Inquiry Search
Rec-ID | Code | Recommendation |
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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. |
REC002-4006 | 17 - Assets and technology | The Commisison would not insist upon a barometer being provided at each mine. Experience has proved that this is a tardy index to atmospheric conditions. Serious changes in the atmospheric pressure occur and are felt before they are indicated by a barometer. |
Rec-ID | Code | Recommendation |
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REC292-2345 | 12 - EM agency and authority | I recommend that the New South Wales Police Force establish procedures and the technical capability to ensure that phone calls from hostages in sieges or the victims of other ongoing high-risk situations are expeditiously transferred to officers involved in responding to the incident. |
REC292-2355 | 12 - EM agency and authority | I recommend that the New South Wales Police Force review its procedures to ensure that handovers between negotiation teams are staggered so that a fully briefed officer is always available to receive a call from the stronghold. |
REC292-2342 | 13 - Mapping and data quality | The development of an integrated intelligence system that allows police officers secure access to all information platforms should also provide for the recording of all command decisions, the reasons for them, and the dissemination of those decisions. |
REC292-2354 | 12 - EM agency and authority | I recommend that the New South Wales Police Force consider expanding the panel of psychological advisers it retains and the range of disciplines it consults. |
REC292-2349 | 12 - EM agency and authority | I recommend that the New South Wales Police Force review its personnel arrangements and structures for the monitoring of surveillance devices, including the number of officers allocated to a listening or viewing post for monitoring purposes, and the demarcation of roles, including primary monitor, scribe/log keeper, and disseminator. I also recommend that clear communication channels be established for reporting data captured during such surveillance, including via integrated electronic intelligence sharing platforms or applications. |
REC292-2369 | 26 - Research | I recommend that the New South Wales Police Force evaluate whether the use of noise-attenuation devices should be mandated when explosive distraction devices are used. |
REC292-2348 | 17 - Assets and technology | I recommend that if it has not already done so, the New South Wales Police Force acquires the audio surveillance technology that in similar circumstances would allow a device to be monitored in the Police Forward Command Post and/or the Police Operations Centre and that the organisation ensures that its capacity in this regard keeps pace with technological advances in the area. |
REC292-2357 | 12 - EM agency and authority | I recommend that the New South Wales Police Force review its policy of requiring negotiators to relinquish that role when they are promoted to commissioned officer rank |
REC292-2346 | 12 - EM agency and authority | I recommend that the New South Wales Police Force investigate the development of an integrated intelligence system that allows selected officers secure access to all information platforms and to record and share operational decisions. |
REC292-2356 | 12 - EM agency and authority | I recommend that the New South Wales Police Force review the number, rank and function of the officers comprising the Negotiation Unit |
Rec-ID | Code | Recommendation |
---|---|---|
REC258-2546 | 12 - EM agency and authority | The Civil Aviation Safety Authority changes its organisational structure to a client-oriented output model. |
REC258-2545 | 12 - EM agency and authority | The Australian Transport Safety Bureau transfers its safety education function to the Civil Aviation Safety Authority. |
REC258-2558 | 12 - EM agency and authority | The Civil Aviation Safety Authority applies a project management approach to the completion of all Civil Aviation Safety Regulation Parts not yet in force, with drafting to be completed within one year and consultation completed one year later, with: |
REC258-2532 | 12 - EM agency and authority | The next Director of Aviation Safety has leadership and management experience and capabilities in cultural change of large organisations. Aviation or other safety industry experience is highly desirable. |
REC258-2553 | 12 - EM agency and authority | The Civil Aviation Safety Authority establishes a safety oversight risk management hierarchy based on a categorisation of operations. Rule making and surveillance priorities should be proportionate to the safety risk. |
REC258-2548 | 17 - Assets and technology | The Civil Aviation Safety Authority shares the risk assessment outputs of Sky Sentinel, its computerised risk assessment system, with the applicable authorisation holder. |
REC258-2547 | 12 - EM agency and authority | The Civil Aviation Safety Authority establishes small offices at specific industry centres to improve monitoring, service quality, communications and collaborative relationships. |
Rec-ID | Code | Recommendation |
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REC236-2797 | 12 - EM agency and authority | The committee recommends that all meetings between the ATSB and CASA, whether formal or informal, where particulars of a given investigation are being discussed be appropriately minuted. |
REC236-2790 | 12 - EM agency and authority | The committee recommends that an expert aviation safety panel be established to ensure quality control of ATSB investigation and reporting processes along the lines set out by the committee. |
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. |
REC236-2800 | 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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC232-2824 | 41 - Emergency Management exercises | The Australian Department of Health and Ageing consult with members of the general public or representatives of health consumers in the pandemic planning process, including in pandemic exercises designed to test the ability of government to respond to a pandemic event. Consumer involvement should include testing the ability of any communication strategy designed to inform and engage consumers about a pandemic event. |
REC232-2822 | 41 - Emergency Management exercises | The Australian Government test Australia’s ability to respond to a widespread outbreak of infectious disease other than influenza, by undertaking a pandemic exercise across the relevant Commonwealth, state and territory government agencies. |
REC232-2821 | 26 - Research | The National Health and Medical Research Council, in conjunction with key stakeholders, work collaboratively to provide more support for initiatives to increase international infectious disease research collaborations and build research capacity, particularly with neighbouring countries in the Asia-Pacific region. |
Rec-ID | Code | Recommendation |
---|---|---|
REC227-2848 | 17 - Assets and technology | I recommend that the AFP take steps to determine whether access can be obtained to the National Search and Rescue Council endorsed SARMAP program covering the Australian Search and Rescue Region as well as adjoining tiles for Indonesia. Steps should be taken to ensure that if possible coverage would include high traffic areas where SIEVs enter the Australian Search and Rescue region allowing timely search and rescue plans to be drawn up for any potential incidents. |
REC227-2858 | 13 - Mapping and data quality | I recommend that the Commonwealth prioritise completion of a hydrographic survey of Christmas Island and ensure that such a survey is completed in the near future. |
REC227-2846 | 17 - Assets and technology | I recommend that Border Protection Command continues to examine ways of improving its surveillance capability around Christmas Island so that the risk of SIEVs arriving undetected is reduced. |
REC227-2856 | 12 - EM agency and authority | I recommend that BPC establish an onshore presence as recommended by Lieutenant Commander Livingstone. |
REC227-2854 | 12 - EM agency and authority | I recommend that the Christmas Island VMRS be given autonomy to maintain operational readiness for the VMRS rescue vessel(s) and an appropriate budget be provided to allow this to take place. |
REC227-2851 | 17 - Assets and technology | I recommend that consideration should be given to acquiring two personal water craft for deployment by appropriately trained and equipped staff of the AFP or the VMRS or both on Christmas Island. |
REC227-2850 | 17 - Assets and technology | I recommend that the AFP be provided with a search and rescue vessel which is suitable to the specific conditions of Christmas Island. I further recommend that steps be taken to ensure that if for any reason the search and rescue vessel is not available, there is a replacement vessel on Christmas Island capable of providing an emergency response in difficult sea conditions. |
REC227-2859 | 17 - Assets and technology | I recommend that the issue of RHIB jet intake protection be allocated a high priority and that there be ongoing investigation of possible solutions to reduce the problem. |
Rec-ID | Code | Recommendation |
---|---|---|
REC169-2998 | 38 - Agency/Department Reporting | Reports on the training exercises should be retained in an appropriately secured central repository so that consolidated results of the exercises can be drawn together effectively. |
REC169-2997 | 38 - Agency/Department Reporting | The Department of Premier and Cabinet and Victoria Police, in consultation with departments, should standardise reporting on training exercises conducted under Part 6 of the Act and the CIP framework to promote greater consistency and to enable better identification of lessons learned and continuous improvement. |
REC169-2989 | 38 - Agency/Department Reporting | The Department of Premier and Cabinet should lead the development of a performance management framework for measuring, monitoring and reporting on the implementation of Part 6 of the Act and the CIP framework. The framework should include key indicators, targets and reporting arrangements for assessing the extent to which departments, agencies and industry have fulfilled their obligations, as well as measures for monitoring achievement of joint objectives. |
Rec-ID | Code | Recommendation |
---|---|---|
REC158-3430 | 17 - Assets and technology | That the nominated marine safety authority is responsible for development of a declared asset system and is required to ensure that port/channel managers utilise and maintain the declared asset system. |
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. |
REC158-3443 | 12 - EM agency and authority | That emergency services increase their capability/capacity to respond to marine emergencies by undertaking the necessary training, increasing their awareness of port and ship operations and ensuring knowledge of the roles/responsibilities of the relevant authorities and stakeholders. |
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. |
REC158-3442 | 12 - EM agency and authority | That emergency services continue to take the lead role in marine emergencies and operate under their respective legislation, the Emergency Management Act and the State’s emergency management arrangements. |
REC158-3432 | 17 - Assets and technology | That port/channel managers are required to ensure, through service agreements, licensing, direct acquisition or other means as appropriate, the availability of the critical Level 1declared assets. |
REC158-3431 | 17 - Assets and technology | That port/channel managers are required to identify in the declared asset system (in conjunction with the emergency services) critical Level 1 declared assets and other Level 2 declared assets, that may be required in support of a marine emergency within the port, and that identified resource availability, accessibility and call out time is recorded. |
Rec-ID | Code | Recommendation |
---|---|---|
REC154-3462 | 41 - Emergency Management exercises | DPI should formalise the approach and framework for evaluating simulation exercises and response to Emergency Animal Disease incidents with guidelines to define the nature of the review process. This should include: |
REC154-3459 | 41 - Emergency Management exercises | To improve response preparedness, DPI should clearly link the selection of simulation exercises to the risk management framework to target coverage of high risks. |
REC154-3463 | 13 - Mapping and data quality | Biosecurity Victoria should enhance controls to provide assurance regarding data integrity. This process should include: |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC148-3178 | 38 - Agency/Department Reporting | That the officer responsible for the importation of horses prepare a report to the Executive Director of AQIS that: |
REC148-3177 | 12 - EM agency and authority | That the officer responsible for the importation of horses ensure that: |
REC148-3149 | 38 - Agency/Department Reporting | That there be established the position of Inspector General of Horse Importation, the duties of that position being: |
Rec-ID | Code | Recommendation |
---|---|---|
REC129-3623 | 41 - Emergency Management exercises | We recommend that NSW Health continue with its good work and apply the lessons learnt from Exercise Cumpston to further improve preparedness for major infectious disease emergencies. |
REC129-3628 | 41 - Emergency Management exercises | We recommend that NSW Health continue with its good work and continue to develop and test the capability of its contact tracing system to deal with a public health emergency. |
REC129-3622 | 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. |
REC129-3627 | 41 - Emergency Management exercises | We recommend that NSW Health continue with its good work and continue to develop and test its surveillance systems for early detection of infectious diseases. |
REC129-3626 | 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. |
REC129-3624 | 41 - Emergency Management exercises | We recommend that NSW Health continue with its good work and formally establish and oversight a comprehensive program of training, testing and evaluation of plans at the state, area and facility level. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC128-3602 | 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. |
REC128-3601 | 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. |
REC128-3619 | 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. |
REC128-3600 | 34 - Local knowledge | The Department of Primary Industries continue to consult local community about emergency planning and sites for disposal to retain confidence in the event of a genuine emergency. |
REC128-3612 | 12 - EM agency and authority | That the Department of Primary Industries should ensure that it retains the services of a specialist poultry industry liaison officer in the future. |
REC128-3611 | 12 - EM agency and authority | That the Department of Primary Industries should endeavour to improve its knowledge and skills base in the pig industry by recruiting a specialist pig industry liaison officer. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC121-3656 | 17 - Assets and technology | Satellite telephones should be provided by RailCorp to all rail commanders at any emergency. |
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. |
REC121-3689 | 12 - EM agency and authority | All RMC communications related staff should be selected upon the basis of the ability to convey information clearly, accurately and concisely and to follow strict communications protocols. |
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. |
REC121-3710 | 39 - Disaster Risk Management | The ITSRR should have permanent access to the RailCorp intranet. |
REC121-3725 | 13 - Mapping and data quality | The data and information management system should be compatible with any data and information management system established by the ATSB for the designated interstate rail network, provided that the establishment of a compatible system does not reduce the amount or quality of the information obtained by ITSRR below the optimum levels which it needs to conduct trend analysis, and otherwise properly manage the safety of rail operations in New South Wales. |
REC121-3684 | 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. |
REC121-3775 | 38 - Agency/Department Reporting | The Minister for Transport Services must table in Parliament, each such quarterly report by ITSRR. |
REC121-3708 | 12 - EM agency and authority | RailCorp should employ a Chief Safety Information Officer to manage the collection, collation, and dissemination of safety information within RailCorp. |
REC121-3724 | 13 - Mapping and data quality | The ITSRR should establish a data and information management system, containing all data and information that it requires, to continually monitor the safety of the New South Wales rail system. |
REC121-3683 | 39 - Disaster Risk Management | RailCorp should undertake risk assessments of each of its activities as follows: |
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: |
REC121-3700 | 39 - Disaster Risk Management | Maintenance plans on all trains should be revised annually. |
REC121-3723 | 38 - Agency/Department Reporting | All ATSB accident investigation reports should be made public. |
REC121-3673 | 41 - Emergency Management exercises | Regular field training exercises should be conducted by RailCorp with the emergency services to ensure that the incident command system and rail displan are able to be fully implemented as quickly as possible and are reviewed and improved. |
REC121-3766 | 12 - EM agency and authority | Staffing arrangements for ITSRR should be reviewed by it to ensure that adequate staff are employed in field positions, actively monitoring the safety of rail operations and compliance with conditions of accreditation. |
REC121-3700 | 12 - EM agency and authority | The RailCorp defects unit should be combined with the passenger fleet maintenance division of RailCorp. |
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. |
REC121-3658 | 12 - EM agency and authority | All emergency services stations should be provided with access keys to, and maps showing, all gates providing access to RailCorp tracks within their geographic area of responsibility. |
REC121-3752 | 12 - EM agency and authority | RailCorp should establish clear safety accountability statements and reporting lines for all management positions. |
REC121-3697 | 38 - Agency/Department Reporting | All train drivers’ defects reports should be entered by RailCorp into a computerised record and tracked to finalisation. |
Rec-ID | Code | Recommendation |
---|---|---|
REC117-3638 | 41 - Emergency Management exercises | The ANAO recommends that the Attorney-General’s Department, in consultation with the Department of the Prime Minister and Cabinet and the National Counter-Terrorism Committee: |
REC117-3637 | 41 - Emergency Management exercises | The ANAO recommends that the Attorney-General’s Department, in consultation with the Department of the Prime Minister and Cabinet and the National Counter-Terrorism Committee, pursue a more strategic and systematic approach to the measurement of performance via the National Capability Development Exercise Programme by: |
REC117-3636 | 41 - Emergency Management exercises | The ANAO recommends that the Attorney-General’s Department, in conjunction with the National Counter-Terrorism Committee’s exercise management advisers, explore options for the incorporation of more contemporary and varied testing and training aids in the National Capability Development Exercise Programme. |
REC117-3634 | 41 - Emergency Management exercises | The ANAO recommends that the Attorney-General’s Department, in consultation with the Department of the Prime Minister and Cabinet and the National Counter- Terrorism Committee, pursue the adoption of a more strategic approach to determining the National Capability Development Exercise Programme so that: |
REC117-3641 | 38 - Agency/Department Reporting | The ANAO recommends that, to ensure the outcomes of evaluations are effectively used to enhance the national counter-terrorism arrangements, the Attorney-General’s Department and the Department of the Prime Minister and Cabinet take appropriate measures to ensure: |
REC117-3633 | 38 - Agency/Department Reporting | The ANAO recommends that, to provide better information to contribute to strategic assessments, decisions and reporting, the Attorney-General’s Department, with input and guidance from the Department of the Prime Minister and Cabinet: |
REC117-3639 | 41 - Emergency Management exercises | The ANAO recommends that the Attorney-General’s Department, in consultation with the National Counter-Terrorism Committee, strengthens the reporting on the National Capability Development Exercise Programme through: |
Rec-ID | Code | Recommendation |
---|---|---|
REC112-3909 | 12 - EM agency and authority | That PSB’s enforcement procedures are consistent with those of the rest of the department. |
REC112-3923 | 12 - EM agency and authority | That DPI negotiates access, as and when required, to an AQIS PC4- accredited laboratory. |
REC112-3921 | 17 - Assets and technology | That the recommendations of the 2000 DPI report into the reference collection’s storage facility be implemented, to secure the collection in a purpose-built facility. |
REC112-3917 | 12 - EM agency and authority | That DPI improves monitoring and surveillance of high priority threats and improves the quality of information provided to the Commonwealth. |
REC112-3915 | 12 - EM agency and authority | That DPI makes arrangements to use contract labour for fruit fly trap monitoring and surveillance before the predicted fruit fly outbreak season. |
REC112-3926 | 13 - Mapping and data quality | That DPI upgrades the Crop Health Services diagnostic database so that it alerts PSB and PIRVIC to the receipt of samples from nearby areas with similar symptoms and can be linked to other PIRVIC diagnostic databases. |
REC112-3914 | 12 - EM agency and authority | That DPI develops a consistent approach to recording and enforcing breaches of the certification and verification system. |
REC112-3925 | 13 - Mapping and data quality | That DPI establishes a system to ensure the security of all samples at all times, but particularly during their handling and transport. |
Rec-ID | Code | Recommendation |
---|---|---|
REC008-3989 | 17 - Assets and technology | The Commission recommends that there be continuous supervision of every chamber in which electrical machinery is worked by currents of medium pressure. |
REC008-3987 | 17 - Assets and technology | The Commission recommends that systematic tests be made and recorded of apparatus and circuits as a precaution against fire and so that any gradual deterioration of the system may be detected. |
REC008-3986 | 17 - Assets and technology | The Commission recommends that every precaution be taken to keep water off electrical machinery. |
REC008-3985 | 17 - Assets and technology | The Commission recommends that conductors carrying currents at medium pressure should not be encased in wood in damp places. |
Rec-ID | Code | Recommendation |
---|---|---|
REC004-3994 | 17 - Assets and technology | That the Railway Department, while gradually reducing the number of different types of locomotives, should steadily keep in view the adoption of English and American railway practice, by providing engines with larger boilers, fire boxers, and smoke-boxes, and with wide blast-pipes, in order to insure ample steaming power with a minimum of forced draught. |
REC004-3992 | 17 - Assets and technology | That the use of a spark-arrester and cinder-arrester by the Railway Department shall not constitute a defence to an action for damage caused by fire escaping from a locomotive, unless the Department proves that such spark-arrester and cinder-arrester were in a thoroughly efficient condition when the fire took place. |
REC004-3996 | 17 - Assets and technology | That the standard pattern of cinder arrester be affixed to the ash-pans in all locomotives during the summer months. |