Inquiry Search
Rec-ID | Code | Recommendation |
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REC314-3273 | 26 - Research | Collate data and research the impact of bushfires upon communities, firefighters and animals (both native and domestic) to identify appropriate medium and long-term welfare and support requirements. |
Rec-ID | Code | Recommendation |
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REC302-2393 | 15 - Inter-service cooperation | In recognising the success of the work of both the volunteer based Rural Fire Service and the full time Fire and Rescue NSW (FRNSW) members in joint operations – both agencies should be represented at major briefings or press conferences to reinforce successful integrated collaborative efforts rather than individual agency achievements |
REC302-2400 | 15 - Inter-service cooperation | Until a single call centre is developed, continue deployments of a senior RFS officer to Fire and Rescue NSW ComCen on a 24/7 day basis. This arrangement should determine the quickest most suitable resource and who is ‘in charge’ of an incident |
REC302-2396 | 15 - Inter-service cooperation | The Commissioners of Fire and Rescue NSW (FRNSW) and the RFS issue an instruction to FRNSW ComCen that while AVL capability is being made available to the RFS vehicle fleet, no offers of assistance by one agency to the other in combatting a fire is rejected or delayed if what is being offered is appropriate |
REC302-2394 | 15 - Inter-service cooperation | Take immediate steps to eliminate fire boundaries for call and dispatch purposes to create an agnostic approach to the threat of fires from both a departmental and organisational perspective |
Rec-ID | Code | Recommendation |
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REC301-2383 | 15 - Inter-service cooperation | Tasmanian Fire Service (TFS), Tasmanian Parks and Wildlife Service (PWS) and Sustainable Timber Tasmania (STT) initiate a discussion among their Australasian peers about good practice around managing new fire starts in remote terrain, to include issues around identification, predictive analysis, risk management and suppression activities. The outcome should be a document which allows for benchmarking to accepted good practice across Australasia, from which Tasmanian fire agencies can develop protocols against which the management of future events can be tested. |
REC301-2392 | 39 - Disaster Risk Management | TFS should engage in discussions with government about the construction of purpose-built State Control Centre facilities for emergency management in Tasmania. |
REC301-2388 | 15 - Inter-service cooperation | TFS, PWS and STT should establish a State Air Desk, to be staffed by specialist staff year-round, with responsibility for managing both preparatory and contractual issues out of season as well as aircraft management when fires or other emergency events are occurring. |
REC301-2386 | 15 - Inter-service cooperation | TFS, PWS and STT should work with government and each other to continue to pursue a whole-of-state fuel management and burning program that encompasses all land tenures, meets the range of outcomes required by the state (township protection, risk reduction and landscape-scale burns) and is inclusive of private landholders and local communities as well as all fire agencies. |
REC301-2385 | 25 - Inquiry, audit, lessons management and after action review | TFS should initiate a policy review (seeking support from government as appropriate) to clearly identify what body or agency is responsible for planning, carrying out and enforcing fuel management on private property at a township level. If current arrangements are unclear or ineffective, TFS should request government to consider making this a statutory responsibility of TFS and provide any additional funding required to support this function. |
Rec-ID | Code | Recommendation |
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REC291-1233 | 25 - Inquiry, audit, lessons management and after action review | The State Government to explore options for streamlining the functions and the independence of the State Emergency Management Committee Secretariat and the Office of Bushfire Risk Management with a view to including an inspectorate function, and appointing a person who is dedicated to that role. The purpose is to provide assurance and reporting, and to inquire into, monitor and report transparently on emergency management standards, preparedness, capability, service delivery and investment performance outcomes. Within two years of the establishment of this arrangement the State Government to review and assess whether it is meeting the desired outcomes. |
REC291-1249 | 25 - Inquiry, audit, lessons management and after action review | The Department of the Premier and Cabinet to conduct an independent review of the current arrangement for the management and distribution of the Emergency Services Levy. The review will have the specific purpose of: · seeking input from key entities including the Departments of Treasury, Finance, Fire and Emergency Services, Lands, and Parks and Wildlife, WA Local Government Association, and the Office of Bushfire Risk Management. · ensuring the arrangement has the flexibility and agility to deal with emerging bushfire risk priorities. · establishing a budget process that enables a shift in investment towards prevention, mitigation and building community resilience and capability. |
REC291-1242 | 15 - Inter-service cooperation | The Departments of Fire and Emergency Services and Parks and Wildlife to investigate and adopt an emergency services resource management system that will enable the registration, tasking, tracking, management and coordination of emergency management personnel, vehicles, plant and aircraft. |
Rec-ID | Code | Recommendation |
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REC287-1188 | 25 - Inquiry, audit, lessons management and after action review | The Tasmanian fire agencies commission a review into the efectiveness of aerial firefghting in the 2016 fires, in order to better understand and to document for future reference the cost-efectiveness of specifc fire suppression strategies and tactics in different vegetation types. The Review should include a comparative analysis of fire suppression options whether aerial or ground-based. |
REC287-1185 | 25 - Inquiry, audit, lessons management and after action review | The Tasmanian fire agencies take steps at a national level to share learnings from the 2016 fires about the administration of interstate assistance and support the codifcation of the workings, structure and reporting lines of an Interstate and International Liaison Unit for future complex deployments within Australia and New Zealand. |
REC287-1180 | 15 - Inter-service cooperation | The Tasmanian fire agencies consider the development of fire operational guidelines to avoid long-term environmental impacts such as: • • • strategies and tactics that will minimise the impact of fire management activities conditions under which earthmoving equipment and fire chemicals may be used information on seasonal conditions and the times of year when various strategies and tactics should be applied, and fuel management strategies. |
REC287-1179 | 15 - Inter-service cooperation | The Tasmanian fire agencies develop a joint multi-agency Fire Preparedness Matrix to guide decision-making in response to severe fire weather conditions or capacity issues. |
Rec-ID | Code | Recommendation |
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REC273-1131 | 15 - Inter-service cooperation | That the Emergency Management Australia’s ‘Arrangements for Interstate Assistance (Fire and Emergency Services)’ be applied to all future requests for assistance by the SACFS, SAMFS and SASES. |
REC273-1132 | 15 - Inter-service cooperation | Noting the implementation of Common Incident Command and Control System (CICCS) in SA that fire and emergency services together with police (including through AFAC and ANZPAA), continue to liaise regarding the development of a national incident management. |
Rec-ID | Code | Recommendation |
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REC264-1072 | 25 - Inquiry, audit, lessons management and after action review | The State empower and require the Auditor-General or another appropriate agency, to: • oversee the implementation of these recommendations and the commitments made by the State and GDF Suez during this Inquiry; and • report publicly every year for the next three years on the progress made in implementing recommendations and commitments. |
REC264-1087 | 25 - Inquiry, audit, lessons management and after action review | GDF Suez: • practice and ensures that, by taking a risk management approach, it is suitable for fire prevention, mitigation and suppression in all parts of the Hazelwood mine; and review its ‘Mine Fire Service Policy and Code of Practice’ so that it refects industry best • work plan for the Hazelwood mine. incorporate the revised ‘Mine Fire Service Policy and Code of Practice’ into the approved |
REC264-1086 | 25 - Inquiry, audit, lessons management and after action review | GDF Suez: • consequences of fire in the worked out areas of the Hazelwood mine, and an assessment of the most effective fre protection for the exposed coal surfaces; conduct, assisted by an independent consultant, a risk assessment of the likelihood and • controls are in place to eliminate or reduce the risk of fre; and prepare an implementation plan that ensures the most effective and reasonably practicable • implement the plan |
REC264-1081 | 26 - Research | The State should continue the long-term health study, and: • extend the study to at least 20 years; • appoint an independent board, which includes Latrobe Valley community representatives, to govern the study; and • direct that the independent board publish regular progress reports |
REC264-1073 | 15 - Inter-service cooperation | The State establish, for any future incident, integrated incident management teams with GDF Suez and other Victorian essential industry providers, to: • essential industry providers; and require that emergency services personnel work with GDF Suez and other appropriate • implement the Australasian Inter-service Incident Management System. |
Rec-ID | Code | Recommendation |
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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. |
REC258-2528 | 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. |
REC258-2556 | 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. |
REC258-2552 | 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. |
REC258-2551 | 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. |
Rec-ID | Code | Recommendation |
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REC257-1546 | 25 - Inquiry, audit, lessons management and after action review | Defence undertake a review of its ability to respond to a fire within Marrangaroo Training Area, whether bushfire or structural. The underlying assumption should be that the only response available to fight a fire within Marrangaroo Training Area will be provided by Defence. Further, such response must occur while a fire is in its initial stages. A review must either acknowledge the risk of fire occurring in th future, or upgrade Defence's firefighting capability at Marrangaroo Training Area. |
REC257-1545 | 15 - Inter-service cooperation | Range Control Officer Marrangaroo Training Area liase with the local Rural Fire Service units to develop a map indicating the areas of the range likely to contain unexploded ordnance. |
REC257-1539 | 25 - Inquiry, audit, lessons management and after action review | Defence Security Authority conduct an investigation into the whereabouts of items of anaccounted explosive ordnance issued to Defence Explosive Ordnance Training School Exercise Marrangaroo. |
REC257-1548 | 25 - Inquiry, audit, lessons management and after action review | The Regional Director-Defence Support-Northern NSW, make contact with Deputy Commissioner ~~~~~ Director of Operational Services Rural Fire Service, to arrange a headquarters driven bipartite review of the events of 16 October 2013 with a review to mitigation of future fire events generally, and with specific reference to: |
REC257-1547 | 15 - Inter-service cooperation | The Marrangaroo Training Area Regional Environmental Officer confer with the local Rural Fire Service at least annually and determine a hazard reduction regime capable of implementation. It is furter recommended all ranges be reviewed in relation to the same issue, that is, that personnel involved in the management of each range under Defence control be directed to confer with local firefighting authorities on at least an annual basis to assess hazard reduction responses to be pursued for that range in subsequent years. |
Rec-ID | Code | Recommendation |
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REC247-0926 | 25 - Inquiry, audit, lessons management and after action review | That membership of the State Emergency Management Committee, and other processes to link in appropriate agencies and organisations to emergency management, be included in the recommended review of the emergency management arrangements. |
REC247-0866 | 26 - Research | That fire agencies continue to develop their predictive modelling capability for use in actively managing fires. |
REC247-0923 | 25 - Inquiry, audit, lessons management and after action review | That a process be established for the timely implementation of approved recommendations from the 2009 Victorian Bushfires Royal Commission. |
REC247-0951 | 25 - Inquiry, audit, lessons management and after action review | That an independent means of monitoring and reporting on the implementation of approved recommendations is established. |
REC247-0854 | 15 - Inter-service cooperation | That in multi-agency response and recovery operations, arrangements be made so it is unambiguous who is in charge of these operations. |
REC247-0921 | 26 - Research | That Tasmania Fire Service promotes a structured approach to research across Australia, to provide a shared understanding and the capacity to benchmark and judge performance. |
REC247-0948 | 15 - Inter-service cooperation | That the Department of Justice conduct an independent review to develop a suitable model for integrated and interoperable emergency management arrangements in Tasmania. |
REC247-0849 | 26 - Research | That Tasmania Fire Service supports the relevant authorities to continue developing methodologies to forecast and simulate fire risk. |
REC247-0909 | 25 - Inquiry, audit, lessons management and after action review | That the plans for social recovery be reviewed, and plans and procedures are established ready for implementation. |
REC247-0941 | 25 - Inquiry, audit, lessons management and after action review | That the Strategic Fuel Management Plan includes measurable targets and they are actively monitored and reported on to the community. |
REC247-0903 | 25 - Inquiry, audit, lessons management and after action review | That the role of Red Cross in emergency management plans and procedures for the activation of Red Cross be reviewed. |
REC247-0927 | 25 - Inquiry, audit, lessons management and after action review | That an accountability process be established for managing improvement in the emergency management arrangements, including annual State of Readiness Reports by relevant departments and agencies and on the overall emergency management arrangements. |
REC247-0873 | 25 - Inquiry, audit, lessons management and after action review | If it is considered more information is required on action to suppress the fires in Dunalley and why fire operations did not continue, the Department of Justice should conduct an independent examination of this matter. |
Rec-ID | Code | Recommendation |
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REC223-0523 | 25 - Inquiry, audit, lessons management and after action review | The Government consider enacting legislation to facilitate the review of all future major incidents, including but not limited to fire, earthquake, storm and marine inundation, and the emergency response to them. |
REC223-0522 | 25 - Inquiry, audit, lessons management and after action review | The response operation to the Margaret River bushfire in November 2011 be the subject of a review with independent oversight. |
REC223-0517 | 26 - Research | The Department of Environment and Conservation be supported to conduct further research into the fuel management of coastal heath in the south west of Western Australia exploring alternatives to burning as well as best practice for burning. |
REC223-0516 | 25 - Inquiry, audit, lessons management and after action review | The Department of Environment and Conservation review its implementation of the findings of the Ferguson Review conducted in 2010. |
Rec-ID | Code | Recommendation |
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REC201-0260 | 15 - Inter-service cooperation | There are a range of opportunities identified from reviewing the three fires that will improve coordination between FESA and DEC, requiring limited resources, potentially generating some efficiencies and reflecting a joint, tenure blind approach to fire management in WA. The MIR acknowledges the progress made through the IBMC in these matters and notes these measures will require ongoing strong leadership. These include: · Clarification and consistent application of the Zone 2 and 2A mobilisation protocols; · Duplicating available information on websites; · Establishing a single State air desk and cross-utilising Air Attack Supervisors; · Completing common training for the conduct of public meetings;· Coordinating IMT training and exercises; · Operating joint IMT‘s during interface fires; FESA utilising the DEC mobile ICC when suitable ICPs are not available; · FESA engaging in daily weather teleconferences with DEC; Engaging a permanent BoM officer to support a common FESA and DEC SOC; · Developing a common ‗Tool Box‘ of forms and operational procedures for fire response; · Developing common jurisdictional arrangements to accommodate interstate support; · Developing a joint FESA/DEC SOC at the new (FESA) Emergency Services facility at Cockburn; · Adopting common and transparent Level 3 IC accreditation · Using a single mapping capability across both agencies and · Using common naming conventions for fires. |
Rec-ID | Code | Recommendation |
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REC200-0338 | 15 - Inter-service cooperation | The Fire and Emergency Services Authority and the Department of Environment and Conservation develop and finalise their Memorandum of Understanding and commit to working in partnership. |
REC200-1697 | 26 - Research | The Fire and Emergency Services Authority, the Department of Environment and Conservation and local governments closely monitor the research and development of alternative fuel reduction techniques to ensure that the most efficient and effective programs are adopted. |
REC200-0392 | 25 - Inquiry, audit, lessons management and after action review | The State Government review implementation of the Special Inquiry’s Recommendations in two years. |
REC200-1732 | 25 - Inquiry, audit, lessons management and after action review | The State Government review implementation of the Special Inquiry's recommendations in two years. |
REC200-1680 | 15 - Inter-service cooperation | Emergency Management Western Australia establish an inter-agency working group to continue the development of the new single emergency services Act. |
REC200-0386 | 15 - Inter-service cooperation | Emergency service agencies undertake more consultation and joint exercising involving the Fire and Emergency Services Authority, the Department of Environment, the Western Australian Police, the Department for Child Protection, local governments and volunteers – including Volunteer Bush Fire Brigades. This should include field exercises which test: Evacuation centres Critical infrastructure (including at the local level) Traffic management, including road blocks. Consideration should also be given to involving the community in exercising (see Recommendation 7) and using prescribed burns as exercises (see Recommendation 14) More detailed planning for exercises should be included in a revised WESTPLANBUSHFIRE to be endorsed by the State Emergency Management Committee. |
REC200-1722 | 39 - Disaster Risk Management | Emergency Management Western Australia and the State Emergency Management Committee amend WESTPLAN-BUSHFIRE to require State Emergency Coordination Group meetings to be held at the State Coordination Centre in West Leederville. |
REC200-1679 | 15 - Inter-service cooperation | The Fire and Emergency Services Authority and the Department of Environment and Conservation develop and finalise their Memorandum of Understanding and commit to working in partnership. |
REC200-0384 | 25 - Inquiry, audit, lessons management and after action review | Emergency Management Western Australia develop mechanisms to calculate the estimated total cost of a fire to the community. |
REC200-1708 | 15 - Inter-service cooperation | The Fire and Emergency Services Authority and the Western Australian Police ensure they receive all necessary legal clarification in relation to Bushfire Responsibilities of Police Officers – Powers Used in Assisting Fire Authorities in Responding to Bushfires, to be promulgated across FESA and WAPOL. |
REC200-0361 | 25 - Inquiry, audit, lessons management and after action review | The Fire and Emergency Services Authority convene a facilitated debriefing session between the families who remained behind to protect their properties, and the incident controllers. This session should include open discussion and explain the decisions of all parties – including how the incident controllers determined priorities, and why residents chose not follow their advice to evacuate. The learning outcomes should be promulgated across all agencies and incorporated in future level 3 incident controller training programs. |
REC200-1701 | 25 - Inquiry, audit, lessons management and after action review | The Fire and Emergency Services Authority convene a facilitated debriefing session between the families who remained behind to protect their properties, and the incident controllers. |
REC200-0357 | 26 - Research | The Fire and Emergency Services Authority, the Department of Environment and Conservation and local governments closely monitor the research and development of alternative fuel reduction techniques to ensure that the most efficient and effective programs are adopted. |
REC200-1698 | 39 - Disaster Risk Management | The Fire and Emergency Services Authority, the Department of Environment and Conservation and local governments jointly develop a single, integrated system for fuel load assessment and management. |
Rec-ID | Code | Recommendation |
---|---|---|
REC183-0117 | 15 - Inter-service cooperation | The Interagency Bushfire Management Committee and its sub-committees are the logical central platform for developing and strengthening future joint bushfire strategies and common systems of work between bushfire management agencies in Western Australia. |
REC183-0116 | 15 - Inter-service cooperation | Triggers and a process for transfer of command and control from DEC to FESA should be developed and documented. |
REC183-0118 | 15 - Inter-service cooperation | A Memorandum of Understanding signed by the Chief Executives of DEC and FESA would be a valuable statement of joint commitment between the two agencies. |
Rec-ID | Code | Recommendation |
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REC182-0129 | 15 - Inter-service cooperation | FESA maintains inter-agency relationships and arrangements, and develops formalised arrangements across the entire emergency management cycle for joint activities such as training, exercises and procedure development. |
REC182-0125 | 15 - Inter-service cooperation | FESA, in partnership with other agencies and the community, develops Western Australia’s urban interface fire fighting capability and capacity. |
REC182-0124 | 15 - Inter-service cooperation | FESA and DEC take a whole of capability approach to joint operations, including developing joint doctrine that provides a common and articulated understanding of roles and responsibilities, resources and capabilities |
Rec-ID | Code | Recommendation |
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REC177-3291 | 39 - Disaster Risk Management | Removal of a barrier must be the subject of consultation between licensees and rig operators prior to removal. A proper risk assessment should be carried out and agreed upon, and documented in writing before removal. Joint written certification as to the appropriateness of removal should take place before removal. Senior onshore representatives of stakeholder entities should be involved in that certification process. |
REC177-3360 | 42 - Culture and Heritage | DEWHA should participate in training programs and exercises relevant to an oil spill in the marine environment. |
REC177-3289 | 39 - Disaster Risk Management | The use/type of barriers (including any change requests relating thereto) must be the subject of consultation between licensees and rig operators prior to installation. A proper risk assessment should be carried out, agreed upon, and documented in writing before installation. Joint written certification as to the appropriateness of the use of particular barriers should take place before installation. Senior onshore representatives of stakeholder entities should be involved in that certification process. |
REC177-3356 | 39 - Disaster Risk Management | The regulator should pre‐assess and review in a generic sense, and in conjunction with the offshore petroleum industry, available options for well control in the event of a blowout. Being ‘match fit’ in this sense will enable a quicker and more effective response in terms of safety assessment, and will ensure that expectations of both operator and regulator are more readily aligned. |
REC177-3286 | 39 - Disaster Risk Management | Problems which arise in the course of installing barriers must be the subject of consultation between licensees, rig operators, and contractors (if used). A proper risk assessment should then be carried out and remedial steps (including further testing/verification) should be agreed upon, and documented in writing before the performance of remedial work whenever practicable. Joint written certification as to resolution of the problem should take place before resumption of drilling operations. Senior onshore representatives of stakeholder entities should be involved in that certification process. |
REC177-3344 | 25 - Inquiry, audit, lessons management and after action review | There should be a review to determine whether it is appropriate to introduce a rigorous civil penalty regime and/or substantially increase some or all of the penalties that can be imposed for breaches of legislative requirements relating to well integrity and safety. |
REC144-3387 | 25 - Inquiry, audit, lessons management and after action review | In order that the ACT public can be reassured about the project management and financial planning in relation to the Fairbairn site as a proposed centralised accommodation facility for emergency services, the Auditor-General undertake a review of the project from a financial probity and project management perspective. |
REC177-3285 | 39 - Disaster Risk Management | Pre‐drilling assessments should include a risk assessment of the worst‐case blowout scenario. |
REC177-3330 | 39 - Disaster Risk Management | Decision‐making about well control issues should be professionalised. Industry participants must recognise that decision‐makers owe independent duties to the public, not just their employer or principal, in relation to well control. Risk management in the context of well control needs to be understood as an ethical/professional duty. Self‐regulation contemplates self‐regulation by the industry, not just by individual licensees and operators. |
REC177-3378 | 25 - Inquiry, audit, lessons management and after action review | In view of the numerous well integrity problems in all of the Montara Oilfield wells, the Minister should commission a detailed audit of all the other offshore wells operated by PTTEPAA to determine whether they too may suffer from well integrity problems. |
REC177-3304 | 26 - Research | It is recommended that industry, regulators, and training/research institutions liaise with one another with a view to developing better techniques for testing and verifying the integrity of cemented casing shoes as barriers (particularly in atypical situations such as where the casing shoe is located within a reservoir in a horizontal or high angle position at great depth). |
REC177-3374 | 25 - Inquiry, audit, lessons management and after action review | The Minister should, as the JA for the offshore area of the Territory of Ashmore and Cartier Islands, undertake a review of PTTEPAA’s permit and licence to operate at the Montara Oilfield. |
Rec-ID | Code | Recommendation |
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REC149-3145 | 25 - Inquiry, audit, lessons management and after action review | NOPSA should consider an audit regime that targets Greenfields operations at commencement of operations. |
REC149-3139 | 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. |
Rec-ID | Code | Recommendation |
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REC132-3597 | 15 - Inter-service cooperation | Investigate engaging with other agencies involved in emergency management including SES, VicRoads, VicPolice, OESC and DHS to establish a single united emergency information line for Victoria that can be used to provide information to the public from all agencies involved. |
REC132-3593 | 26 - Research | Analysing information from the joint CFA/DSE Post 2006 Wildfire Community Survey about public perceptions of information provision during January bushfires. Note implications for the VBIL and other information provision methods |
Rec-ID | Code | Recommendation |
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REC121-3683 | 39 - Disaster Risk Management | RailCorp should undertake risk assessments of each of its activities as follows: |
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. |
REC121-3700 | 39 - Disaster Risk Management | Maintenance plans on all trains should be revised annually. |
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. |
REC121-3694 | 25 - Inquiry, audit, lessons management and after action review | The ITSRR should conduct random audits of accredited rail organisations for compliance with communications protocols. |
REC121-3726 | 25 - Inquiry, audit, lessons management and after action review | The OTSI should continue to conduct rail accident investigations on behalf of ITSRR and report directly to the Chief Executive of ITSRR. |
REC121-3758 | 25 - Inquiry, audit, lessons management and after action review | Following completion of any external audit, a corrective action plan to remedy any identified safety deficiencies should be developed by RailCorp, implemented and followed up within the business groups affected, to ensure appropriate and timely completion of the action plan, by a formal examination of the effectiveness of the controls put in place. Senior management personnel should certify that the corrective action plan has been implemented and is effective. Senior management personnel should be accountable for any such certification. |
REC121-3693 | 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. |
REC121-3757 | 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. |
REC121-3691 | 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. |
REC121-3713 | 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. |
REC121-3753 | 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. |
REC121-3684 | 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. |
REC121-3710 | 39 - Disaster Risk Management | The ITSRR should have permanent access to the RailCorp intranet. |