Inquiry Search
Rec-ID | Code | Recommendation |
---|---|---|
REC002-4012 | 38 - Agency/Department Reporting | Complete sets of daily-report books should be provided, and kept in the mine or office, to be overlooked by the Inspector during his periodical visits. |
REC002-4003 | 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. |
REC002-4010 | 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. |
REC002-4002 | 19 - Offences | Where safety-lamps are necessary - gas being present for (say) one month after being found in dangerous quantity - they should be securely locked by a man duly appointed, and tampering with them must be punishable by a simple and inexpensive process of law. |
REC002-4008 | 35 - Business and Industry in relation to industry | Where dust exists in quantity, and under conditions favourable for ignition, it should be periodically and sufficiently dampened by water |
REC002-4001 | 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. |
REC002-4007 | 40 - Equipment and consumables | A measure of safety may be found in the use of high explosives combined with wet tamping, or, still better, water cartridges, instead of powder under any of its modifications. Encouragement ought also to be given to the use of patent multiple wedges and applicances of a like nature, for supplanting the use of explosives. Under all circumstances and conditions some provision should be adopted for compelling workmen to thoroughly undercut, shear, or nick, and generally to work the coal as directed by the Manager. |
REC002-4005 | 40 - Equipment and consumables | Where safety-lamps are used the lock should be of such a character as to prevent any workman opening it. If the "Protector" type of lamp be employed the necessity for a lock is the less necessary, as the unscrewing of this type of lamp extinguishes the light. |
REC002-4013 | 19 - Offences | Infringement of the regulations by either party should be followed by a summary form of justice, instituted before two Magistrates. |
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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC258-2540 | 6 - Insurance and legal liability | The Civil Aviation Safety Authority continues to provide appropriate indemnity to all industry personnel with delegations of authority. |
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. |
REC258-2539 | 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. |
REC258-2550 | 6 - Insurance and legal liability | The Civil Aviation Safety Authority introduces grading of Non-Compliance Notices on a scale of seriousness. |
REC258-2561 | 24 - Govt responsibility | The Australian Government amends regulations so that background checks and the requirement to hold an Aviation Security Identification Card are only required for unescorted access to Security Restricted Areas, not for general airside access. This approach would align with international practice. |
REC258-2530 | 24 - Govt responsibility | The Australian Government appoints an additional Australian Transport Safety Bureau Commissioner with aviation operational and safety management experience. |
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. |
REC258-2557 | 6 - Insurance and legal liability | The Civil Aviation Safety Authority reassesses the penalties in the Civil Aviation Safety Regulations. |
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. |
REC258-2544 | 6 - Insurance and legal liability | The Australian Transport Safety Bureau transfers information from Mandatory Occurrence Reports to the Civil Aviation Safety Authority, without redaction or de-identification. |
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. |
REC258-2526 | 24 - Govt responsibility | The Australian Government develops the State Safety Program into a strategic plan for Australia’s aviation safety system, under the leadership of the Aviation Policy Group, and uses it as the foundation for rationalising and improving coordination mechanisms. |
REC258-2543 | 6 - Insurance and legal liability | The Civil Aviation Safety Authority reintroduces a ‘use of discretion’ procedure that gives operators or individuals the opportunity to discuss and, if necessary, remedy a perceived breach prior to CASA taking any formal action. This procedure is to be followed in all cases, except where CASA identifies a Serious and Imminent Risk to Air Safety. |
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. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC236-2801 | 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. |
REC236-2791 | 37 - Funding | The committee recommends that the government develop a process by which the ATSB can request access to supplementary funding via the minister. |
REC236-2800 | 38 - Agency/Department Reporting | The committee recommends that where a safety action has not been completed before a report being issued that a recommendation should be made. If it has been completed the report should include details of the action, who was involved and how it was resolved. |
REC236-2799 | 38 - Agency/Department Reporting | The committee recommends that the ATSB prepare and release publicly a list of all its identified safety issues and the actions which are being taken or have been taken to address them. The ATSB should indicate its progress in monitoring the actions every 6 months and report every 12 months to Parliament. |
REC236-2808 | 38 - Agency/Department Reporting | The committee recommends that in relation to mandatory and confidential reporting, the default position should be that no identifying details should be provided or disclosed. However, if there is a clear risk to safety then the ATSB, CASA and industry representatives should develop a process that contains appropriate checks and balances. |
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. |
REC236-2806 | 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. |
REC236-2793 | 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. |
REC236-2805 | 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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC232-2819 | 9 - Community education | The Australian Government, coordinated by the Department of Health and Ageing and in consultation with the wider Australian community, develop a national public awareness campaign to better inform and engage the travelling public about infectious disease issues. This campaign should cover the risks associated with travelling overseas, preventative measures that can be undertaken to minimise these risks, and screening measures used at the border to prevent the importation of infectious disease. |
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. |
REC232-2817 | 21 - Role of Commonwealth Government | The Australian Government work with the state and territory governments to assess the viability of providing a centralised refugee and migrant health service in each state and territory, which would automatically refer people who move from immigration detention into the wider Australian community. |
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: |
REC232-2815 | 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. |
REC232-2826 | 21 - Role of Commonwealth Government | The Australian Government coordinate the development of a highly skilled workforce which can respond effectively to a sustained pandemic in Australia. |
REC232-2825 | 21 - Role of Commonwealth Government | The Commonwealth Government support the growth of vaccine development and production capacity for vaccines in Australia, to enhance Australia’s preparedness to respond to outbreaks of infectious disease in Australia, and in particular, pandemic influenza. |
REC232-2820 | 21 - Role of Commonwealth Government | Having regard to the terms of the Torres Strait Treaty, the Department of Health and Ageing, Queensland Health, AusAID and the Papua New Guinea Government: |
Rec-ID | Code | Recommendation |
---|---|---|
REC227-2853 | 21 - Role of Commonwealth Government | I recommend that the Commonwealth liaise closely with representatives of the Christmas Island VMRS prior to purchasing or replacing any vessels for the VMRS in the future. |
REC227-2852 | 21 - Role of Commonwealth Government | I recommend that the Commonwealth and the Shire of Christmas Island take steps to ensure that the Ethel Beach boat ramp is significantly upgraded, that it should be provided with shelter in the form of a rock groyne or similar buffer and that provision should be made so that a person can walk beside the ramp on a stable footing; or If this is not considered likely to be effective in providing an appropriate means of deploying a rescue vessel in adverse conditions, such other action be taken as is necessary to ensure that there is a means of deploying a rescue vessel in adverse conditions. |
REC227-2857 | 21 - Role of Commonwealth Government | I recommend that the Commonwealth ensure that there is a mooring buoy which will enable the mooring of SIEVs to take place and free up the Christmas Island response vessel for ongoing surveillance duties. |
Rec-ID | Code | Recommendation |
---|---|---|
REC208-0527 | 35 - Business and Industry in relation to industry | That the Office of Environment and Heritage require Orica to engage and fund appropriate independent experts to oversee any modifications to the plant in the next major maintenance overhaul of the plant in 2016 and in any upgrades to the plant prior to that date. |
REC208-0526 | 25 - Inquiry, audit, lessons management and after action review | That OEH’s testing procedures for determining the impact of pollution incidents incorporate additional requirements for the checking and verification of results before those results are released. |
REC208-0525 | 7 - Inter-agency communication | That the Office of Environment and Heritage amend its operating procedures for the Environment Line to ensure that there are clear obligations to pass on information relevant to other agencies, to those agencies in a timely manner. |
Rec-ID | Code | Recommendation |
---|---|---|
REC189-2913 | 21 - Role of Commonwealth Government | In developing and improving its policies and practices for stakeholder engagement, NOPSA should ensure that: |
REC189-2910 | 21 - Role of Commonwealth Government | NOPSA should: |
REC189-2908 | 21 - Role of Commonwealth Government | To ensure that NOPSEMA is in a strong position to perform its functions effectively: |
REC189-2906 | 21 - Role of Commonwealth Government | In order to improve the effectiveness of National Offshore Petroleum Safety and Environmental Management Authority (NOPSEMA), with similar benefits for State or Territory regulators, attention should be given to the following actions. |
Rec-ID | Code | Recommendation |
---|---|---|
REC177-3348 | 21 - Role of Commonwealth Government | Responsibility for well integrity should be moved to NOPSA (as also proposed by the Productivity Commission). |
REC144-3387 | 25 - Inquiry, audit, lessons management and after action review | In order that the ACT public can be reassured about the project management and financial planning in relation to the Fairbairn site as a proposed centralised accommodation facility for emergency services, the Auditor-General undertake a review of the project from a financial probity and project management perspective. |
REC177-3285 | 39 - Disaster Risk Management | Pre‐drilling assessments should include a risk assessment of the worst‐case blowout scenario. |
REC177-3358 | 21 - Role of Commonwealth Government | The body established to undertake a central coordination and facilitation role in the event of any future blowout in Commonwealth waters should undertake to make all relevant information publically available from one, authoritative and easy to access source. |
REC177-3291 | 39 - Disaster Risk Management | Removal of a barrier must be the subject of consultation between licensees and rig operators prior to removal. A proper risk assessment should be carried out and agreed upon, and documented in writing before removal. Joint written certification as to the appropriateness of removal should take place before removal. Senior onshore representatives of stakeholder entities should be involved in that certification process. |
REC177-3371 | 21 - Role of Commonwealth Government | The Government should examine the scope for a single environment plan to meet the regulatory requirements of both the OPGGS Act and the EPBC Act. This could possibly be achieved by way of bilateral agreements and accreditation arrangements and/or legislative amendment. |
REC177-3347 | 21 - Role of Commonwealth Government | The proposal of the Productivity Commission’s Research Report (Review of Regulatory Burden on the Upstream Petroleum (Oil and Gas) Sector, April 2009) to establish a NOPR should be pursued at a minimum. |
REC177-3378 | 25 - Inquiry, audit, lessons management and after action review | In view of the numerous well integrity problems in all of the Montara Oilfield wells, the Minister should commission a detailed audit of all the other offshore wells operated by PTTEPAA to determine whether they too may suffer from well integrity problems. |
REC177-3274 | 21 - Role of Commonwealth Government | The Minister should appoint a senior policy adviser to investigate and report on the best means to implement the recommendations contained in this Chapter 3 of this report. |
REC177-3357 | 21 - Role of Commonwealth Government | In any future similar blowout or offshore emergency situation, the Minister appoint (through either a NOPR or the relevant Department) a senior public servant to establish and oversight a central coordinating body that will facilitate interaction between regulators, industry, AMSA and the owner/operator. Primary responsibility for stopping a blowout should remain with the owner/operator but should be subject to direction from the central coordinating body in consultation with stakeholders (including the owner/operator). |
REC177-3290 | 38 - Agency/Department Reporting | The successful installation of every barrier should be the subject of written verification within and between licensees and rig operators; and should be the subject of explicit reporting to the relevant regulator(s). |
REC177-3369 | 6 - Insurance and legal liability | The obligation of companies involved in an incident to meet the full costs of monitoring and remediation should be made a condition of approval of proposals under the EPBC Act and OPGGS Act. Suitable arrangements (insurance or otherwise) need to be in place to ensure that companies have this capacity. |
REC177-3346 | 21 - Role of Commonwealth Government | A single, independent regulatory body should be created, looking after safety as a primary objective, well integrity and environmental approvals. Industry policy and resource development and promotion activities should reside in government departments and not with the regulatory agency. The regulatory agency should be empowered (if that is necessary) to pass relevant petroleum information to government departments to assist them to perform the policy roles. |
REC177-3376 | 21 - Role of Commonwealth Government | In carrying out a review of PTTEPAA’s permit and licence, the Minister should have regard to this Report, particularly (i) the adverse findings set out in this Chapter; and (ii) the extent to which PTTEPAA has implemented the Action Plan submitted to the Inquiry, or otherwise addressed the matters canvassed in this Report. |
REC177-3356 | 39 - Disaster Risk Management | The regulator should pre‐assess and review in a generic sense, and in conjunction with the offshore petroleum industry, available options for well control in the event of a blowout. Being ‘match fit’ in this sense will enable a quicker and more effective response in terms of safety assessment, and will ensure that expectations of both operator and regulator are more readily aligned. |
REC177-3289 | 39 - Disaster Risk Management | The use/type of barriers (including any change requests relating thereto) must be the subject of consultation between licensees and rig operators prior to installation. A proper risk assessment should be carried out, agreed upon, and documented in writing before installation. Joint written certification as to the appropriateness of the use of particular barriers should take place before installation. Senior onshore representatives of stakeholder entities should be involved in that certification process. |
REC177-3365 | 6 - Insurance and legal liability | The National Plan should specify that the cost of responding to an oil spill, or other damage to the offshore marine environment, will be totally met by the owner/operator. This would be consistent with the Inquiry’s recommendation for legislative changes to the regulatory framework concerning owner/operators meeting the cost of monitoring and remediation of environmental damage. |
REC177-3344 | 25 - Inquiry, audit, lessons management and after action review | There should be a review to determine whether it is appropriate to introduce a rigorous civil penalty regime and/or substantially increase some or all of the penalties that can be imposed for breaches of legislative requirements relating to well integrity and safety. |
REC177-3375 | 21 - Role of Commonwealth Government | For the purposes of that review, the Minister should issue a ‘show cause’ notice to PTTEPAA under s 276 of the OPGGS Act. |
REC177-3351 | 21 - Role of Commonwealth Government | In the future, and in the interests of ensuring that all possible well control options are comprehensively pursued to exhaustion, decisions as to well control response options should be the result of collaboration between the regulator and the operator rather than leaving one party to make unilateral judgements as to the appropriateness of various well control operations. The regulator should provide transparent and contemporaneous explanations to the public of all well control options under consideration at any particular time. |
REC177-3287 | 38 - Agency/Department Reporting | Licensees should be subject to an express obligation to inform regulators of problems which arise in the course of installing barriers, even if they consider that well integrity is not thereby compromised. The information should be provided by way of special report, rather than included in a standard reporting document (such as a DDR). The information provided should include risk assessment details. |
REC177-3364 | 37 - Funding | The funding arrangements that support the National Plan should be reviewed to ensure that the costs associated with both preparedness and response capability are equitably shared between the shipping and offshore petroleum industries. |
REC177-3330 | 39 - Disaster Risk Management | Decision‐making about well control issues should be professionalised. Industry participants must recognise that decision‐makers owe independent duties to the public, not just their employer or principal, in relation to well control. Risk management in the context of well control needs to be understood as an ethical/professional duty. Self‐regulation contemplates self‐regulation by the industry, not just by individual licensees and operators. |
REC177-3374 | 25 - Inquiry, audit, lessons management and after action review | The Minister should, as the JA for the offshore area of the Territory of Ashmore and Cartier Islands, undertake a review of PTTEPAA’s permit and licence to operate at the Montara Oilfield. |
REC177-3349 | 21 - Role of Commonwealth Government | In the meantime, the Minister should: |
REC177-3286 | 39 - Disaster Risk Management | Problems which arise in the course of installing barriers must be the subject of consultation between licensees, rig operators, and contractors (if used). A proper risk assessment should then be carried out and remedial steps (including further testing/verification) should be agreed upon, and documented in writing before the performance of remedial work whenever practicable. Joint written certification as to resolution of the problem should take place before resumption of drilling operations. Senior onshore representatives of stakeholder entities should be involved in that certification process. |
REC177-3360 | 42 - Culture and Heritage | DEWHA should participate in training programs and exercises relevant to an oil spill in the marine environment. |
REC177-3310 | 6 - Insurance and legal liability | Consideration should be given to ways to ensure that contractors who are involved in barrier installation (such as cementing companies) have a direct interest in the performance of works to a proper standard. In particular, consideration should be given to (i) preventing contractors from avoiding the economic consequences of negligent installation of barriers; and/or (ii) imposing specific legislative standards of workmanship on contractors with respect to well control (similar to those which presently apply to licensees). |
REC177-3372 | 21 - Role of Commonwealth Government | OSCPs should be endorsed by AMSA prior to regulatory approval to ensure that they align with the National Plan. Once field operations commence, the capability of operators should be assessed against their plans, and exercises conducted to ensure the plans remain effective. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC158-3429 | 38 - Agency/Department Reporting | That the nominated marine safety authority is required to ensure that incident notification and data recording requirements for Victorian commercial ports are consistent and adhered to. |
REC158-3451 | 37 - Funding | That port/channel managers should be able, within the general context of the pricing/cost recovery arrangements established under the Port Services Act 1995 and pricing determinations made by the Essential Services Commission, to recover the reasonable costs of meeting their statutory obligations (as per recommendation 26) through charges for prescribed service applied to port users. |
REC158-3428 | 38 - Agency/Department Reporting | That the nominated marine safety authority, in consultation with the Emergency Services Commissioner and senior emergency services personnel, is responsible for monitoring the implementation and auditing against appropriate performance standards, risk management guidelines and good practice guidelines. |
REC158-3450 | 37 - Funding | That emergency services are responsible for funding the development of the emergency services marine emergency response capacity/capability to meet their statutory obligations. |
REC158-3449 | 37 - Funding | That port/channel managers are responsible for funding the preparation of marine emergency risk assessments and marine emergency response arrangements and ensuring the availability of identified marine resources in support of response to a marine emergency, to meet their statutory obligations. |
REC158-3448 | 24 - Govt responsibility | That the Director of Marine Safety works with the Australian Maritime Safety Authority to ensure that State and port emergency arrangements interface appropriately with the National Maritime Emergency Response Arrangements. |
REC158-3454 | 24 - Govt responsibility | That the Department of Transport ensures that key stakeholders are engaged during the implementation of the approved Review recommendations. |
REC158-3433 | 24 - Govt responsibility | That Harbour Masters are employed by a government body and remain geographically located at the port. |
Rec-ID | Code | Recommendation |
---|---|---|
REC154-3461 | 24 - Govt responsibility | DPI should develop an Memorandum of Understanding (MOU) with the Department of Human Services that capitalises on and strengthens the current good working relationship to support joint forward planning and risk management and mitigates against relationship failure in the event of leadership change. The MOU should clarify: |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC149-3142 | 19 - Offences | NOPSA should use encouragement as the primary tool of enforcing compliance provided willingness to improve is exhibited by the players. |
REC149-3139 | 39 - Disaster Risk Management | The industry should develop in conjunction with the Regulator a process for addressing the need to maintain the risk profile of a facility moving into extended life operation at the same risk profile as when it was within design life. |
REC149-3138 | 38 - Agency/Department Reporting | The current KPI measures used by the Regulator and industry need to be reassessed and the performance indicators need to be related to the risk profiles of the industry. The industry needs to develop the indicators, which need to be agreed and measured by the industry in discussion with other stakeholders. The KPI's selected should be published in comparison with the worldwide offshore industry and with other industries. NOPSA should continue discussions with Australian Safety and Compensation Council (ASCC) with a view to adopting their goals. |
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. |
REC149-3133 | 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. |
REC149-3145 | 25 - Inquiry, audit, lessons management and after action review | NOPSA should consider an audit regime that targets Greenfields operations at commencement of operations. |
REC149-3132 | 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. |
REC149-3143 | 21 - Role of Commonwealth Government | The role of the advisory Board, namely to give advice to Ministers and NOPSA when asked, should be made clear to Board members and all stakeholders. The Board and NOPSA should consider the need for a clear description of who does what based on the legislated responsibilities of the NOPSA CEO. |
Rec-ID | Code | Recommendation |
---|---|---|
REC148-3178 | 38 - Agency/Department Reporting | That the officer responsible for the importation of horses prepare a report to the Executive Director of AQIS that: |
REC148-3148 | 21 - Role of Commonwealth Government | That the Secretary of the Department of Agriculture, Fisheries and Forestry designate, without delay, a Senior Executive Service officer to be primarily responsible and accountable for the importation of horses into Australia and to that end to have the power to exercise all necessary authority. |
REC148-3161 | 21 - Role of Commonwealth Government | That the facilities for unloading and transferring of horses at Sydney (Kingsford Smith) Airport be upgraded without delay, following the advice of experts in biosecurity containment, so as to enable appropriate biosecurity precautions to be taken effectively and to minimise the risk of injury to horses and those handling them. The facilities should include at least one padded box or stall sound-proofed to the extent that it is reasonable to do so. |
REC148-3166 | 21 - Role of Commonwealth Government | That, in the absence of other satisfactory government controlled and operated post-arrival quarantine stations becoming available before the options to renew the leases of Eastern Creek and Spotswood Quarantine Stations expire, those options be exercised. |
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. |
REC148-3185 | 37 - Funding | That, until the review of those fees has been completed, the fee charged by the government controlled and operated quarantine stations for thoroughbred stallions temporarily imported into Australia be not be less than $165.00 plus GST a day and the fee for all other horses be not less than $65.00 plus GST a day. No discount is to be allowed for the number of horses in a consignment. |
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. |
REC148-3165 | 21 - Role of Commonwealth Government | That there continue to be in Australia government controlled and operated post-arrival quarantine stations for horses. |
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: |
REC148-3184 | 37 - Funding | That the fees charged in relation to the importation and quarantining of horses be reviewed and fixed without delay having regard to the following factors: |
REC148-3152 | 21 - Role of Commonwealth Government | That the person holding the position of Inspector General of Horse Importation may be removed in the following circumstances only: |
REC148-3164 | 21 - Role of Commonwealth Government | That there be similar facilities for the unloading and transfer of horses at any other airport in Australia that might receive horses imported from places other than New Zealand. |
REC148-3169 | 37 - Funding | That the budgets for airport reception of horses and government controlled and operated quarantine stations be determined so as to be sufficient to fund the operations of the Quarantine Stations in accordance with these recommendations and any further procedures and requirements that are laid down from time to time. |
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. |
REC148-3151 | 21 - Role of Commonwealth Government | That the person holding the position of Inspector General of Horse |
REC148-3163 | 21 - Role of Commonwealth Government | That there be provided without delay at Sydney (Kingsford Smith) and Tullamarine Airports facilities to enable people who might have had contact with imported horses to shower and change their clothes, under supervision, before leaving the airport. |
REC148-3168 | 21 - Role of Commonwealth Government | That each government controlled and operated quarantine station have sufficient staff to carry out properly all activities and measures required by the current operating procedures dealing with the quarantine of horses. |
REC148-3181 | 39 - Disaster Risk Management | That Biosecurity Australia undertake and complete within 12 months a non-regulated but formal import risk analysis relating to the importation of horses from the countries and regions from which Australia currently permits such importation, and make such recommendations for any changes to policies for importation as are warranted by its risk analysis to the officer responsible for the importation of horses and the Executive Director of AQIS. |
REC148-3149 | 38 - Agency/Department Reporting | That there be established the position of Inspector General of Horse Importation, the duties of that position being: |
REC148-3162 | 21 - Role of Commonwealth Government | That facilities for the unloading and transferring of horses at Tullamarine Airport in Melbourne be constructed urgently, upon advice of experts in biosecurity containment, to enable adequate biosecurity precautions to be taken effectively and to minimise the risk of injury to horses and those handling them. |
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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC137-3533 | 21 - Role of Commonwealth Government | Accordingly I recommend that the Federal Minister for Transport, consider engaging an external consultant to assess whether high level intervention is warranted. |
Rec-ID | Code | Recommendation |
---|---|---|
REC134-3520 | 21 - Role of Commonwealth Government | To improve the management of the National Medical Stockpile, the ANAO recommends that the Department of Health and Ageing incorporate into its governance framework: |
Rec-ID | Code | Recommendation |
---|---|---|
REC129-3622 | 39 - Disaster Risk Management | We recommend that NSW Health continue with its good work and consider building on influenza pandemic preparedness planning to develop broader contingency plans to address the emergence of other new, highly transmissible and/or severe infectious diseases. |
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. |
REC129-3626 | 39 - Disaster Risk Management | We recommend that NSW Health continue with its good work and consider a more structured and systematic approach to the planning and risk assessment of major infectious diseases to assist transparency and decision making. |
REC129-3625 | 38 - Agency/Department Reporting | We recommend that NSW Health continue with its good work and establish a performance management framework with targets and indicators to assess progress in preparing for infectious disease emergencies. |
Rec-ID | Code | Recommendation |
---|---|---|
REC128-3615 | 9 - Community education | That the Department of Primary Industries should continue to raise awareness among producers of OJD risks and the operation of Sheep Health Statements. |
REC128-3603 | 37 - Funding | That the Department of Primary Industries consider applying discretion to the use of user charging policies for testing in times when farm incomes are affected by external circumstances such as widespread drought. |
REC128-3614 | 37 - Funding | The Committee encourages the Department and the Rural Land Protection Boards to discuss the need for funding of poultry surveillance activities in the context of reviewing the Memorandum of Understanding between the two parties. |
REC128-3602 | 38 - Agency/Department Reporting | That the Department’s performance against tactical and strategic benchmarks be regularly reported in annual reports or animal and plant health emergency evaluation reports and compared to other jurisdictions where possible. |
REC128-3613 | 9 - Community education | That the Department of Primary Industries and Rural Lands Protection Boards employ outreach activities to alert these small producers to their responsibilities and improve their awareness of animal and plant pests and diseases. |
REC128-3619 | 38 - Agency/Department Reporting | That the Department of Primary Industries should ensure the roles and capacities of Rural Lands Protection Boards and industry are effectively monitored to enable assessment of the effectiveness of animal health programs. |
REC128-3601 | 38 - Agency/Department Reporting | That, as a matter of principle, the NSW Government provide public reports on the lessons learned from emergency exercises which it manages or in which it participates. If necessary, such reports should exclude material which might jeopardise security. |
REC128-3606 | 24 - Govt responsibility | That the Department of Primary Industries address the forthcoming potential shortage of veterinary pathologists and agronomists within its testing facilities by positive recruitment actions over the next five years such as offering scholarships or training existing professional staff to develop skills in pathology. |
REC128-3617 | 37 - Funding | That the Department of Primary Industries should provide specific information on levies to contributing producers through a separate document, rather than rely on standard audit documents and annual reporting requirements. |
REC128-3598 | 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. |
REC128-3605 | 38 - Agency/Department Reporting | That the Department of Primary Industries make every effort to meet its targets for the TSE program and encourage public and private sector veterinarians across the State to submit samples. The Department should include reports on its performance against these targets in annual reports. |
REC128-3616 | 37 - Funding | That the Department of Primary Industries continue to pursue improvements to consultation with industry and accountability mechanisms to further build trust between industry and government, thereby enhancing the effectiveness of the OJD Program. |
REC128-3604 | 37 - Funding | That the Department of Primary Industries restore the level of discretionary testing funds provided to District Veterinarians to previous levels and maintain these in the future in real terms. |
Rec-ID | Code | Recommendation |
---|---|---|
REC121-3767 | 24 - Govt responsibility | All accredited rail organisations should be required to re-apply every three years to ITSRR for accreditation. |
REC121-3703 | 6 - Insurance and legal liability | Alcohol and drug testing should be mandatory for any train driver or guard involved in any accident or incident. |
REC121-3665 | 14 - Incident Mgt Teams | The role of the rail commander should be to provide support and assistance to the site controller and emergency services personnel until the rescue phase of the emergency response to any rail accident is completed. |
REC121-3720 | 24 - Govt responsibility | The New South Wales Government should make the necessary arrangements with the Australian Government, including any necessary legislation, for the Australian Transport Safety Bureau (ATSB) to have the power to investigate all rail accidents occurring on the New South Wales rail network the investigation of which may advance the knowledge of the causes of rail accidents in Australia. |
REC121-3729 | 38 - Agency/Department Reporting | All reports of the Chief Investigator of OTSI should be delivered, upon completion and without being reviewed, to ITSRR and the Minister for Transport Services. |
REC121-3684 | 39 - Disaster Risk Management | The ITSRR should conduct its own risk assessment in relation to the risk of any such high consequence, low probability accident and, if necessary, direct RailCorp to conduct a further risk assessment to reduce the level of residual risk to a level ITSRR regards as acceptable. |
REC121-3765 | 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. |
REC121-3700 | 39 - Disaster Risk Management | Maintenance plans on all trains should be revised annually. |
REC121-3776 | 38 - Agency/Department Reporting | The Minister for Transport Services should retain, independently of ITSRR, safety auditors to provide a report to the Minister confirming or qualifying the contents of each such ITSRR quarterly report. |
REC121-3663 | 14 - Incident Mgt Teams | The incident command system should clearly identify the roles of the rail commander, site controller, police commander and commanders of the other emergency services, and the way in which each is to work together during the recovery phase of any rail accident. |
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. |
REC121-3726 | 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. |
REC121-3683 | 39 - Disaster Risk Management | RailCorp should undertake risk assessments of each of its activities as follows: |
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. |
REC121-3697 | 38 - Agency/Department Reporting | All train drivers’ defects reports should be entered by RailCorp into a computerised record and tracked to finalisation. |
REC121-3775 | 38 - Agency/Department Reporting | The Minister for Transport Services must table in Parliament, each such quarterly report by ITSRR. |
REC121-3652 | 14 - Incident Mgt Teams | A designated staff member at the RMC should act as the rail emergency management co-ordinator. He or she should be the sole point of contact at the RMC with other rail personnel involved in the rail accident and emergency services personnel during the rescue phase of the emergency response. |
REC121-3712 | 38 - Agency/Department Reporting | RailCorp and ITSRR should co-operate with national programs for the collection, collation, trend analysis and dissemination of safety critical information. |
REC121-3723 | 38 - Agency/Department Reporting | All ATSB accident investigation reports should be made public. |
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. |
REC121-3757 | 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. |
REC121-3694 | 25 - Inquiry, audit, lessons management and after action review | The ITSRR should conduct random audits of accredited rail organisations for compliance with communications protocols. |
REC121-3774 | 38 - Agency/Department Reporting | The ITSRR must provide a quarterly report to the Minister for Transport Services on the progress made by RailCorp in implementing these recommendations, including: |
REC121-3710 | 39 - Disaster Risk Management | The ITSRR should have permanent access to the RailCorp intranet. |
REC121-3676 | 14 - Incident Mgt Teams | A direct line of communication should be established between the RMC and Emergency Services Operations Control Centre by a “tie line” or otherwise, so as to ensure that in the case of a serious rail accident there is an open line of communication between the officer in charge of the management of the incident at the RMC and the various emergency response services. |
REC121-3722 | 38 - Agency/Department Reporting | The ATSB should deliver any report of any such rail accident which it investigates to the Board of any rail organisation involved in the accident, ITSRR and the Minister for Transport Services. |
REC121-3753 | 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. |
REC121-3693 | 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. |
REC121-3768 | 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. |
REC121-3704 | 28 - Personal responsibility | RailCorp should continue its system of voluntary self-identification and rehabilitation of employees with alcohol or drug related problems. |
REC121-3666 | 14 - Incident Mgt Teams | The rail commander should have complete authority to direct and control any rail employees attending the site of a rail accident, in accordance with directions given or arrangements put in place by the site controller, until the rescue phase of the emergency response to the rail accident has been completed. |
REC121-3721 | 24 - Govt responsibility | The ITSRR should ensure that OTSI, as a division of ITSRR, co-operates and assists the ATSB in the conduct of any independent investigation by the ATSB of any rail accident or incident in New South Wales. |
REC121-3742 | 19 - Offences | The risk of abuse of internal passenger emergency door releases should be further reduced by introducing significant penalties for any improper use of such an emergency facility. It should be a criminal offence for anyone to use or tamper improperly with an emergency escape facility in a train. |
REC121-3691 | 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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC112-3928 | 3 - Biodiversity | That DPI formalises agreements within the Regional Services and Agriculture Division to ensure that plant health information is included in extension programs. |
REC112-3912 | 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. |
REC112-3927 | 6 - Insurance and legal liability | That PSB and PIRVIC review their service agreement to ensure that PIRVIC is compensated for its costs in providing PSB with the specified level of service. |
REC112-3911 | 3 - Biodiversity | That DPI develops a consistent process to identify, assess and prioritise potential plant pest and disease threats, and aligns it with prioritisation processes used at the national level by Plant Health Australia. |
REC112-3922 | 25 - Inquiry, audit, lessons management and after action review | That DPI maintains ISO 9000 accreditation for at least one laboratory and seeks NATA accreditation for key diagnostic tests. This should be done in combination with Plant Health Australia’s laboratory accreditation project. |
REC112-3934 | 37 - Funding | That DPI prepares guidelines, both internally and externally with Treasury, about funding arrangements for an outbreak. |
REC112-3907 | 25 - Inquiry, audit, lessons management and after action review | That Department of Primary Industries (DPI), in partnership with the Department of Sustainability and Environment, reviews all legislation relating to plant biosecurity with a view to streamlining the legislative framework. |
REC112-3919 | 25 - Inquiry, audit, lessons management and after action review | That the model for state funding be reviewed to ensure that DPI can confidently build and maintain a core level of diagnostic expertise and research capability. |
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. |
REC112-3918 | 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. |
REC112-3929 | 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. |
REC112-3913 | 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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC008-3988 | 40 - Equipment and consumables | The Commission recommends that buckets of sand or other apparatus for extinguishing fire be kept in any chamber where high powered electricity is used. |
Rec-ID | Code | Recommendation |
---|---|---|
REC004-3998 | 19 - Offences | That a by-law be made forbidding, under a heavy penalty, any persons travelling in such trains to throw lighted tobacco, cigars, cigarettes, pipe ashes, matches, or other inflammable matter on the railway line or right-of-way, or in any part of a railway carriage except the receptacles duly provided for the purpose. |
REC004-3997 | 40 - Equipment and consumables | That suitable metal receptacles be fitted under the spittoons of all smoking compartments of country trains, to receive pipe ashes, lighted tobacco, cigars, cigarettes, matches, or other inflammable matter used by smokers. |