councils) are fully consulted before and during the development of drainage strategies and plans. These plans should consider councils’ drainage systems. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC121-3698 | 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. |
REC121-3733 | 29 - Operational Health and Safety | RailCorp’s approach to occupational health and safety should be proactive and involve the systematic analysis of all current hazards, risks and controls and an assessment of their adequacy to reduce the risk of injury to, or death of, employees to an acceptable level. |
REC121-3755 | 29 - Operational Health and Safety | The RailCorp Board should require a full review of the safety competence of RailCorp managers to ensure that each has the ability to bring about those safety reforms recommended in this report which are applicable to his or her position. |
REC121-3681 | 29 - Operational Health and Safety | RailCorp should progressively implement, within a reasonable time, level 2 automatic train protection with the features identified in chapter 8 of this report. |
REC121-3706 | 29 - Operational Health and Safety | RailCorp should establish a comprehensive safety document management system. |
REC121-3738 | 29 - Operational Health and Safety | All passenger trains must be fitted with an internal passenger emergency door release. |
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. |
REC121-3659 | 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. |
REC121-3747 | 29 - Operational Health and Safety | All trains should have windows available through which passengers can escape. |
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. |
REC121-3668 | 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. |
REC121-3696 | 32 - Doctrine, standards, and reform | Defects reporting, recording and rectification should be integrated with the RailCorp regimes for train maintenance. |
REC121-3732 | 29 - Operational Health and Safety | If ITSRR accepts such a plan as an appropriate response to the existing weak safety culture, ITSRR should approve it and monitor the effectiveness of the plan. |
REC121-3754 | 29 - Operational Health and Safety | The RailCorp Board should ensure that RailCorp has an adequate and integrated safety management system, including adequate systems for risk assessment, clearly defined safety responsibilities and accountabilities for persons holding management positions, and specific performance criteria against which evaluations can be made of safety performance and accountability for safety performance of all managers. |
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. |
REC121-3680 | 29 - Operational Health and Safety | All trains must be fitted with a minimum of two independent engineering defences to minimise the risk of derailment or collision in the event of train driver incapacitation. |
REC121-3705 | 32 - Doctrine, standards, and reform | The ITSRR should develop standards for periodic medical examinations which include the following: |
REC121-3737 | 29 - Operational Health and Safety | There must be a minimum of two independent methods of self-initiated emergency escape for passengers from all trains at all times. |
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. |
REC121-3688 | 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. |
REC121-3713 | 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. |
REC121-3743 | 29 - Operational Health and Safety | All passenger trains operating in New South Wales must have the external emergency door release clearly marked with the words “Emergency Door Release”. |
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. |
REC121-3667 | 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. |
REC121-3731 | 29 - Operational Health and Safety | RailCorp should develop a plan to be submitted to ITSRR to address the deficiencies in the safety culture of RailCorp, including: |
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. |
REC121-3772 | 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. |
REC121-3679 | 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. |
REC121-3702 | 29 - Operational Health and Safety | Random alcohol testing should be continued. |
REC121-3736 | 32 - Doctrine, standards, and reform | The RailCorp passenger containment policy must be abandoned. |
REC121-3759 | 29 - Operational Health and Safety | A Safety Reform Program Director (hereafter referred to as SRPD), reporting directly to the Chief Executive of RailCorp, should be retained to manage, as head of a Safety Reform Program Office, any safety reform program being undertaken by RailCorp. The SRPD should work with the Chief Executive and senior management to ensure the implementation of an integrated safety management system and the cultural change required. The SRPD must have qualifications suitable for recognition by the Australian Institute of Project Management as a master program director. He or she should report to and be under the control of the Chief Executive, to ensure that the accountability of the Chief Executive is not reduced. The SRPD should co-ordinate and integrate any existing rail safety reform programs and, in consultation with and with the authority of the Chief Executive he or she should: |
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. |
REC121-3711 | 29 - Operational Health and Safety | The ITSRR should establish an electronic document control system to enable effective and reliable information to be gathered for monitoring the safety of the New South Wales rail system. |
REC121-3741 | 29 - Operational Health and Safety | The operation of the train doors should have an override facility whereby the train driver or the guard can override an internal passenger emergency door release system if the door release is interfered with when there is no emergency. There should be an alarm, together with an intercom, in the train guard’s compartment so that, if a passenger attempts to initiate an emergency door release, there is an appropriate delay during which time an alarm sounds in the train guard’s compartment and the guard can then, after first attempting to speak via the intercom to the person concerned, if necessary, override the door release, and make an appropriate announcement over the intercom system in the train. |
REC121-3764 | 29 - Operational Health and Safety | The ITSRR should not grant accreditation to any rail organisation unless it has an integrated safety management system in accordance with any safety management system regulation and the guidelines published from time to time by ITSRR. |
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. |
REC121-3750 | 32 - Doctrine, standards, and reform | ITSRR should initiate and/or participate in the development of a national standard for crashworthiness of all passenger trains. |
REC121-3771 | 32 - Doctrine, standards, and reform | RailCorp should establish an integrated safety management system which includes the following: |
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. |
REC121-3701 | 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. |
REC121-3735 | 29 - Operational Health and Safety | Risk assessments of occupational health and safety issues by RailCorp should include an analysis of broader public safety risks and not be confined to narrow occupational health and safety issues. |
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. |
REC121-3685 | 32 - Doctrine, standards, and reform | The ITSRR should impose a standard in relation to the collection and use of data from data loggers. |
REC121-3709 | 29 - Operational Health and Safety | RailCorp should provide access to electronic versions of safety documentation for all operational staff at their workplace. |
REC121-3740 | 29 - Operational Health and Safety | The internal passenger emergency door release should be fitted with a facility which prevents it from operating unless the train is stationary. |
REC121-3763 | 32 - Doctrine, standards, and reform | The ITSRR should publish guidelines to be followed by accredited organisations. |
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. |
REC121-3749 | 29 - Operational Health and Safety | All new rolling stock must be designed with an area of the roof through which emergency services personnel can access a rail car without encountering wiring or other equipment. That access point must be clearly marked with words such as “emergency services cut here”. |
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 |
REC121-3674 | 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. |
REC121-3734 | 29 - Operational Health and Safety | RailCorp should integrate its management of occupational health and safety into its overall safety management. |
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. |
REC121-3682 | 29 - Operational Health and Safety | All new rolling stock should be designed to be compatible with at least level 2 automatic train protection discussed in chapter 7 of this report. |
REC121-3707 | 29 - Operational Health and Safety | The safety document management system should provide for the distribution of electronic versions of safety documentation to relevant staff. |
REC121-3739 | 29 - Operational Health and Safety | All passenger trains operating in New South Wales must be fitted with external emergency door releases which do not require any special key or other equipment to operate. |
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. |
REC121-3660 | 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. |
REC121-3748 | 29 - Operational Health and Safety | All new rail cars must have appropriate signage and lighting identifying escape routes in the case of emergency. |
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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC112-3908 | 32 - Doctrine, standards, and reform | That DPI develops a department-wide enforcement policy and specific guidelines for Plant Standards Branch (PSB). |
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. |
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. |
REC112-3918 | 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. |
REC112-3932 | 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. |
REC112-3913 | 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. |
REC112-3929 | 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. |
REC112-3912 | 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. |
REC112-3924 | 32 - Doctrine, standards, and reform | That DPI develops diagnostic protocols for high-priority threats, in conjunction with other jurisdictions and industry, as soon as practicable. |
REC112-3910 | 32 - Doctrine, standards, and reform | That the Agricultural and Veterinary Chemicals (Control of Use) Act 1992, Plant Health and Plant Products Act 1995 and Livestock Disease Control Act 1994 be registered with the Department of Justice’s PERIN system. |
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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC008-3991 | 32 - Doctrine, standards, and reform | The Commission recommends that the provisios of section 185 of the "Mining Act 1905" relating to exits from coal mines be extended to metalliferous mines employing more than 20 men in any one shift. |
Rec-ID | Code | Recommendation |
---|---|---|
REC004-3993 | 32 - Doctrine, standards, and reform | That in any case where there is primá facie evidence of a fire, creating damage to the extent of $100 or upwards in value, having been caused by the escape of particles of lighted matter from a locomotive engine, or by the action of railway employes in burning off grass or other inflammable material along any line of railway, a Special Board of Inquiry shall investigate and report on the subject, such Board to consist of a Police Magistrate as Chairman, with a railway officer and a competent person chosen from outside the State service as members. |
REC004-4000 | 32 - Doctrine, standards, and reform | That section 22 of the Police Offences Act 1890 be amended, to enable the burning of grass and debris along the railway lines in the summer season to be carried out at an earlier hour than two o'clock in the afternoon, when, in the judgement of the railway inspectors, it is safe and necessary to do so. |
REC004-3995 | 32 - Doctrine, standards, and reform | That the standard double arrester, fitted to the locomotives during the summer months, be subjected to more careful daily inspection before and after each journey during such months, in addition to the present periodical examination by the locomotive foreman and boiler inspector; and that any omission of this duty on the part of the running staff be severely punished. |