Inquiry Search
Rec-ID | Code | Recommendation |
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REC314-3262 | 10 - Infrastructure | Invest in upgrading and integrating ICT platforms to eliminate manual data transfers, and ensure IT and radio communication interoperability across the agencies, together with a dedicated focus on the development of a coordinated risk intelligence capability to provide all stakeholders with a common operating picture and rapid damage assessments. |
REC314-3260 | 32 - Doctrine, standards, and reform | Align risk assessment tools and processes to Risk Management Standard ISO 31000 and the National Emergency Risk Assessment Guidelines (NERAG) and communicate these on public-facing platforms. Make Bushfire Management Area Plans (BMAP) accountable for managing and reporting on region-specific risk and identifying critical infrastructure such as mobile phone towers as key risks. |
REC314-3259 | 32 - Doctrine, standards, and reform | Implement previous review recommendations for bushfire management including those relating to the 2009 amendments to the Fire and Emergency Services Act 2005, State Bushfire Coordination Committee operation, State Bushfire Management Plan, as well as urgent completion of Codes of Practice for fuel hazard reduction on all land tenures, and redevelopment of Bushfire Management Area Plans accompanied by effective community engagement to build an understanding of risk. |
REC314-3272 | 10 - Infrastructure | Clarify business continuity and restoration of critical infrastructure in the planning and response phases to facilitate water replenishment, fireground remediation and access to businesses (including farming properties). |
REC314-3271 | 8 - Communications and warnings | Better coordinate public information and warnings including evacuation plans and provide a single source of information about, the location and direction of fires, how and when to use Safer Places, Places of Last Resort, relief and recovery centres and directed evacuations. |
REC314-3269 | 32 - Doctrine, standards, and reform | Develop and practice procedures for the CFS, DEW and local governments to access and deploy heavy plant and machinery for fuel reduction operations both before and during bushfires. |
Rec-ID | Code | Recommendation |
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REC302-2404 | 8 - Communications and warnings | Review the effectiveness of emergency public information arrangements, and give consideration to embedding an ABC Manager (not a journalist) into the RFS headquarters during emergencies to broadcast warnings to the community that can be pooled to commercial media outlets |
REC302-2395 | 32 - Doctrine, standards, and reform | Remove those policies, guidelines, memoranda of understanding and committees that are made redundant as a result of adopting recommendation #2 while updating any remaining policies that are considered to still be relevant |
Rec-ID | Code | Recommendation |
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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. |
REC301-2387 | 32 - Doctrine, standards, and reform | TFS, PWS and STT agree an updated version of the Interagency Fire Management Protocol which maintains the principle that there will be one state-wide point of command for major unwanted fires burning in the State of Tasmania, explicitly recognises the right of each of TFS, PWS and STT to have their objectives prioritised in incident action planning and adequate resources applied to those objectives, and provides a mechanism for executive decision-makers from TFS, PWS and STT to come together and agree objectives and resourcing levels that will then be operationalised by whole-of-State control structures. |
Rec-ID | Code | Recommendation |
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REC291-1247 | 32 - Doctrine, standards, and reform | The State Government to create a Rural Fire Service to enhance the capability for rural fire management and bushfire risk management at a State, regional and local level. The proposed Rural Fire Service will: · be established as a separate entity from the Department of Fire and Emergency Services or, alternatively, be established as a sub-department of the Department of Fire and Emergency Services; · have an independent budget; · be able to employ staff; · have a leadership structure which, to the greatest degree possible, is regionally based and runs the entity; · be led by a Chief Officer who reports to the responsible Minister on policy and administrative matters; and to the Commissioner for Fire and Emergency Services during operational and emergency response; · have responsibilities and powers relating to bushfire prevention, preparedness and response; and · operate collaboratively with the Department of Fire and Emergency Services, the Department of Parks and Wildlife, Local Government and volunteer Bush Fire Brigades. In creating the Rural Fire Service, the State Government to consider whether back office and corporate support services could be effectively provided by an existing Department, such as the Department of Fire and Emergency Services or the Department of Parks and Wildlife. The State Government to review the creation of the Rural Fire Service two years after its establishment, to assess whether its structure and operations are achieving the intended outcome. |
REC291-1243 | 8 - Communications and warnings | The Department of Fire and Emergency Services to investigate and adopt a system that will allow the public to opt in, monitor and receive, through a ‘push mechanism’, bushfire and other emergency warnings, maps and information using a wide variety of devices including personal hand held smart devices. |
REC291-1238 | 32 - Doctrine, standards, and reform | The State Emergency Management Committee to adopt, across all hazards, the doctrine of: · the primacy of life; · the ‘Strategic Control Priorities’ (as documented by the Department of Fire and Emergency Services); and · community warnings that are timely, tailored and relevant. Agencies will reinforce amongst emergency management personnel the importance of this doctrine through briefings and intent statements. |
Rec-ID | Code | Recommendation |
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REC287-1182 | 32 - Doctrine, standards, and reform | The fire agencies consider how the Regional Fire Operations Centre (RFOC) as a concept adds value once a level 3 IMT is up and running in a region. |
Rec-ID | Code | Recommendation |
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REC273-1133 | 32 - Doctrine, standards, and reform | That a complete review of current naming conventions of personnel and centres, in accordance with the outcomes of the Victorian Bushfire Royal Commission is undertaken, to ensure clarity around command, control and coordination within SA. |
REC273-1145 | 32 - Doctrine, standards, and reform | Review relevant Legislation associated Acts and Plans to establish a consistent approach to fire and emergency management to minimise duplication and risk of contradiction. That the Hazard and Functional area plans be amalgamated and establish a SA Bushfire Plan, under the SEMP, which clearly define role of SACFS. |
REC273-1129 | 32 - Doctrine, standards, and reform | Incorporating ‘triggers’ within Chief Officers Standing Orders No. 17, which requires the escalation of the State Controller role to the rank of Assistant Chief Officer or greater, depending on the increased risk or activity. |
REC273-1144 | 7 - Inter-agency communication | That SACFS consider a review to develop an effective interagency messaging system and agency resource management system. |
REC273-1128 | 32 - Doctrine, standards, and reform | Incorporate in operational doctrine the ability for the State Controller to determine the operational readiness levels of the state or regions based on either the predicted and/or actual risk and/or activity to some or all of the regions. |
REC273-1143 | 32 - Doctrine, standards, and reform | That SACFS in consultation with SAMFS consider adopting common terminology and capability requirements for strike teams being ‘4-5 appliances and a group officer’ in line with other jurisdictions. |
REC273-1140 | 8 - Communications and warnings | Review the current practise of issuing an ‘emergency alert’ telephone message or an emergency warning and/or watch and act alert to ensure that it is consistent, relevant and necessary. Prior to issuing an emergency alert message, consider state level involvement so that other agencies are made aware of message and intent. |
REC273-1134 | 8 - Communications and warnings | That future declarations be undertaken to ensure that the areas affected by the declaration are clear and concise. |
Rec-ID | Code | Recommendation |
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REC264-1078 | 32 - Doctrine, standards, and reform | The State review and revise the community carbon monoxide response protocol and the firefghter carbon monoxide response protocol, to: |
REC264-1085 | 10 - Infrastructure | GDF Suez establish enhanced back-up power supply arrangements that do not depend wholly on mains power, to: • ensure that the Emergency Command Centre can continue to operate if mains power is lost; and • ensure that the reticulated fre services water system can operate with minimal disruption if mains power is lost. |
REC264-1077 | 32 - Doctrine, standards, and reform | The State take the lead in advocating for a national compliance standard for PM |
REC264-1084 | 32 - Doctrine, standards, and reform | GDF Suez revise its Emergency Response Plan, to: • require an increased state of readiness on days of Total Fire Ban; • require pre-establishment of an Emergency Command Centre; • require pre-positioning of an accredited Incident Controller as Emergency Commander; and • require any persons nominated as Emergency Commander to have incident controller accreditation and profciency in the use of the Australasian Inter-service Incident Management System. |
REC264-1075 | 32 - Doctrine, standards, and reform | The State: • bring forward the commencement date of s.16 of the Mineral Resources (Sustainable Development) Amendment Act 2014 (Vic), to facilitate the requirement that approved work plans specifcally address fre prevention, mitigation and suppression; and • acquire the expertise necessary to monitor and enforce compliance with fre risk measures adopted by the Victorian coal mining industry under both the mine licensing and occupational health and safety regimes. |
REC264-1082 | 8 - Communications and warnings | The State review and revise its communication strategy, to: • needed for effective and rapid public communications during an emergency; and ensure all emergency response agencies have, or have access to, the capability and resources • ensure, where appropriate, that private operators of essential infrastructure are included in the coordination of public communications during an emergency concerning that infrastructure. |
REC264-1074 | 32 - Doctrine, standards, and reform | The State enact legislation, to: • require Integrated Fire Management Planning; and • authorise the Emergency Management Commissioner to develop and implement regional and municipal fire management plans. |
REC264-1080 | 32 - Doctrine, standards, and reform | The State develop and widely disseminate an integrated State Smoke Guide, to: • incorporate the proposed State Smoke Plan for the management of public health impacts from large scale, extended smoke events; • include updated Bushfre Smoke, carbon monoxide and PM protocols; and 2.5 • provide practical advice and support materials to employers, communities and individuals on how to minimise the harmful effects of smoke. |
REC264-1089 | 8 - Communications and warnings | GDF Suez improve its crisis management communication strategy for the Hazelwood mine in line with international best practice. |
REC264-1079 | 32 - Doctrine, standards, and reform | The State review and revise the Bushfre Smoke Protocol and the PM Health Protection Protocol, to: 2.5 • ensure both protocols are consistent with each other; and • ensure both protocols include assessment methods and trigger points for specifc responses. |
REC264-1088 | 32 - Doctrine, standards, and reform | GDF Suez adopt and apply the firefghter carbon monoxide response protocol. |
Rec-ID | Code | Recommendation |
---|---|---|
REC258-2527 | 32 - Doctrine, standards, and reform | The Department of Infrastructure and Regional Development plays a stronger policy role in the State Safety Program. |
REC258-2536 | 32 - Doctrine, standards, and reform | The Australian Transport Safety Bureau and the Civil Aviation Safety Authority amend the wording of their existing Memorandum of Understanding to make it more definitive about interaction, coordination, and cooperation. |
REC258-2562 | 32 - Doctrine, standards, and reform | The Civil Aviation Safety Authority amends the current Terms of Reference of the Industry Complaints Commissioner so that: |
REC258-2535 | 32 - Doctrine, standards, and reform | Airservices Australia, in conjunction with the Department of Infrastructure and Regional Development and the Civil Aviation Safety Authority, reconsiders the policy on ‘Assessment of Priorities’ that stipulates that air traffic controllers sequence arriving aircraft based on category of operation, rather than on the accepted international practice of ‘first come, first served’. |
REC258-2555 | 32 - Doctrine, standards, and reform | The Civil Aviation Safety Authority changes the current two-tier regulatory framework (act and regulations) to a three-tier structure (act, regulations and standards), with: |
REC258-2533 | 32 - Doctrine, standards, and reform | The Civil Aviation Safety Authority: |
REC258-2554 | 32 - Doctrine, standards, and reform | Recreational Aviation Administration Organisations, in coordination with the Civil Aviation Safety Authority, develop mechanisms to ensure all aircraft to be regulated under CASR Part 149 are registered. |
REC258-2531 | 32 - Doctrine, standards, and reform | The Civil Aviation Safety Authority’s Board exercises full governance control. The nonexecutive directors should possess a range of appropriate skills and backgrounds in aviation, safety, management, risk, regulation, governance and government. |
REC258-2538 | 32 - Doctrine, standards, and reform | The Department of Infrastructure and Regional Development and Department of Defence (and appropriate agencies) establish an agreed policy position on safety oversight of civil operations into joint user and military airports. |
REC258-2529 | 32 - Doctrine, standards, and reform | The Australian Transport Safety Bureau and the Civil Aviation Safety Authority utilise the provision in their bilateral Memorandum of Understanding to accredit CASA observers to ATSB investigations. |
REC258-2537 | 32 - Doctrine, standards, and reform | The Civil Aviation Safety Authority delegates responsibility for the day-to-day operational management of airspace to Airservices Australia, including the designation of air routes, short term designations of temporary Restricted Areas, and temporary changes to the classification of airspace for operational reasons. |
Rec-ID | Code | Recommendation |
---|---|---|
REC257-1538 | 32 - Doctrine, standards, and reform | Commanding Officer Defence Explosive Ordnance Training School amend relevant instructions, both generally and specifically, so as to ensure that explosive ordnance used in training serials is logged in real time, in accordance with extant doctrine. |
REC257-1552 | 32 - Doctrine, standards, and reform | Authority be given to the regional Environmental Officer to close a range or impose live-firing restriction in addition to any set out in Range Standing Orders if circumstances so warrant. |
REC257-1537 | 32 - Doctrine, standards, and reform | Commanding Officer Defence Explosive Ordnance Training School review and enforce Standard Operating Procedures to ensure that appropriate explosive ordnance accounting and handling practices, in accordance with Defence doctrine, are adhered to during all training activities. |
REC257-1551 | 32 - Doctrine, standards, and reform | The use of Internal and External ranges at MTA for patrolling activities be prohibited. |
REC257-1550 | 32 - Doctrine, standards, and reform | Defence engage with both the Bureau of Meteorology and the Rural Fire Service to determine a more suitable index system. In the interim, Range Standing Orders be amended so that live-firing on the ranges on Marrangaroo Training Area not be permitted where the Forest Fire Danger Index for either the Central Ranges District or Greater Sydney Region is 12, it being the threshold for HIGH Fire Danger Rating or above. put another way, and in a practical sense, Range Standing Orders should, as an interim measure, require the Officer in Charge Practice and the Range Control Officer to consider the Forest Fire Danger Index for both Central Ranges District AND Greater Sydney Region on the day of any given serial. If either index is as 12 or above, live-firing should not be permitted. Any indication in Range Standing Orders or elsewhere that live-firing is permitted on Marrangaroo Training Area when the Fire Danger rating is HIGH should be rescinded. |
REC257-1549 | 32 - Doctrine, standards, and reform | Marrangaroo Training Area Range Standing Orders should be reviewed to impose a requirement that the Officer in Charge of any live-firing practice ascertain and consider current weather parameters, temperature, humidity, wind strength and direction, registered at Mt Boyce immediately prior to any demolition serial. The setting of those parameters and their limits should be decided in consulation with the Bureau of Meteorology and Rural Fire Service and inserted into Range Standing Orders. |
REC257-1554 | 32 - Doctrine, standards, and reform | All documents be reviewed to remove ambiguity and perceived inconsistencies. Marrangaroo Training Area Range Standing Orders be subject to further examination, with particular consideration of the bushfire mitigation strategies referred to in the Bushfire Management Plan 2011-2014 before amendments to Chapter 10 are made. the basis upon which Range Standing Orders might fix a cut-off point for live-firing exercises should depend on continued bushfire strategies. Range Standing orders and Marrangaroo Training Area Bushfire Management Plan be reviewed annually. if hazard reduction has not occurred or the fire trails degraded, Range Standing Orders should take into account of heightened risk. |
REC257-1543 | 32 - Doctrine, standards, and reform | Range Standing Orders be amended to include a direction that no Defence vehicle is to leave the administration area of Marrangaroo Training Area during a bushfire, except to leave Marrangaroo Training Area itself through the main gate, unless it is a properly equipped bushfire fighitng vehicle havig at least four wheel drive capabiliy and self-protection equipment. |
REC257-1553 | 32 - Doctrine, standards, and reform | On matters relating directly to safety or risk, or when live-firing may occur, where there is ambiguity or apparent inconsistency, the most conservative or restrctive order should be followed until formal clarification has been provided. |
Rec-ID | Code | Recommendation |
---|---|---|
REC247-0872 | 32 - Doctrine, standards, and reform | That Tasmania Fire Service considers what adjustments may be necessary to the promotion and use of the Six Operational Priorities to ensure plans are suitable for the circumstances of each fire. |
REC247-0914 | 32 - Doctrine, standards, and reform | That the Tasmanian Emergency Management Plan includes a comprehensive all hazards communications policy and plan. |
REC247-0882 | 32 - Doctrine, standards, and reform | That Tasmania Fire Service documents and publishes its operational policies and procedures so they are accessible to and suitable for operational personnel. |
REC247-0919 | 8 - Communications and warnings | That Tasmania Fire Service and Tasmania Police review their use of modern forms of communication with the community, including social media, and commit resources to fully use this capability where appropriate. |
REC247-0859 | 7 - Inter-agency communication | That police and other emergency services examine options for achieving radio interoperability between them in the absence of an integrated radio system. |
REC247-0902 | 7 - Inter-agency communication | That evacuation centres and other centres have a standard operating procedure for communications. |
REC247-0940 | 32 - Doctrine, standards, and reform | That the Government actively support the timely development and implementation of an ongoing Strategic Fuel Management Plan. |
REC247-0871 | 32 - Doctrine, standards, and reform | That Tasmania Fire Service critically reviews the operation of the Six Operational Priorities to determine whether they are appropriate and effective. |
REC247-0913 | 32 - Doctrine, standards, and reform | That the State Fire Commission structures its Tasmania Bushfire Safety Policy so policy outcomes are identifiable and progress in achieving outcomes can be evaluated. |
REC247-0881 | 32 - Doctrine, standards, and reform | That Tasmania Fire Service establishes sufficient resources and expertise to research, develop, implement and review its policies and operations. |
REC247-0918 | 8 - Communications and warnings | That the State Emergency Management Committee makes arrangements to actively manage the use of social media in the community during an emergency, to avoid negative consequences for emergency operations. |
REC247-0858 | 7 - Inter-agency communication | That all agencies and the Government support moving to an integrated communications technology for police and the emergency services. |
REC247-0900 | 8 - Communications and warnings | That a public information plan be developed as a part of the State Special Emergency Plan–Recovery, for implementation in the immediate recovery phase. |
REC247-0930 | 32 - Doctrine, standards, and reform | That the State Emergency Management Committee determine suitable risk management tools, such as the Bushfire Risk Assessment Model, and encourages their use in assessing bushfire risk in a consistent manner. |
REC247-0870 | 32 - Doctrine, standards, and reform | That Tasmania Fire Service considers adopting a primary tactic of an aggressive first attack on fires. |
REC247-0912 | 32 - Doctrine, standards, and reform | That the State Fire Commission finalise its position on the Tasmania Bushfire Safety Policy without further delay. |
REC247-0877 | 32 - Doctrine, standards, and reform | That Tasmania Fire Service reviews its approach to fire management operations at night, and develop and effectively implement unambiguous policy and operating procedures. |
REC247-0917 | 8 - Communications and warnings | That the State Emergency Management Committee makes timely decisions and resource commitments on the appropriate use of social media in emergency management. |
REC247-0852 | 32 - Doctrine, standards, and reform | That the role and expected duties of the State Controller be clearly defined in the Emergency Management Act 2006. |
REC247-0898 | 32 - Doctrine, standards, and reform | That the State Special Emergency Plan–Recovery and the emergency management structure for recovery be reviewed. |
REC247-0929 | 32 - Doctrine, standards, and reform | That the State Emergency Management Committee considers structuring the Tasmania Emergency Management Plan in a way that provides more specific guidance, commitment to and accountability for action to be taken. |
REC247-0869 | 32 - Doctrine, standards, and reform | That Tasmania Fire Service ensures that planning for active fires includes a proactive approach wherever possible. |
REC247-0908 | 32 - Doctrine, standards, and reform | That the State Emergency Management Committee examine whether there are any legal issues associated with continuing recovery operations where the overarching emergency management arrangements have ceased. |
REC247-0876 | 32 - Doctrine, standards, and reform | That Tasmania Fire Service reviews its approach to blacking out and mopping up, including its policies, operating procedures and training. |
REC247-0916 | 8 - Communications and warnings | That Tasmania Fire Service ensures that the priority on warning communities at risk of active bushfires is not confined to when bushfires are burning out of control. |
REC247-0897 | 32 - Doctrine, standards, and reform | That a standing plan is developed to manage the transition from immediate recovery to medium and long-term recovery, and arrangements are made to ensure this plan can be effectively implemented in a timely way. |
REC247-0922 | 8 - Communications and warnings | That Tasmania Fire Service develops a research base from which to inform the design of communication campaigns for communities threatened by bushfire. |
REC247-0867 | 7 - Inter-agency communication | That Tasmania Fire Service reviews the communication systems used for all emergency management operations, ensures operators are qualified, and ensures there is appropriate accountability. |
REC247-0905 | 8 - Communications and warnings | That the Government consider whether it should discuss options for greater mobile phone coverage and redundancy in areas of high risk in emergency situations where there are presently telecommunications limits. |
REC247-0950 | 32 - Doctrine, standards, and reform | That resources are committed to developing and implementing approved reforms to the emergency management arrangements. |
REC247-0874 | 32 - Doctrine, standards, and reform | That Tasmania Fire Service reviews operational practices to ensure there is continuity of fire operations when fire suppression action is required. |
REC247-0915 | 8 - Communications and warnings | That Tasmania Fire Service actively uses predictive modelling to design emergency communications for communities threatened by bushfire, unless there is a compelling reason for not doing so. |
REC247-0883 | 32 - Doctrine, standards, and reform | That Tasmania Police ensures planning for emergency operations includes a proactive approach wherever possible. |
REC247-0920 | 8 - Communications and warnings | That Tasmania Fire Service reviews its approach to communicating with communities threatened by bushfire and consider the matters referred to in this Report. |
REC247-0864 | 32 - Doctrine, standards, and reform | That Tasmania Fire Service reviews its position on fire ground management to determine whether a unified command model at the fire ground should be adopted. |
REC247-0904 | 10 - Infrastructure | That the Department of Infrastructure Energy and Resources consult Aurora Energy on the use of wooden poles for overhead infrastructure with a view to mitigating the risk in bushfires. |
REC247-0949 | 32 - Doctrine, standards, and reform | That following any review, the Emergency Management Act 2006 be amended. |
Rec-ID | Code | Recommendation |
---|---|---|
REC201-0252 | 7 - Inter-agency communication | FESA must actively manage the transition to WAERN and provide alternative means for regional crews to communicate when in areas where WAERN is not operated. |
REC201-0250 | 8 - Communications and warnings | Initial StateAlert messages should provide timely broad advice to a wide audience authorised by the SDD, while subsequent messages may provide more detail. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC200-0362 | 32 - Doctrine, standards, and reform | The Fire and Emergency Services Authority immediately comply with the provisions of WESTPLAN BUSHFIRE and formally declare incidents at their appropriate level and document and communicate those decisions in a similar way to the systems used by the Department of Environment and Conservation and the Western Australian Police. |
REC200-1710 | 8 - Communications and warnings | The Fire and Emergency Services Authority and the ABC commence a thorough review of emergency warning messages. This review should give consideration to: |
REC200-0380 | 32 - Doctrine, standards, and reform | The State Emergency Management Committee amend State Emergency Management Policy 4.1 (Operational Management) to: give clear and explicit direction about when and how an incident should be declared clearly articulate the actions to be taken clearly define accountabilities provide detailed criteria for elevating issues and engaging other agencies. |
REC200-1721 | 32 - Doctrine, standards, and reform | The State Government amend section 50 of the Emergency Management Act 2005 to allow the Chair of the State Emergency Coordination Group to declare an emergency situation. |
REC200-1696 | 32 - Doctrine, standards, and reform | The State Government reaffirm its 2009 decision to approve DEC exercising greater flexibility in managing smoke within national guidelines, in order to achieve its prescribed burn program. |
REC200-0341 | 32 - Doctrine, standards, and reform | The State Government give legislative effect to the Planning for Bush Fire Protection Guidelines. |
REC200-1709 | 32 - Doctrine, standards, and reform | The Western Australian Police and the Fire and Emergency Services Authority jointly examine the Traffic Management System developed in response to the 2009 Victorian bushfires and seek its adaptation to use in WA with additional attention to the access and egress by bona fide residents to areas that are evacuated. |
REC200-0372 | 7 - Inter-agency communication | FESA and local governments jointly review radio communications capability prior to the 2011/12 bushfire season with a view to improving the current delivery of service to firefighters. |
REC200-1720 | 32 - Doctrine, standards, and reform | The State Emergency Management Committee amend State Emergency Management Policy 4.1 (Operational Management) to: |
REC200-0339 | 32 - Doctrine, standards, and reform | Emergency Management Western Australia establish an inter-agency working group to continue the development of the new single emergency services Act. |
REC200-1690 | 8 - Communications and warnings | The Fire and Emergency Services Authority work in partnership with Main Roads Western Australia and local governments to develop and implement a comprehensive strategy for the use of mobile variable message boards to alert the community to the declaration of a total fire ban and what it means. |
REC200-1704 | 32 - Doctrine, standards, and reform | The Fire and Emergency Services Authority review its use of the Australian Interagency Incident Management System to ensure that the most appropriate resources (including aerial resources) are used to respond to an incident. If resources are rejected during an incident either through the decision making process or other grounds, the reason for the decision should be documented. |
REC200-0371 | 8 - Communications and warnings | FESA develop in partnership with other emergency service agencies a ‘one source: one message’ multi layered system similar to that recommended by the Victoria Bushfire royal Commission. |
REC200-1713 | 7 - Inter-agency communication | The Department for Child Protection, the Western Australian Police and the Fire and Emergency Services Authority develop improved arrangements for communicating the loss of home and possessions to persons gathered at evacuation centres with a view to increasing privacy. |
REC200-1689 | 8 - Communications and warnings | The Fire and Emergency Services Authority consider alternative wording to Total Fire Ban that ensures people gain a more complete understanding of what actions are prohibited. |
REC200-1703 | 32 - Doctrine, standards, and reform | The Fire and Emergency Services Authority develop formal procedures for mandating the completion of Incident Action Plans, ensuring the documents are detailed and that they record critical decision making. |
REC200-0370 | 8 - Communications and warnings | The Fire and Emergency Services Authority and the ABC commence a thorough review of emergency warning messages. This review should give consideration to: The content, structure and presentation of emergency warning messages Media access to the Incident Management Team and State Operations Centre. This review should be expanded to include other media organisations should they demonstrate a willingness and capacity to contribute. 20 |
REC200-1712 | 10 - Infrastructure | FESA and local governments jointly review radio communications capability prior to the 2011/12 bushfire season with a view to improving the current delivery of service to firefighters. |
REC200-1702 | 32 - Doctrine, standards, and reform | The Fire and Emergency Services Authority immediately comply with the provisions of WESTPLAN BUSHFIRE and formally declare incidents at their appropriate level and document and communicate those decisions in a similar way to the systems used by the Department of Environment and Conservation and the Western Australian Police. |
REC200-0363 | 32 - Doctrine, standards, and reform | The Fire and Emergency Services Authority develop formal procedures for mandating the completion of Incident Action Plans, ensuring the documents are detailed and that they record critical decision making. |
REC200-1711 | 8 - Communications and warnings | FESA develop in partnership with other emergency service agencies develop a 'one source: one message' multi layered system similar to that recommended by the Victoria Bushfire royal Commission. |
REC200-0382 | 32 - Doctrine, standards, and reform | 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. |
REC200-1722 | 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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC189-2914 | 32 - Doctrine, standards, and reform | The review team recommend that: |
REC189-2909 | 32 - Doctrine, standards, and reform | Equipping the regulator with a wider range of compliance tools under the legislation should continue to be a policy priority. The aim should be to enhance the regulator’s capacity to secure compliance in an appropriately graduated way. The opportunity should be taken to ensure that the regulator and inspectors can, in appropriate cases, bring proceedings that do not require referral to the Commonwealth Director of Public Prosecutions, such as actions for civil penalties or injunctions. |
Rec-ID | Code | Recommendation |
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REC183-0108 | 32 - Doctrine, standards, and reform | DEC should consider publishing a new reference document that describes policy, doctrine and key systems of work of the fire management system. This document would be a “brief case” or “back pack” reference and would be reviewed annually and issued to all senior staff and fire management personnel. |
REC183-0107 | 32 - Doctrine, standards, and reform | The DEC Fire Management Policy should be reviewed and updated. |
REC183-0115 | 32 - Doctrine, standards, and reform | The Hazard Management Agency for bushfire has not been defined. Defining the HMA for bushfire should be addressed. |
Rec-ID | Code | Recommendation |
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REC182-0123 | 32 - Doctrine, standards, and reform | FESA implements measures that will ensure unity and clarity of command. |
Rec-ID | Code | Recommendation |
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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. |
REC177-3312 | 32 - Doctrine, standards, and reform | The BOP and rig should not move from a well until barrier integrity has been verified. |
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. |
REC177-3362 | 32 - Doctrine, standards, and reform | Procedures for the approval of development projects should ensure that conditions of approval are comprehensive and clearly set out the obligations of their proponents in relation to environmental matters (including expected monitoring and remediation obligations). |
REC177-3297 | 32 - Doctrine, standards, and reform | A minimum of two barriers should be in place at all times (including during batched operations) whenever it is reasonably practicable to do so. |
REC177-3317 | 32 - Doctrine, standards, and reform | Any equipment (including PCCCs) used as, or to install, a barrier should be manufactured for that purpose and be generally recognised as fit for purpose. If equipment is designed in‐house by a licensee or rig operator it should not be approved for use unless and until it is subjected to expert external analysis. |
REC177-3341 | 32 - Doctrine, standards, and reform | The definition of ‘good oilfield practice’ in the OPGGS Act is unduly narrow. The current definition is incapable of application except where things ‘are generally accepted as good and safe’. The definition should be amended such that ‘good oilfield practice includes…’. |
REC177-3370 | 32 - Doctrine, standards, and reform | Environment plans and OSCPs should be made publicly available as a condition of approval of proposals under the OPGGS Act, and should clearly set out Scientific Monitoring requirements in the event of an oil spill. |
REC177-3276 | 32 - Doctrine, standards, and reform | WOMPs should be comprehensive and freestanding, rather than an overarching document cross‐referencing many other documents (although the Inquiry also recommends a freestanding well control manual; this should be a guide to rig and onshore personnel on good oilfield practice). |
REC177-3305 | 32 - Doctrine, standards, and reform | Cement integrity should be evaluated wherever practicable by way of cement evaluation tests, rather than relying on pre‐operational calculations of cement and displacement fluid volumes. |
REC177-3323 | 32 - Doctrine, standards, and reform | Where multiple wells are drilled, operations and occurrences at one well must be carefully assessed for any implications with respect to well control at other wells. |
REC177-3353 | 32 - Doctrine, standards, and reform | The regulatory regime should also impose an obligation on an operator to ascertain the availability, and provide details to the regulator, of any potential relief well rigs, prior to the commencement of drilling operations (including prior to each phase of a drilling operation where applicable). |
REC177-3285 | 39 - Disaster Risk Management | Pre‐drilling assessments should include a risk assessment of the worst‐case blowout scenario. |
REC177-3311 | 32 - Doctrine, standards, and reform | Horizontal or high angle penetration of a reservoir should be avoided wherever practicable until such time as the apparent problems associated with the cementing of a casing shoe in these situations are satisfactorily overcome. If a casing string does penetrate a well horizontally or at a high angle, standard practice should be to install two secondary barriers in addition to the cemented casing shoe. |
REC177-3328 | 32 - Doctrine, standards, and reform | All communications between on‐rig and onshore personnel relating to well control should be documented in a timely manner. |
REC177-3361 | 32 - Doctrine, standards, and reform | The National Plan should be revised to ensure that it fully comprehends environmental matters and that it recognises the importance of the prompt implementation of Scientific Monitoring to facilitate the assessment of the environmental impacts of an incident. |
REC177-3296 | 32 - Doctrine, standards, and reform | Use of single strings of intermediate casing to penetrate hydrocarbon bearing zones should be carefully risk assessed. Multiple strings of intermediate casing have the advantage of isolating lost circulation zones and sealing off anomalous pressure zones. If intermediate casing is set in a hydrocarbon zone it should be treated as production casing. |
REC177-3316 | 32 - Doctrine, standards, and reform | Wells should be re‐entered with a BOP in place unless a documented risk assessment indicates that well control can be maintained at all times. |
REC177-3340 | 32 - Doctrine, standards, and reform | To better ensure that ‘risks’ are identified and managed in accordance with sound engineering principles and good oilfield practice, it is recommended that regulation 25(1)(a)(i) and (2)(a)(i) of the Management of Well Operations Regulations, be reworded as follows: ‘A titleholder must not commence / continue a well activity if…a well integrity hazard exists in relation to the well’. |
REC177-3368 | 32 - Doctrine, standards, and reform | The regulatory framework should provide that in respect of all activities in Commonwealth waters: |
REC177-3275 | 32 - Doctrine, standards, and reform | Well Operations Management Plan (WOMPs) submitted by licensees to the regulator(s) should continue to be the primary framework document for achieving well integrity. |
REC177-3302 | 32 - Doctrine, standards, and reform | Industry, regulators, and training/research institutions should develop standards that address best practices for cementing operations (including liaising, as appropriate, with overseas regulators) with a view to overcoming problems which can effect the integrity of cemented casing shoes, annulus and cement plugs. |
REC177-3322 | 32 - Doctrine, standards, and reform | Batched drilling operations should only be undertaken after careful assessment of the special risks which such operations give rise to; well control must be maintained during the course of batched drilling operations. |
REC177-3352 | 32 - Doctrine, standards, and reform | The regulator, rather than the responsible Minister, should be given the power to direct an operator to use a particular rig for the purpose of well control operations, if appropriate in the circumstances, and the power should be used in the future if that rig is the best option available. This would necessarily involve the operator fully compensating for the use of the rig and any other associated costs. The Inquiry suggests that this power could be invoked and given effect as a condition of an operator’s licence. |
REC177-3284 | 32 - Doctrine, standards, and reform | Memoranda of Agreement should be entered into between operators in relation to provision of emergency assistance in the event of blowouts. |
REC177-3309 | 32 - Doctrine, standards, and reform | If performance of barrier installation is outsourced by a licensee, the contractor (for example, the cementing company) should be engaged on terms which clearly require the provision of expert advisory services by the contractor with respect to barrier integrity. |
REC177-3327 | 32 - Doctrine, standards, and reform | Information relevant to well control must be captured and communicated within and between licensees and rig operators (and relevant third party contractors), in a manner which ensures it comes to the attention of relevant personnel. In particular, protocols should be developed to ensure that changes in shift and hitch do not operate as communication barriers. |
REC177-3359 | 32 - Doctrine, standards, and reform | The National Plan should be reviewed to clarify the arrangements to apply in Commonwealth waters regarding key roles and responsibilities, including in relation to the ESC, in the event of an oil spill. This should also address any necessary training required. |
REC177-3292 | 32 - Doctrine, standards, and reform | Licensees should be subject to an express obligation to inform regulators of the proposed removal of a barrier, even if they consider that well integrity is not thereby compromised. The information should be provided by way of special report, rather than included in a standard reporting document (such as a DDR). The information provided should include risk assessment details. Removal of a barrier should not take place without prior written approval of the relevant regulator(s). |
REC177-3315 | 32 - Doctrine, standards, and reform | PCCCs should be installed in a timely manner (for example, to prevent corrosion in the MLS apparatus). Non‐installation in order to park a BOP is not acceptable. |
REC177-3339 | 32 - Doctrine, standards, and reform | The Inquiry supports the objective (rather than prescriptive) approach to regulation now followed in Australia. However, the pendulum has swung too far away from prescriptive standards. In some areas relating to well integrity there needs to be minimum standards. |
REC177-3367 | 32 - Doctrine, standards, and reform | Procedures and accountabilities should be established to ensure, in the event of a future incident, that: |
REC177-3301 | 32 - Doctrine, standards, and reform | The industry standard of two barriers should be replaced with the concept of ‘two or more barriers’ as a minimum standard. A minimum standard when operations proceed normally should never be regarded as a sufficient standard in other circumstances. |
REC177-3320 | 32 - Doctrine, standards, and reform | Any pro‐formas used by licensees, rig operators and contractors for recording information about installation of barriers should explicitly provide for ‘exception reporting’, that is, the form should include provision for recording any unforseen or untoward events which occur in the course of installation. |
REC177-3350 | 32 - Doctrine, standards, and reform | The recommendations of the Inquiry in relation to suitable ways of achieving well integrity contained in Chapter 3 be included in a guidance manual that is issued for the assistance of industry and regulators. |
REC177-3283 | 32 - Doctrine, standards, and reform | A separate, identifiable barrier manual should be agreed upon and used by licensees, rig operators, and cementing contractors. These manuals should set out best industry practice in relation to achieving and maintaining well integrity. They should describe barrier types, barrier standards, general principles of well integrity, testing and verification methods and technologies, standard operating procedures (including procedures for the capture and communication of relevant information within and between relevant stakeholder entities). Barrier manuals should address blowout control during drilling, completion, re‐entry, tie‐back of casing strings and so on. Barrier manuals should be the subject of expert external review, and should be regularly updated. |
REC177-3308 | 32 - Doctrine, standards, and reform | Volumes of cement used in connection with barrier installation should be calculated with the assistance of a pro‐forma which records all relevant baseline data, which should be verified by onshore personnel. |
REC177-3326 | 32 - Doctrine, standards, and reform | Prior to commencement of drilling operations, senior representatives of the licensee and rig operator should exchange certificates to the effect that their respective key personnel and contractors have been informed in writing of agreed well control arrangements. |
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. |
REC177-3291 | 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. |
REC177-3314 | 32 - Doctrine, standards, and reform | Secondary barriers (including PCCCs) should only be installed, tested, and removed with a BOP in place unless a documented risk assessment indicates that well control can be maintained at all times. |
REC177-3335 | 32 - Doctrine, standards, and reform | Licensees, rig operators and relevant third party contractors should develop well control competency standards for key personnel in other entities involved in well control operations. |
REC177-3366 | 32 - Doctrine, standards, and reform | The National Plan should be reviewed: |
REC177-3300 | 32 - Doctrine, standards, and reform | Licensees and rig operators should install an additional barrier whenever (i) there is any real doubt as to the integrity of any barrier; (ii) whenever the risk of flow from a reservoir increases materially in the course of operations; and (iii) where the consequences of a blowout are grave (for example, for reef systems or shorelines). |
REC177-3319 | 32 - Doctrine, standards, and reform | Drilling programs dealing with barrier installation should incorporate relevant aspects of manufacturer’s instructions. |
REC177-3343 | 32 - Doctrine, standards, and reform | The OPGGS Act should be amended to allow for a power to suspend a petroleum production licence (in addition to the current power to cancel a licence or suspend its conditions). |
REC177-3377 | 32 - Doctrine, standards, and reform | The Minister consider legislative amendments to the OPGGS Act which make clear that |
REC177-3280 | 32 - Doctrine, standards, and reform | Well construction and management plans should include provision for an independent compliance review of well integrity (i) in the event of stipulated triggers; and (ii) at least once in the period between perceived achievement of well integrity and production. The independent compliance review should be undertaken by an expert who is not involved in the day‐to‐day drilling operations. Reviews should be completed in sufficient time to enable results to be implemented in a meaningful manner. |
REC177-3307 | 32 - Doctrine, standards, and reform | Any indication of a compromised cemented shoe which cannot be resolved with a high measure of confidence should result in the installation of additional well control barrier(s). |
REC177-3325 | 32 - Doctrine, standards, and reform | Relevant personnel from licensees and rig operators should meet face to face to agree on, and document, well control issues/arrangements prior to commencement of drilling operations. Well control should be regarded as a so‐called SIMOP to signify its critical importance to both licensees and rig operators, and to ensure that they each take responsibility for achievement and maintenance of well control. |
REC177-3355 | 32 - Doctrine, standards, and reform | The Inquiry also supports Bills and Agostini’s recommendation: ‘…in relation to safety case development and compliance overall, that NOPSA revise its approach to interacting with operators prior to the safety case assessment process and subsequently direct more resources into its advisory functions. We further recommend that NOPSA develop and implement a formal plan for supporting and guiding each operator prior to safety case acceptance, as well as for ongoing compliance with that safety case, recognising the unique experience, capabilities and assessed risk of that operator. Each plan needs to include advice, education and liaison meetings with the operators. The plan needs to be continuously reviewed and reassessed based on the latest information, including the interaction with the operator’. |
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. |
REC177-3313 | 32 - Doctrine, standards, and reform | Barriers should not be installed or removed off‐line. The derrick should be located over a well at the time of removal and installation of any barrier. This will enable more decisive action to be taken in the event a problem arises. |
REC177-3334 | 32 - Doctrine, standards, and reform | Licensees, rig operators, and relevant third party contractors should develop well control competency standards for their key personnel. Wherever possible, the competencies of key personnel should be benchmarked against their roles and responsibilities. |
REC177-3363 | 32 - Doctrine, standards, and reform | DEWHA, in concert with AMSA and with expert input, should develop ‘off the shelf’ monitoring programs that can be speedily implemented following incidents in Commonwealth waters. In this context, the utility of the current Scientific Monitoring program should be peer reviewed to inform future policy. |
REC177-3298 | 32 - Doctrine, standards, and reform | Reliance upon one barrier against a blowout must not take place except with the prior written approval of the relevant regulator and then only in a true emergency situation (see below). |
REC177-3318 | 32 - Doctrine, standards, and reform | Manufacturers should be consulted about how to address non‐routine operational problems affecting their well control equipment. |
REC177-3342 | 32 - Doctrine, standards, and reform | Written (rather than verbal) approval from the DA (or new regulator) should be obtained before the commencement of well activities that lead to a physical change of a wellbore, other than in a true emergency situation (requiring amendment to regulation 17 of the Management of Well Operations Regulations). |
REC177-3373 | 32 - Doctrine, standards, and reform | Arrangements should be developed to minimise duplication between the EPBC Act and the OPGSS Act Environment Regulation. |
REC177-3277 | 32 - Doctrine, standards, and reform | The concept of ‘good oilfield practice’ should be supplemented by the requirement to incorporate into WOMPs non‐exhaustive minimum compliance standards in relation to well control: for example, stipulations as to when BOPs and/or well control systems must be in place and when they can be removed and minimum barrier requirements (a number of other factors that should be stipulated are outlined in other recommendations below). |
REC177-3306 | 32 - Doctrine, standards, and reform | It should be standard industry practice to re‐test a cemented casing shoe (that is, after WOC) whenever the plugs do not bump or the float valves apparently fail. Standard industry practice should require consideration of other tests in addition to a repeat pressure test. |
REC177-3324 | 32 - Doctrine, standards, and reform | The mere fact that the rig is over the platform should not be regarded by licensees or regulators as sufficient justification for reliance on only one barrier. The default position should be that producible wells are shut‐in when a rig is moved on and off a platform, or when a drilling unit is moved between wells on a platform. |
REC177-3354 | 32 - Doctrine, standards, and reform | NOPSA develop a policy of engagement with operators so as to enable experts (including safety experts) to canvas all available options for well control in the event of a blowout. |
Rec-ID | Code | Recommendation |
---|---|---|
REC149-3139 | 39 - Disaster Risk Management | The industry should develop in conjunction with the Regulator a process for addressing the need to maintain the risk profile of a facility moving into extended life operation at the same risk profile as when it was within design life. |
REC149-3134 | 32 - Doctrine, standards, and reform | Improved and agreed guidelines for Safety Case application and assessment, including suggested structure and content, would alleviate many current problems related to Safety Case processes. |
REC149-3130 | 32 - Doctrine, standards, and reform | The regulations pertaining to vessels of opportunity or their interpretation should be changed to facilitate a risk based approach to regulation. This approach will be consistent with the approach taken in other jurisdictions. |
REC149-3129 | 32 - Doctrine, standards, and reform | The consequences of the disapplication of the Navigation Act 1912 should be analysed, the actual consequences identified and unintended consequences addressed. |
REC149-3141 | 32 - Doctrine, standards, and reform | NOPSA should complete the next revision of Safety Case guidelines in consultation and agreement with stakeholders and continue its program to achieve consistency with a firmer hand from the CEO and management. |
REC149-3140 | 32 - Doctrine, standards, and reform | The industry should provide advice to NOPSA on where the regulations do not provide sufficient clarity and consider developing broad policy/process guidelines in consultation with the regulator to provide clarity and consistency. Regulators should not take personal views or preferences. |
Rec-ID | Code | Recommendation |
---|---|---|
REC132-3592 | 32 - Doctrine, standards, and reform | Clarifying protocols for activating VBIL beyond normal working hours and for 24 hour activations |
REC132-3591 | 32 - Doctrine, standards, and reform | Joint development of templates for provision of core incident information by regional Incident Management Teams to CFA and DSE emergency coordination centres as basis for updates to the VBIL and other authorised information recipients |
REC132-3590 | 8 - Communications and warnings | Investigate procedures for updating the Victoria Bushfire Information Line (VBIL) Integrated Voice Response recorded message system to allow recording of permanent bushfire safety, and incident-specific, messages, accessible when the VBIL is experiencing high call volumes during large and/or numerous significant incidents |
REC132-3595 | 32 - Doctrine, standards, and reform | Development of framework document investigating future direction of VBIL including its role during incidents and its role in the transition from bushfire preparation to incident to bushfire recovery phases |
REC132-3594 | 8 - Communications and warnings | Need for scripting of messages by fire agency representatives when promoting VBIL services via radio, TV and newspapers. |
Rec-ID | Code | Recommendation |
---|---|---|
REC121-3736 | 32 - Doctrine, standards, and reform | The RailCorp passenger containment policy must be abandoned. |
REC121-3653 | 10 - Infrastructure | The RMC should be equipped by RailCorp with a transcriber system, or mimic board, or such other system as is necessary to enable identification of the precise location at any time of any train on the RailCorp network. |
REC121-3687 | 10 - Infrastructure | There must be compatibility of communications systems throughout the rail network. It is essential that all train drivers, train controllers, signallers, train guards and supervisors of trackside work gangs in New South Wales be able to communicate using the same technology. |
REC121-3763 | 32 - Doctrine, standards, and reform | The ITSRR should publish guidelines to be followed by accredited organisations. |
REC121-3661 | 32 - Doctrine, standards, and reform | The rail displan should include provision for the appointment of a rail emergency management co-ordinator at the RMC, and an on-site rail commander with the sole function of assisting and supporting the emergency services during the rescue phase of the emergency response. |
REC121-3696 | 32 - Doctrine, standards, and reform | Defects reporting, recording and rectification should be integrated with the RailCorp regimes for train maintenance. |
REC121-3773 | 32 - Doctrine, standards, and reform | The ITSRR should ensure that RailCorp establishes a safety management system containing the 29 elements identified in the SMSEP report, and ensure the ongoing monitoring and improvement of the safety management system established. |
REC121-3674 | 32 - Doctrine, standards, and reform | Uniform verbal descriptions identifying that power has been isolated should be developed by RailCorp and utilised by all railway personnel, electrical service providers and all emergency response personnel. |
REC121-3705 | 32 - Doctrine, standards, and reform | The ITSRR should develop standards for periodic medical examinations which include the following: |
REC121-3730 | 32 - Doctrine, standards, and reform | Legislation should be enacted and any necessary arrangements made, to enable the ATSB to review any reports of any investigation by a rail organisation or the OTSI into any serious incident or accident in New South Wales. |
REC121-3651 | 10 - Infrastructure | A dedicated telephone line should be established by RailCorp between the RMC and any Emergency Services Control Centre for use during any emergency. |
REC121-3686 | 32 - Doctrine, standards, and reform | The standard in relation to the collection and use of data from data loggers should provide that such information must be accessed in the circumstances of any accident or incident and can be accessed to monitor driver performance generally. |
REC121-3762 | 32 - Doctrine, standards, and reform | The Chief Executive of ITSRR should have sole accountability and responsibility for the regulation of rail safety in New South Wales. |
REC121-3660 | 32 - Doctrine, standards, and reform | The rail displan should include the use by all emergency response personnel of a uniform incident command system, involving procedures for such matters as the establishment of inner and outer perimeters, control of access to the site, orderly evacuation of injured passengers and the establishment of a staging area remote from the accident site, in a unified command structure with the site controller co-ordinating the various emergency services through representatives of each service. |
REC121-3695 | 10 - Infrastructure | There should be interoperability of communications equipment between all trains operating on the New South Wales rail network. |
REC121-3772 | 32 - Doctrine, standards, and reform | RailCorp should establish a safety management system containing the 29 elements identified in the SMSEP report which is in volume 2 of this report. |
REC121-3671 | 32 - Doctrine, standards, and reform | The RailCorp emergency response plan should include a requirement for the debriefing of all senior rail and emergency response personnel involved in any rail accident, so as to determine the way or ways in which emergency response arrangements for rail accidents can be continually improved, and thereafter implement such improvements. |
REC121-3701 | 32 - Doctrine, standards, and reform | Train inspections should be carried out at the time of stabling RailCorp trains, as well as a part of train preparation prior to entering service. |
REC121-3728 | 32 - Doctrine, standards, and reform | Any barriers to communication between OTSI and ITSRR should be removed, so as to ensure that any findings made by OTSI in relation to any investigation it conducts are reported immediately to ITSRR. |
REC121-3685 | 32 - Doctrine, standards, and reform | The ITSRR should impose a standard in relation to the collection and use of data from data loggers. |
REC121-3761 | 32 - Doctrine, standards, and reform | Legislative changes should be enacted to ensure the complete independence of ITSRR from the Minister for Transport Services. |
REC121-3659 | 32 - Doctrine, standards, and reform | A railway disaster plan, or rail displan, should be developed by RailCorp and the emergency services to ensure co-ordinated inter-agency response to rail accidents and incidents on the RailCorp network. |
REC121-3692 | 32 - Doctrine, standards, and reform | Communications protocols and procedures should be standardised and mandated by regulations making them a condition of accreditation. |
REC121-3771 | 32 - Doctrine, standards, and reform | RailCorp should establish an integrated safety management system which includes the following: |
REC121-3668 | 32 - Doctrine, standards, and reform | The RailCorp emergency response plan should include action checklists of the steps that each employee is required to take, and the order for specific employees to follow in case of emergency. |
REC121-3700 | 39 - Disaster Risk Management | Maintenance plans on all trains should be revised annually. |
REC121-3727 | 32 - Doctrine, standards, and reform | The relevant legislation should be amended to provide expressly that OTSI and the Chief Investigator have the power to initiate a rail accident or incident investigation. |
REC121-3684 | 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. |
REC121-3760 | 32 - Doctrine, standards, and reform | The Advisory Board established under the Transport Legislation Amendment (Safety and Reliability) Act 2003 must be abolished. |
REC121-3657 | 10 - Infrastructure | All signal telephones must be maintained by RailCorp in proper working order. |
REC121-3690 | 32 - Doctrine, standards, and reform | All communications protocols must be strictly enforced by all accredited rail organisations. |
REC121-3770 | 32 - Doctrine, standards, and reform | A safety management system regulation should be promulgated, specifying the requirements of safety management systems in all accredited organisations, using Annexure I to this report as a guide |
REC121-3667 | 32 - Doctrine, standards, and reform | RailCorp should develop and implement an emergency response plan for management of all rail accidents. Such a plan should be subsumed by the rail displan in the case of serious accidents or incidents. |
REC121-3699 | 32 - Doctrine, standards, and reform | All reported train defects should be certified by a person in a supervisory position in RailCorp as having been rectified. |
REC121-3683 | 39 - Disaster Risk Management | RailCorp should undertake risk assessments of each of its activities as follows: |
REC121-3710 | 39 - Disaster Risk Management | The ITSRR should have permanent access to the RailCorp intranet. |
REC121-3750 | 32 - Doctrine, standards, and reform | ITSRR should initiate and/or participate in the development of a national standard for crashworthiness of all passenger trains. |
REC121-3655 | 32 - Doctrine, standards, and reform | Procedures should be put in place by RailCorp to ensure that electrical power supply to the area of an accident can be immediately isolated, if necessary, in the event of a rail accident, so as to reduce any risk of exposure of emergency response personnel to injury or harm. |
REC121-3688 | 32 - Doctrine, standards, and reform | Communications procedures must be standardised throughout the rail network, so that all railway employees describe the same subject matter in an identical way. |
REC121-3769 | 32 - Doctrine, standards, and reform | The ITSRR should continue to participate in the development of a national system for rail safety regulation, provided that any ultimate agreement between the States and Territories and the Australian Government does not produce a safety outcome for New South Wales that is less than would be achieved by the implementation of all the recommendations contained in this report. |
REC121-3662 | 32 - Doctrine, standards, and reform | The rail displan should provide for the site controller to have complete control of the site, with other agencies co-ordinating with and supporting him or her, until the rescue phase of the emergency response has been completed. |
REC121-3698 | 32 - Doctrine, standards, and reform | No RailCorp train should enter into revenue service or remain in service if, in the opinion of the driver in charge of that train, any defect in it creates a risk of injury. |
REC121-3679 | 32 - Doctrine, standards, and reform | The rail safety regulator should set standards for the design, manufacture, testing and commissioning of rolling stock to ensure that the rolling stock is fit for its purpose. |