Inquiry Search
Rec-ID | Code | Recommendation |
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REC002-4013 | 19 - Offences | Infringement of the regulations by either party should be followed by a summary form of justice, instituted before two Magistrates. |
REC002-4003 | 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. |
REC002-4012 | 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. |
REC002-4002 | 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. |
REC002-4010 | 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. |
REC002-4001 | 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. |
REC002-4009 | 16 - Training and behaviour | In gassy mines the Manager should be specially competent, and one possessing a thorough knowledge of the principles and practice of mining, the properties of gases, and systems of ventilation; and, above all, he must be prudent and cautious, yet resolute, possessing sound judgement. He must have absolute and supreme control over the whole operations, and of the men within the mine, to maintain rigid discipline, and be perfectly free and untrammelled by any outside influences. The competency of a manager should be certified by an examination before a specially-appointed Board. The Commission consider that better results may be obtained if such examinations be oral, and probably assume a more practical form than those hitherto conducted in Great Britain for the same object. |
REC002-4008 | 35 - Business and Industry in relation to industry | Where dust exists in quantity, and under conditions favourable for ignition, it should be periodically and sufficiently dampened by water |
REC002-4004 | 35 - Business and Industry in relation to industry | Where safety-lamps are used, and the obligation is laid upon the men to cleanse the same, all examinations, tests, and repairs to these should be done by the owners. |
Rec-ID | Code | Recommendation |
---|---|---|
REC258-2545 | 12 - EM agency and authority | The Australian Transport Safety Bureau transfers its safety education function to the Civil Aviation Safety Authority. |
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. |
REC258-2530 | 24 - Govt responsibility | The Australian Government appoints an additional Australian Transport Safety Bureau Commissioner with aviation operational and safety management experience. |
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. |
REC258-2542 | 16 - Training and behaviour | The Civil Aviation Safety Authority publishes and demonstrates the philosophy of ‘just culture’ whereby individuals involved in a reportable event are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training. However, actions of gross negligence, wilful violations and destructive acts should not be tolerated. |
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. |
REC258-2528 | 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. |
REC258-2559 | 15 - Inter-service cooperation | The Civil Aviation Safety Authority’s Director of Aviation Safety meet with industry sector leaders to jointly develop a plan for renewing a collaborative and effective Standards Consultative Committee. |
REC258-2541 | 16 - Training and behaviour | The Civil Aviation Safety Authority finalises its Capability Framework and overhauls its training program to ensure identified areas of need are addressed, including: |
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. |
REC258-2526 | 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. |
REC258-2558 | 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: |
REC258-2539 | 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. |
REC258-2547 | 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. |
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. |
REC258-2534 | 16 - Training and behaviour | The Civil Aviation Safety Authority develops a staff exchange program with industry. |
REC258-2546 | 12 - EM agency and authority | The Civil Aviation Safety Authority changes its organisational structure to a client-oriented output model. |
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. |
REC258-2532 | 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. |
Rec-ID | Code | Recommendation |
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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. |
REC236-2805 | 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. |
REC236-2793 | 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. |
REC236-2792 | 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. |
REC236-2800 | 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. |
REC236-2790 | 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. |
REC236-2799 | 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. |
REC236-2788 | 16 - Training and behaviour | The committee recommends that, as far as available resources allow, ATSB investigators be given access to training provided by the agency's international counterparts. Where this does not occur, resultant gaps in |
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. |
REC236-2806 | 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. |
REC236-2787 | 16 - Training and behaviour | The committee recommends that the training offered by the ATSB across all investigator skills sets be benchmarked against other agencies by an independent body by, for example, inviting the NTSB or commissioning an industry body to conduct such a benchmarking exercise. |
Rec-ID | Code | Recommendation |
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REC233-1599 | 35 - Business and Industry in relation to industry | Providers of personal alert devices consider telecommunications outages in their service continuity plans and provide clear advice to their customers regarding their options during a telecommunications service outage. |
REC233-1604 | 8 - Communications and warnings | Governments and other stakeholders consider reviewing their existing emergency management arrangements to ensure public communications are clear and the public is kept informed of the incident response. |
REC233-1593 | 35 - Business and Industry in relation to industry | Telstra and other service providers to consider improving processes to assist customers with setting up temporary call diversions during future outages. |
REC233-1598 | 35 - Business and Industry in relation to industry | Community service providers consider developing information and advice regarding telecommunications outages for clients managed remotely using telecommunication services, including personal alert devices. |
REC233-1603 | 8 - Communications and warnings | Department of Broadband, Communications and the Digital Economy (DBCDE) to work with the Triple Zero Awareness Work Group through Australian Communications and Media Authority's (ACMA) Emergency Service Advisory Committee to review Triple Zero awareness messages with regard to telecommunications outages. |
REC233-1592 | 8 - Communications and warnings | Department of Broadband, Communications and the Digital Economy will work with the Communications Sector Group within the Trusted Information Sharing Network to develop best practice guidance for owners of critical communications infrastructure regarding public messaging during a prolonged telecommunications outage covering: |
REC233-1597 | 35 - Business and Industry in relation to industry | Community service providers consider updating their business continuity plans to take into account the possibility of a major telecommunications outage involving both fixed and mobile voice and data services. |
REC233-1602 | 28 - Personal responsibility | Individuals without a mobile phone who are concerned about access to Triple Zero during a prolonged telecommunications outage could consider purchasing a low cost mobile phone with a charger to keep at home for use during such outages. Since mobile phones do not require SIM cards to make emergency calls (‘000’ and ‘112’), there will be no ongoing costs. |
REC233-1591 | 35 - Business and Industry in relation to industry | While noting the importance of voice communications, telecommunications providers should consider as part of their mass outage business continuity planning, options for the provision of interim mobile broadband services for the community e.g. local wireless broadband access hubs (i.e. Wi-Fi). |
REC233-1596 | 24 - Govt responsibility | Department of Broadband, Communications and the Digital Economy to review the content of the Government’s digital business website at www.digitalbusiness.gov.au and liaise with the Department of Industry, Innovation, Climate Change, Science, Research and Tertiary Education, which manages the www.business.gov.au, to ensure these business advice sites provide appropriate information regarding business continuity planning in the event of telecommunications outages. |
REC233-1601 | 35 - Business and Industry in relation to industry | Community service providers consider in their business continuity planning how they could assist with facilitating access to telecommunications services for the public during mass outages. |
REC233-1590 | 25 - Inquiry, audit, lessons management and after action review | Department of Broadband, Communications and the Digital Economy seek regular updates from Telstra on the implementation of the recommendations of its inquiry into the Warrnambool exchange fire. |
REC233-1595 | 35 - Business and Industry in relation to industry | Department of Broadband, Communications and the Digital Economy to work with the Trusted Information Sharing Network’s Communications Sector Group to develop general telecommunications continuity advice for businesses and individuals to assist in developing continuity plans. |
REC233-1600 | 35 - Business and Industry in relation to industry | Community service providers consider, in consultation with relevant government authorities, reviewing their current privacy practices concerning personal information about vulnerable persons to ensure they are able to appropriately share information during major disruptive incidents. |
REC233-1594 | 35 - Business and Industry in relation to industry | When businesses review their business continuity plans they should take into account the prospect of a major telecommunications outage that affects both mobile and fixed voice and data services. |
Rec-ID | Code | Recommendation |
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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. |
REC232-2821 | 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. |
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. |
REC232-2820 | 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: |
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: |
REC232-2819 | 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. |
REC232-2826 | 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. |
REC232-2818 | 16 - Training and behaviour | The Royal Australian College of General Practitioners provide resources and training to general practitioners on the complex health needs of migrants and refugees, with a focus on identifying infectious diseases which are notifiable in Australia, or diseases which are of specific concern to refugee and migrant communities. |
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. |
REC232-2817 | 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. |
REC232-2823 | 8 - Communications and warnings | The Australian Government, in consultation with consumers and other relevant federal, state and territory agencies, develop a national communication strategy for consumers to be used in the event of an infectious disease outbreak. |
Rec-ID | Code | Recommendation |
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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. |
REC227-2847 | 15 - Inter-service cooperation | I recommend that Border Protection Command implement a surveillance strategy, possibly with the assistance of other Commonwealth authorities and organisations on the island such as the AFP, which heightens its coverage at times when the weather and sea conditions are rough. |
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. |
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. |
Rec-ID | Code | Recommendation |
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REC215-1874 | 15 - Inter-service cooperation | Fire services can improve outcomes by working with EPA as the regulator and licensing authority to achieve improved compliance with the required outcomes specified in the BPEM guidelines |
REC215-1881 | 35 - Business and Industry in relation to industry | Landfill operators must be encouraged to achieve greater compliance with the required outcomes relating to fire that are set out in the BPEM guidelines, particularly with regard to water supplies |
REC215-1873 | 8 - Communications and warnings | Fire services can improve outcomes by implementing standard procedures that ensure the welfare and safety of crews and the public are not compromised |
REC215-1880 | 24 - Govt responsibility | Regulators can help to achieve improved outcomes by involving fire services in the planning and licensing processes |
REC215-1870 | 12 - EM agency and authority | Fire services can improve outcomes by using a pre-planned response to provide appropriate resources |
REC215-1879 | 25 - Inquiry, audit, lessons management and after action review | Regulators can help to achieve improved outcomes by auditing compliance with the BPEM guidelines on a regular basis |
REC215-1877 | 39 - Disaster Risk Management | Regulators can help to achieve improved outcomes by considering the issues identified by this review |
REC215-1876 | 39 - Disaster Risk Management | Fire services can improve outcomes by initiating discussions with landfill operators about fire management planning and emphasising the critical importance of water supplies and early intervention |
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. |
REC208-0524 | 8 - Communications and warnings | That the Premier issue clear and unambiguous guidelines to all Government Ministers specifying the timing of notifications to the public of any matters that may affect public health or safety. |
Rec-ID | Code | Recommendation |
---|---|---|
REC204-1908 | 39 - Disaster Risk Management | As part of the current revision of its contract template for sponsorship agreements, Tourism WA should ensure that: |
REC204-1914 | 15 - Inter-service cooperation | FESA, WA Police and St John Ambulance establish a uniform protocol for handling multiple agency emergency responses that does not involve callers having to make multiple calls to 000. |
REC204-1913 | 25 - Inquiry, audit, lessons management and after action review | The Department of the Attorney General consider conducting a review of the Civil Liability Act 2002 (WA) in light of the 2011 Kimberley Ultramarathon. Such a review should consider issues such as the effectiveness given to competitor waivers under the Act and the potential difficulties of establishing proceedings and enforcing a judgement against foreign‐based providers of recreational activities. |
REC204-1912 | 38 - Agency/Department Reporting | The Board of Tourism WA should take action to ensure that it reviews the quality of Board papers that are submitted to it by the executive of Tourism WA. |
REC204-1911 | 24 - Govt responsibility | As part of the review of its due diligence processes, Tourism WA should ensure that: |
REC204-1916 | 25 - Inquiry, audit, lessons management and after action review | Local Emergency Management Committee (LEMC) processes should be reviewed to ensure that: |
REC204-1909 | 35 - Business and Industry in relation to industry | Eventscorp should ensure that organisers of events its sponsors are directed to all appropriate authorities and stakeholders to ensure the responsible, safe and efficient planning and conduct of the event. |
REC204-1915 | 24 - Govt responsibility | The Department of Regional Development and Lands should ensure that event organisers and government agencies responsible for sponsoring and approving events have a greater level of awareness about the requirements of section 91 licences under the Land Administration Act 1977 (WA). |
Rec-ID | Code | Recommendation |
---|---|---|
REC198-2904 | 16 - Training and behaviour | The CFA, in collaboration with the other agencies develop a case study of the response to and recovery from the TriTech fire as a training and development opportunity. |
REC198-2903 | 15 - Inter-service cooperation | The CFA works with MFB to ensure that the MFB control unit is available for responding to large fires and multi-agency incidents in fringe CFA areas |
REC198-2901 | 12 - EM agency and authority | The Fire Services Commissioner ensures that policy, operational procedures, systems and training relating to information and warnings that have been applied to bushfires are now also applied to other emergencies. In particular: |
Rec-ID | Code | Recommendation |
---|---|---|
REC197-1749 | 16 - Training and behaviour | The CFA proceed with a review of the Minimum Skills training program. |
REC197-1765 | 16 - Training and behaviour | The CFA continue the development of Vector Command Training and its availability and utilisation by volunteers. The feasibility of this training being provided online be explored by the CFA as part of the consideration of the use of the NBN. |
REC197-1754 | 16 - Training and behaviour | The CFA proceed with the update of facilities and infrastructure at Fiskville to enable its better utilisation by volunteers and employees for training. Where necessary, the Government support this update when determining CFA funding. |
REC197-1771 | 12 - EM agency and authority | The CFA, in consultation with the VFBV and volunteers, develop a comprehensive strategy for the administrative support of volunteer brigades to ensure that such brigades can operate efficiently and effectively. |
REC197-1741 | 9 - Community education | A. The CFA further develop community education programs to specifically engage culturally and linguistically diverse (CALD) communities to address the importance of ethnic diversity. |
REC197-1759 | 12 - EM agency and authority | The CFA continue its consultations with the UFU to establish a satisfactory and workable process for the use of sessional instructors. |
REC197-1748 | 16 - Training and behaviour | The CFA establish forward strategic planning initiatives for training with resource allocation covering short term, mid term, and long term. |
REC197-1764 | 16 - Training and behaviour | A. The CFA, in consultation with volunteers, employees, the VFBV and the UFU, examine the feasibility of utilising the TAFE system for training delivery. |
REC197-1753 | 16 - Training and behaviour | The CFA continue the Mobile Training Infrastructure Project and the Fixed Training Infrastructure Project. Where necessary, the Government support these initiatives in determining CFA funding. |
REC197-1769 | 12 - EM agency and authority | The CFA, in consultation with the VFBV and volunteers, explore and develop initiatives whereby qualified volunteers may be more utilised in Incident Management Teams. |
REC197-1738 | 12 - EM agency and authority | A. The CFA, in consultation with its volunteers and employees, determine and adopt a statement of Vision, Mission and Values. |
REC197-1758 | 12 - EM agency and authority | The CFA revisit with the UFU the arrangements contained in industrial agreements relating to the engagement of instructors with a view to increasing the ability and flexibility of the CFA to fill instructor positions and thereby ensure maximum training capacity to the benefit of CFA members, both volunteer and paid. |
REC197-1747 | 16 - Training and behaviour | The CFA, in consultation with the VFBV and volunteers, review its arrangements with respect to First Aid training and maintenance of currency of qualifications, with a view to the delivery of such training and maintenance best meeting brigade needs. |
REC197-1763 | 16 - Training and behaviour | The CFA, in consultation with the VFBV and volunteers, review the process for RCC and RPL with the view to making that process transparent, efficient and fair. |
REC197-1752 | 16 - Training and behaviour | The CFA take initiatives to improve the accessibility of Field Training Grounds, including Fiskville, to volunteers for training. |
REC197-1768 | 16 - Training and behaviour | The CFA, in consultation with the VFBV and volunteers, explore and develop initiatives whereby more volunteers are qualified to participate in Incident Management Teams. |
REC197-1737 | 12 - EM agency and authority | A. The CFA, in consultation with employers and volunteers, explore the establishment of employer consultation and support mechanisms along the lines of those developed by the Australian Defence Force. |
REC197-1757 | 16 - Training and behaviour | The CFA, in consultation with the VFBV and volunteers, examine options to enable the engagement of an adequate instructor strength to serve the training needs of volunteers. Those options should include making more use of volunteers as instructors. |
REC197-1746 | 12 - EM agency and authority | The CFA revisit with the UFU the arrangements relating to the employment of part‐time and casual employees. |
REC197-1762 | 16 - Training and behaviour | The CFA provide greater opportunities for leadership training for volunteers at all levels but particularly at the brigade level. The CFA, as far as practicable, endeavour to ensure that persons appointed to positions of leadership have the necessary capability. |
REC197-1751 | 16 - Training and behaviour | The CFA ensure that there is transparency with respect to training budgets and, in particular, with respect to what relates to volunteer training and what relates to career staff training. |
REC197-1767 | 16 - Training and behaviour | Consideration be given to the establishment of a dedicated CFA training academy. |
REC197-1736 | 12 - EM agency and authority | The CFA and the Chief Officer continue to develop the initiatives outlined in relation to service delivery and standards, decision‐making and allocation of resources. |
REC197-1756 | 16 - Training and behaviour | CFA develop an individual training pathway for operational volunteers to enable volunteers to be able to better identify their career and training options and pursue a pathway that meets their expectation. |
REC197-1773 | 12 - EM agency and authority | The CFA continue, in consultation with volunteers, paid personnel and their representatives, its review of disciplinary arrangements and as part of that review consider the concept of the establishment of a Volunteer Ombudsman. |
REC197-1744 | 12 - EM agency and authority | The CFA revisit with the UFU the arrangements relating to lateral entry and secondment. |
REC197-1761 | 16 - Training and behaviour | The CFA continue the development of key principles in relation to training, in consultation with volunteers and paid personnel. In the development of those principles, account should be taken of matters raised by volunteers to this Inquiry and the comments that I have made about training delivery. Account should also be taken of principles contained in any statement of Vision, Mission and Values adopted by the CFA. |
REC197-1750 | 16 - Training and behaviour | The CFA ensure that there is transparency with respect to the identification and meeting of training demand, and plans to meet such demand. |
REC197-1766 | 12 - EM agency and authority | The CFA as part of any examination of the utilisation of the NBN give priority to the establishment of internet access for brigades. |
REC197-1733 | 25 - Inquiry, audit, lessons management and after action review | That a review of the Country Fire Authority Act 1958 and the Country Fire Authority Regulations 2004 be undertaken. |
REC197-1755 | 16 - Training and behaviour | The CFA examine options to enable sufficient training materials to be available to ensure effective training delivery. As part of this examination, the CFA explore the feasibility of utilising the TAFE system. |
REC197-1772 | 12 - EM agency and authority | The CFA, in relation to developing any process for brigade support or career structure or position description for Brigade Administrative Support Officers, as referred to in Clause 8 of the 2010 Deed, consult with the VFBV and volunteers before reaching any decision on those matters. |
REC197-1743 | 12 - EM agency and authority | The CFA revisit with the UFU the arrangement relating to the recruitment of volunteer firefighters as an employee. |
REC197-1760 | 12 - EM agency and authority | The CFA continue with its initiatives to implement the Garnock Report, keeping volunteers and paid personnel fully informed of progress and consulting with them in relation to the implementation. This implementation should be given priority, having regard to its importance. |
Rec-ID | Code | Recommendation |
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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. |
REC189-2913 | 21 - Role of Commonwealth Government | In developing and improving its policies and practices for stakeholder engagement, NOPSA should ensure that: |
Rec-ID | Code | Recommendation |
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REC166-3009 | 25 - Inquiry, audit, lessons management and after action review | That the Tasmania Fire Service conduct an audit of all shopping centres to ensure that there exists within those centres adequate fire protection and evacuation systems. |
REC166-3007 | 15 - Inter-service cooperation | That Tasmania Fire Service implement Recommendation 5 above; and that Aurora continue to co-operate with that Service. |
REC166-3003 | 12 - EM agency and authority | That the Tasmania Fire Service provide additional training in power disconnection and improvements in communication between Tasmania Fire Service and Aurora: |
REC166-3002 | 16 - Training and behaviour | That the Tasmania Fire Service provide additional training in the use of thermal camera imaging: |
REC166-3001 | 16 - Training and behaviour | That the Tasmania Fire Service provide further training in respect to sprinkler systems, namely: |
REC166-2999 | 35 - Business and Industry in relation to industry | That Aurora ensure that regular audits are conducted of all electrical systems of all commercial buildings to confirm that they comply with modern standards. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC158-3447 | 15 - Inter-service cooperation | That emergency services are required to work directly with port/channel managers and the nominated marine safety authority to ensure that a training and exercise regime is established to enable emergency services personnel to develop and maintain the skills and knowledge relevant to marine emergency management. |
REC158-3433 | 24 - Govt responsibility | That Harbour Masters are employed by a government body and remain geographically located at the port. |
REC158-3446 | 15 - Inter-service cooperation | That emergency services are required to work directly with port/channel managers and the nominated marine safety authority to identify and ensure availability of marine resources necessary for emergency services to meet their statutory obligations in responding to marine emergencies (this recommendation should be read in conjunction with recommendation 26 & 27). |
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. |
REC158-3445 | 15 - Inter-service cooperation | That emergency services are required to work directly with ports and the nominated marine safety authority when ports are preparing marine 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. |
REC158-3428 | 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. |
REC158-3444 | 15 - Inter-service cooperation | That the Office of the Emergency Services Commissioner ensures that an emergency services multi-agency working group is established to develop a specialist marine emergency response capability for Victoria based on the multi-agency Urban Search and Rescue (USAR) model. The specialist personnel should be required to have: |
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. |
REC158-3443 | 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. |
REC158-3448 | 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. |
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 |
---|---|---|
REC149-3136 | 16 - Training and behaviour | There is a need for industry in consultation with NOPSA to establish a priority programme of accredited education modules in the Safety Case regime targeting stakeholders in the regime at their respective levels to improve the understanding of the Safety Case and correspondent 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. |
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. |
REC149-3142 | 19 - Offences | NOPSA should use encouragement as the primary tool of enforcing compliance provided willingness to improve is exhibited by the players. |
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. |
REC149-3139 | 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. |
REC149-3131 | 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. |
REC149-3138 | 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. |
REC149-3137 | 16 - Training and behaviour | As professional competency is one of the key pillars of any Safety Case, commitment to training for current and future needs remains a fundamental requirement for achieving best practice outcomes in safety. Industry should be encouraged to build on its training commitment now being made to achieve a competent and fully accredited workforce over the next five years. |
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. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC148-3177 | 12 - EM agency and authority | That the officer responsible for the importation of horses ensure that: |
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. |
REC148-3175 | 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. |
REC148-3152 | 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. |
REC148-3170 | 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: |
REC148-3182 | 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. |
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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC137-3532 | 16 - Training and behaviour | I recommend that CASA reconsider the introduction of measures to ensure the efficiency of training and checking organisations for air transport operations. I recommend that this include the way in which particular training needs of an air operator’s flight crew are to be identified (including recurrent training and CRM training) and how those needs are to be met by approved or certified training and checking organisations. |
REC137-3530 | 16 - Training and behaviour | I recommend that Civil Aviation Safety Authority (CASA) expedite the introduction of mandatory crew resource management training. |
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 |
---|---|---|
REC129-3625 | 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. |
REC129-3622 | 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. |
REC129-3629 | 8 - Communications and warnings | We recommend that NSW Health continue with its good work and continue to improve communication mechanisms with those, such as GPs, likely to be affected in major infectious disease outbreaks. |
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. |
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. |
REC128-3606 | 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. |
REC128-3612 | 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. |
REC128-3605 | 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. |
REC128-3611 | 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. |
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. |
REC128-3609 | 16 - Training and behaviour | That the Department of Primary Industries be conscious of its responsibilities in maintaining the continued enthusiasm of Industry Liaison Officers and offer training and refresher training as required. |
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. |
REC128-3608 | 16 - Training and behaviour | That emergency animal health training be included in induction programs for newly recruited District Veterinarians and all District Veterinarians be encouraged to maintain their skills by attending regular refresher training as appropriate. |
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. |
REC128-3600 | 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. |
REC128-3607 | 16 - Training and behaviour | That the Department of Primary Industries should continue efforts to develop the skills of private sector veterinarians to increase the level of resources available in emergency responses. |
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. |
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. |
REC121-3670 | 16 - Training and behaviour | The RailCorp emergency response plan should be provided to all emergency response agencies. The officers of each emergency service should be trained in any rail specific features of the plan, so as to better ensure inter-agency co-ordination in the circumstances of an emergency. |
REC121-3710 | 39 - Disaster Risk Management | The ITSRR should have permanent access to the RailCorp intranet. |
REC121-3744 | 16 - Training and behaviour | All RailCorp operational personnel should be trained in the location and operation of external emergency door release mechanisms. |
REC121-3683 | 39 - Disaster Risk Management | RailCorp should undertake risk assessments of each of its activities as follows: |
REC121-3716 | 16 - Training and behaviour | Train driver and guard training should encourage teamwork and discourage authority gradients. |
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. |
REC121-3694 | 25 - Inquiry, audit, lessons management and after action review | The ITSRR should conduct random audits of accredited rail organisations for compliance with communications protocols. |
REC121-3721 | 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. |
REC121-3766 | 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. |
REC121-3669 | 16 - Training and behaviour | All operational rail staff should be trained by RailCorp in the action check list relevant to each. |
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. |
REC121-3742 | 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. |
REC121-3776 | 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. |
REC121-3678 | 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. |
REC121-3715 | 16 - Training and behaviour | RailCorp should use its simulators to train drivers and guards in methods of dealing with degraded operations on the rail network. |
REC121-3752 | 12 - EM agency and authority | RailCorp should establish clear safety accountability statements and reporting lines for all management positions. |
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. |
REC121-3720 | 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. |
REC121-3765 | 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. |
REC121-3658 | 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. |
REC121-3704 | 28 - Personal responsibility | RailCorp should continue its system of voluntary self-identification and rehabilitation of employees with alcohol or drug related problems. |
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. |
REC121-3775 | 38 - Agency/Department Reporting | The Minister for Transport Services must table in Parliament, each such quarterly report by ITSRR. |
REC121-3677 | 16 - Training and behaviour | A training centre for emergency services personnel should be established by RailCorp. The emergency services personnel should be required to undertake training at such a centre, which should be equipped with features replicating railway infrastructure and rolling stock. |
REC121-3714 | 16 - Training and behaviour | RailCorp should use its simulators in an interactive manner. |
REC121-3751 | 16 - Training and behaviour | RailCorp should make it a condition of employment that all level 2 managers have or obtain a formal qualification in system safety management. |
REC121-3691 | 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. |
REC121-3719 | 16 - Training and behaviour | The position of team leader should be created by RailCorp to be responsible for a group of approximately 30 train drivers, with responsibility to ensure that each train driver’s training needs are being met and that any safety concerns of train drivers are being properly addressed. The team leaders are to have direct access to the Chief Executive of RailCorp if any safety concerns they have are not addressed. |
REC121-3758 | 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. |
REC121-3654 | 16 - Training and behaviour | All train guards should be trained by RailCorp in the use of the Metronet radio and instructed to use it in any emergency. |
REC121-3700 | 39 - Disaster Risk Management | Maintenance plans on all trains should be revised annually. |
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. |
REC121-3774 | 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: |
REC121-3675 | 16 - Training and behaviour | All rail employees should be trained by their employer to commence any emergency communication with the words “Emergency, emergency, emergency”, thereafter to identify themselves, the train, its location, what has occurred, the approximate passenger load and whether death or injuries have occurred. |
REC121-3713 | 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. |
REC121-3689 | 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. |
REC121-3718 | 16 - Training and behaviour | Training should be based upon a needs analysis, to determine what skills a particular person will require to carry out the tasks of any position safely and efficiently, and instruction and practice, to acquire and demonstrate those skills. |
REC121-3757 | 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. |
REC121-3650 | 16 - Training and behaviour | Staff at the Rail Management Centre (RMC) should receive training from RailCorp to enable them to quickly and accurately assess that an emergency has occurred and to provide precise and reliable information to emergency response personnel about the location of the emergency, the available access to the site and the resources necessary. |
REC121-3700 | 12 - EM agency and authority | The RailCorp defects unit should be combined with the passenger fleet maintenance division of RailCorp. |
REC121-3723 | 38 - Agency/Department Reporting | All ATSB accident investigation reports should be made public. |
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. |
REC121-3672 | 16 - Training and behaviour | All emergency response personnel should be specifically trained in the features of railways which are relevant to their work, such as the location and means of operation of all emergency door releases on trains, the location and use of signal telephones, the methods by which electrical power can be isolated and the means by which they can readily identify and obtain information from the on-site rail commander. |
REC121-3712 | 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. |
REC121-3746 | 16 - Training and behaviour | All emergency services personnel should be trained in the location and operation of emergency door release mechanisms on all rail cars. |
REC121-3684 | 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. |
REC121-3717 | 16 - Training and behaviour | RailCorp must establish a task analysis for particular categories of employees, to identify the specific skills and responsibility of those employees or groups of employees, and thereafter undertake a training needs analysis, to develop the skills required in particular areas. |
REC121-3756 | 16 - Training and behaviour | RailCorp should ensure that where the safety competency of any manager is deficient such manager is required to undertake professional development courses to raise his or her safety competency level to an adequate standard. |
REC121-3697 | 38 - Agency/Department Reporting | All train drivers’ defects reports should be entered by RailCorp into a computerised record and tracked to finalisation. |
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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC112-3923 | 12 - EM agency and authority | That DPI negotiates access, as and when required, to an AQIS PC4- accredited laboratory. |
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. |
REC112-3932 | 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. |
REC112-3916 | 16 - Training and behaviour | That DPI reviews the work of entry level graduates to ensure career paths are clear and encourage the retention of staff. |
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. |
REC112-3909 | 12 - EM agency and authority | That PSB’s enforcement procedures are consistent with those of the rest of the department. |
REC112-3931 | 16 - Training and behaviour | That DPI ensures that AIIMS training includes information to ensure that everyone understands their role, and how information will be managed internally and externally, in the event of an incursion. |
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. |
REC112-3920 | 15 - Inter-service cooperation | That better use be made of Primary Industries Research Victoria's (PIRVIC) facilities by strengthening links with relevant groups of expertise, such as the Forest Science Centre. |
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. |
REC112-3930 | 16 - Training and behaviour | That DPI provides plant incursion-specific AIIMS training for anyone who might be involved in, or providing resources for, an incursion response. This includes senior management, field and research staff, contractors and industry participants. |
REC112-3914 | 12 - EM agency and authority | That DPI develops a consistent approach to recording and enforcing breaches of the certification and verification system. |
REC112-3919 | 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. |
REC112-3929 | 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. |
REC112-3918 | 35 - Business and Industry in relation to industry | That DPI effectively communicates to all sectors of the industry their responsibilities to report new threats, and how to report them. |
REC112-3928 | 3 - Biodiversity | That DPI formalises agreements within the Regional Services and Agriculture Division to ensure that plant health information is included in extension programs. |
REC112-3912 | 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. |
REC112-3933 | 15 - Inter-service cooperation | That DPI formalises agreements between divisions and groups that allow staff to be involved in incursion responses and reflects this requirement in individual duty statements. |
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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC061-3411 | 12 - EM agency and authority | The Committee recommends that collocation shall occur unless it can be demonstrated to the satisfaction of the Minister that it is inappropriate. |
REC061-3421 | 12 - EM agency and authority | The Committee recommends that a new Board be appointed, consisting of nine members nominated by the Minister for Police and Emergency Services and including the Chief Executive Officer who shall not be Chairman. |
REC061-3246 | 38 - Agency/Department Reporting | The Committee recommends that performance monitoring standards be established, reviewed and maintained through a common reporting system by the Minister for Police and Emergency Services. |
REC061-3256 | 12 - EM agency and authority | The Committee recommends that a new Board be appointed, consisting of nine members nominated by the Minister for Police and Emergency Services and including the Chief Executive Officer who shall not be Chairman. |
REC061-3409 | 12 - EM agency and authority | The Committee recommends that one standard model of fire cover be developed for Victoria as a matter of urgency. |
REC061-3420 | 12 - EM agency and authority | The Committee recommends that the Metropolitan Fire Brigades Board remain a statutory authority. |
REC061-3245 | 12 - EM agency and authority | The Committee recommends that collocation shall occur unless it can be demonstrated to the satisfaction of the Minister that it is inappropriate. |
REC061-3255 | 12 - EM agency and authority | The Committee recommends that the Metropolitan Fire Brigades Board remain a statutory authority. |
REC061-3408 | 24 - Govt responsibility | It is inappropriate for an emergency services provider to develop its own standards, core objectives and functions. The Committee recommends that these be the responsibility of the Minister for Police and Emergency Services. |
REC061-3419 | 12 - EM agency and authority | The Committee recommends that: |
REC061-3243 | 12 - EM agency and authority | The Committee recommends that one standard model of fire cover be developed for Victoria as a matter of urgency. |
REC061-3254 | 12 - EM agency and authority | The Committee recommends that: |
REC061-3407 | 12 - EM agency and authority | The Committee recommends that the Metropolitan Fire Brigades Board continue to exist. |
REC061-3415 | 24 - Govt responsibility | The Committee recommends that the Bureau of Emergency Services Telecommunications Centre extend its services as a commercial venture to smaller government agencies who could not develop such a dedicated system. |
REC061-3242 | 24 - Govt responsibility | It is inappropriate for an emergency services provider to develop its own standards, core objectives and functions. The Committee recommends that these be the responsibility of the Minister for Police and Emergency Services. |
REC061-3423 | 25 - Inquiry, audit, lessons management and after action review | The Committee recommends that the Metropolitan Fire Brigades Board be reviewed five years from the tabling of this report in Parliament. |
REC061-3250 | 24 - Govt responsibility | The Committee recommends that the Bureau of Emergency Services Telecommunications Centre extend its services as a commercial venture to smaller government agencies who could not develop such a dedicated system. |
REC061-3258 | 25 - Inquiry, audit, lessons management and after action review | The Committee recommends that the Metropolitan Fire Brigades Board be reviewed five years from the tabling of this report in Parliament. |
REC061-3241 | 12 - EM agency and authority | The Committee recommends that the Metropolitan Fire Brigades Board continue to exist. |
REC061-3413 | 15 - Inter-service cooperation | The Committee recommends to the Minister for Police and Emergency Services that a joint communications and dispatch facility be established under the Minister's control to implement the following minimum services to the Victoria Police and the emergency services: |
REC061-3422 | 9 - Community education | The Committee recommends that the FireVision concept used by the Metropolitan Fire Brigades Board be extended through the Directorate of School Education's Interactive Television Program to all emergency services and in particular to rural fire and emergency services. |
REC061-3248 | 15 - Inter-service cooperation | The Committee recommends to the Minister for Police and Emergency Services that a joint communications and dispatch facility be established under the Minister's control to implement the following minimum services to the Victoria Police and the emergency services: |
REC061-3257 | 9 - Community education | The Committee recommends that the FireVision concept used by the Metropolitan Fire Brigades Board be extended through the Directorate of School Education's Interactive Television Program to all emergency services and in particular to rural fire and emergency services. |
Rec-ID | Code | Recommendation |
---|---|---|
REC008-3984 | 16 - Training and behaviour | The Commission recommends that the live parts of resistances should be fixed so that no unprotected combustible material is within 6ins of the frames or cases containing them or within 24ins measured vertically above. |
REC008-3990 | 16 - Training and behaviour | The Commission recommends that more than one means of exit should be provided in every mine from every level of it to the surface; and that the miners should be kept informed where they are situated. |
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. |