Inquiry Search
Rec-ID | Code | Recommendation |
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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). |
REC314-3263 | 4 - Fire season preparation | Clarify and streamline processes and educate the community about their roles and responsibilities in managing native vegetation to improve hazard reduction on both public and private land. Provide additional resources to manage fuel in a shorter off fire season and develop a risk reduction target linked to prioritised objectives. |
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. |
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. |
REC301-2385 | 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. |
REC291-1237 | 5 - Hazard reduction burns | The Department of Fire and Emergency Services, utilising the Office of Bushfire Risk Management, to develop a simplified and fast track hazard reduction burn (and other fuel mitigation techniques) planning and approval process to ensure the timely conduct of township and asset protection burns by Bush Fire Brigades and individual property owners. The process is to be agile and adaptable for the range of stakeholders which may participate in low risk, small scale, low complexity burn planning and approvals. |
REC291-1236 | 4 - Fire season preparation | The Departments of Parks and Wildlife and Fire and Emergency Services to develop options for the expansion of the ‘Bushfire Mitigation Grant Scheme’ 20 January 2016 Waroona Fire Special Inquiry utilising both State and Commonwealth Government funding to enable the implementation of hazard reduction works identified through the Bushfire Risk Management Planning process. This will target hazard reduction projects on land owned by private landholders in rural-urban interface areas, critical infrastructure protection, local government land, roadsides and land managed by utilities. |
REC291-1235 | 5 - Hazard reduction burns | The Department of Parks and Wildlife to continue emphasis on landscape hazard reduction burning with the annual objective of treating 140,000 hectares per annum in Land Management Zone C. In combination with Recommendation 2 (above) the strategic objective will be that a fuel age of less than six years will be maintained across 45% of the landscape on State Forest, National Parks and other Parks and Wildlife managed lands in the South West and Perth Hills. This will address the current backlog (created from under achievements of the recent two decades of burn programs) by the end of the 2020-2021 burning season (i.e. within the next 5 years). |
REC291-1234 | 5 - Hazard reduction burns | The Department of Parks and Wildlife to plan for the highest priority hazard reduction burning effort around settlements and critical assets in the South West and Perth Hills. The annual objective is to treat a total of 60,000 hectares of priority hazard reduction per annum, comprising 20,000 hectares per annum of Land Management Zone A and 40,000 hectares per year of Land Management Zone B. |
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. |
Rec-ID | Code | Recommendation |
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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. |
REC264-1076 | 13 - Mapping and data quality | The State equip itself to undertake rapid air quality monitoring in any location in Victoria, to: • collect all relevant data, including data on PM , carbon monoxide and ozone; and 2.5 • ensure this data is used to inform decision-making within 24 hours of the incident occurring. |
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 |
Rec-ID | Code | Recommendation |
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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. |
REC258-2556 | 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. |
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. |
Rec-ID | Code | Recommendation |
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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: |
REC257-1546 | 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. |
REC257-1539 | 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. |
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. |
REC247-0935 | 4 - Fire season preparation | That the State Emergency Management Committee includes in its planning, the development of contingency emergency management plans for areas of high risk due to local conditions. |
REC247-0860 | 13 - Mapping and data quality | That Tasmania Fire Service establishes suitable systems and practices for recording fire management objectives and tactics. |
REC247-0945 | 20 - Role of police | That Tasmania Police conducts a review to ensure emergency management is treated as a priority and a core function throughout the organisation, including the development of contemporary capabilities, and is supported by an appropriate culture. |
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. |
REC247-0934 | 4 - Fire season preparation | That the State Fire Management Committee considers developing a structured, systemic and proactive bushfire hazard reduction program with municipal councils and Tasmania Fire Service; and advises the Government on any legislative or other changes required to implement such a program. |
REC247-0851 | 13 - Mapping and data quality | That if a sound business case is developed, the Emergency Information Management and Sharing Project be supported. |
REC247-0942 | 1 - Land-use and building regs | That the Government makes land use planning and building construction to prevent and mitigate bushfire risk a high priority and establishes a means to progress improvements in this area, such as a designated body or group, as soon as possible. |
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. |
REC247-0933 | 4 - Fire season preparation | That the Government considers whether a peak body should be established, with authority to effectively implement a bushfire mitigation plan. |
REC247-0850 | 13 - Mapping and data quality | That police and other emergency service agencies establish and maintain effective recording systems for emergency operations. |
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. |
REC247-0904 | 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. |
REC247-0951 | 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. |
REC247-0931 | 4 - Fire season preparation | That a specific risk prevention and mitigation advisory body be established for the State Emergency Management Committee. |
REC247-0939 | 5 - Hazard reduction burns | That Tasmania Fire Service conducts a review of the fire permit system in the Fire Service Act 1979, and implements change to improve the efficiency and effectiveness of the system by: • considering whether it is appropriate to authorise persons or organisations to conduct fuel reduction burning during a permit period • providing a better match between the period, area and fire risk • maintaining a timely and efficient process for issuing permits • naming the period in a way that draws attention to bushfire risk • establishing a reporting and accountability process. |
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. |
REC247-0947 | 20 - Role of police | That Tasmania Police develops and implements a program for examining emergency management arrangements and facilities in Australia. |
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. |
REC247-0938 | 5 - Hazard reduction burns | That Tasmania Fire Service or another suitable agency provides information to the community which shows, in simple form, the legislation applicable to approvals for lighting fires on private property and the various relationships between that legislation. |
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. |
REC247-0946 | 20 - Role of police | That Tasmania Police establishes a section within its structure with responsibility for developing and maintaining contemporary expertise in emergency management, progressing innovation, assisting organisational change initiatives and supporting its responsibilities in state emergency management arrangements. |
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. |
REC223-0516 | 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. |
REC223-0515 | 5 - Hazard reduction burns | The Department of Environment and Conservation urgently undertake a review of its risk management practices as they relate to prescribed burns including but not limited to: *reviewing risk management practices to ensure that they are in accordance with AS/NZS ISO 31000:2009; * finalising and implementing the new complexity model developed in house by the DEC; * considering a broader set of parameters of risk by conducting an environmental scan or similar tool for areas under consideration for a prescribed burn; *updating the prescribed fire plans to reflect the broader risk considerations discovered through environmental scanning; *better informing the risk considerations by updating the ‘Red Book’ to reflect current research on burning in coastal heath; and * reconsidering the utility of the ‘Red Flag Burn’ notification on files and either adopting it as a policy across the State or removing it as a consideration. |
REC223-0514 | 5 - Hazard reduction burns | The Department of Environment and Conservation review its current policies and operational guidelines in particular by: * strengthening the governance of operations by ensuring the Guidelines are relevant and practical; * ensuring the processes that are implemented for prescribed burns are: (a) value adding to the decisions and approvals required (b) informed by substantive input (c) focussed on outcome rather than process; *completing the draft management plan for the Leeuwin-Naturaliste Capes Area Parks and Reserves in accordance with the provisions of the Conservation and Land Management Act 1989; * exploring the possibility of automating and streamlining the various processes for formulating a prescription for prescribed burns for ease of access and updating; and * clarifying the guidance provided to decision makers as to the ‘edging’ and security of prescribed burns. |
Rec-ID | Code | Recommendation |
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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. |
REC200-0352 | 13 - Mapping and data quality | The Fire and Emergency Services Authority and local governments ensure that the ability to: measure and map fuel loads maintain fuel load databases draw up prescriptions for, and oversee controlled burns are included as key competencies in any future recruitment of Chief Bushfire Control Officers and Community and Emergency Services Managers. |
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. |
REC200-0360 | 4 - Fire season preparation | The Interagency Bushfire Management committee develop and oversee a work program to: conduct site specific assessments to assess current fuel loads assess, analyse and prioritise bushfire risk on land within and adjacent to communities develop a three year rolling mitigation works program with annual implementation and review. This work should commence independently of any decision on the most effective online integrated system. All data collected should be uploaded to the SLIP. |
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. |
REC200-1692 | 5 - Hazard reduction burns | The Fire and Emergency Services Authority, the Department of Environment and Conservation and local governments take proactive steps to conduct their prescribed burning programs as joint exercises. This will give effect to: |
REC200-0351 | 5 - Hazard reduction burns | The Fire and Emergency Services Authority, the Department of Environment and Conservation and local governments take proactive steps to conduct their prescribed burning programs as joint exercises. This will give effect to: Reducing fuel load Improving inter-operability A mutual understanding of the fire fighting techniques of each agency. |
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. |
REC200-0359 | 13 - Mapping and data quality | The State Government ensure that the continued development of the Fire and Emergency Service Authority’s Integrated Bushfire Risk Management System is dependent on an independent comparative assessment of its functionality and cost effectiveness against the Spatial Support System used by the Department of Environment and Conservation. |
REC200-0377 | 1 - Land-use and building regs | The State Government mandate that the title deeds for relevant properties be amended to indicate if the property is in a declared bushfire prone area. |
REC200-1691 | 5 - Hazard reduction burns | The State Government consider resourcing the Department of Environment and Conservation and local governments to develop and administer a comprehensive prescribed burning program in Perth‟s urban/rural interface to compliment DEC's existing landscape-scale program. |
REC200-0350 | 5 - Hazard reduction burns | The State Government consider resourcing the Department of Environment and Conservation and local governments to develop and administer a comprehensive prescribed burning program in Perth’s urban/rural interface to compliment DEC’s existing landscape-scale program. |
REC200-1707 | 1 - Land-use and building regs | Main Roads Western Australia undertake more frequent examinations of its bridges located in areas prone to bushfire and ensure that the risk posed to loss of infrastructure in a fire is understood by local authorities. |
REC200-0358 | 13 - Mapping and data quality | 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. The system should enable public access to allow members of the community to access information about the fuel load in a given locality. |
REC200-0376 | 1 - Land-use and building regs | State and locals governments: a) recognise that regardless of future declarations of bushfire prone areas, the existing planning and building problems in the Perth Hills related to bushfire risk will persist; b) urge residents in these areas to retrofit their homes and evaporative air conditioners in compliance with AS 3959 - 2009; c) examine options to retrospectively bring these areas into compliance with Planning for Bushfire Protection Guidelines. |
REC200-0346 | 1 - Land-use and building regs | The Fire and Emergency Services Authority work in partnership with the Real Estate Institute of Western Australia to develop a package of information for new residents moving into bushfire prone areas, and a process to ensure this information is provided through real estate agents. |
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. |
REC200-0356 | 5 - Hazard reduction burns | 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. |
REC200-1732 | 25 - Inquiry, audit, lessons management and after action review | The State Government review implementation of the Special Inquiry's recommendations in two years. |
REC200-0368 | 20 - Role of police | 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. |
REC200-0340 | 1 - Land-use and building regs | The State Government transfer responsibility for declaring bushfire prone areas from local government to the Western Australian Planning Commission. The Western Australian Planning Commission should urgently assess those areas that should be declared bushfire prone. |
REC200-1700 | 4 - Fire season preparation | The Interagency Bushfire Management committee develop and oversee a work program to: |
REC200-0355 | 13 - Mapping and data quality | The Western Australian Local Government Association explore the feasibility of local governments utilising aerial and satellite imagery to monitor firebreaks and fuel loads on private property. |
REC200-1726 | 41 - Emergency Management exercises | 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. |
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. |
REC200-0392 | 25 - Inquiry, audit, lessons management and after action review | The State Government review implementation of the Special Inquiry’s Recommendations in two years. |
Rec-ID | Code | Recommendation |
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REC183-0109 | 1 - Land-use and building regs | It is sensible that, in considering planning development proposals on land adjacent to the DEC estate, that development authorities invite comment from DEC on the fire management consequences of development proposals. |
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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REC121-3695 | 10 - Infrastructure | There should be interoperability of communications equipment between all trains operating on the New South Wales rail network. |
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. |
REC121-3725 | 13 - Mapping and data quality | The data and information management system should be compatible with any data and information management system established by the ATSB for the designated interstate rail network, provided that the establishment of a compatible system does not reduce the amount or quality of the information obtained by ITSRR below the optimum levels which it needs to conduct trend analysis, and otherwise properly manage the safety of rail operations in New South Wales. |
REC121-3683 | 39 - Disaster Risk Management | RailCorp should undertake risk assessments of each of its activities as follows: |
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. |
REC121-3724 | 13 - Mapping and data quality | The ITSRR should establish a data and information management system, containing all data and information that it requires, to continually monitor the safety of the New South Wales rail system. |
REC121-3673 | 41 - Emergency Management exercises | Regular field training exercises should be conducted by RailCorp with the emergency services to ensure that the incident command system and rail displan are able to be fully implemented as quickly as possible and are reviewed and improved. |
REC121-3758 | 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. |
REC121-3713 | 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. |
REC121-3664 | 20 - Role of police | The location of the command post for site control at the scene of any rail accident should be identified by NSW Police by a distinctive flashing light. |
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. |
REC121-3710 | 39 - Disaster Risk Management | The ITSRR should have permanent access to the RailCorp intranet. |
REC121-3657 | 10 - Infrastructure | All signal telephones must be maintained by RailCorp in proper working order. |
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. |
REC121-3687 | 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. |
REC121-3700 | 39 - Disaster Risk Management | Maintenance plans on all trains should be revised annually. |
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. |
REC121-3726 | 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. |
REC121-3684 | 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. |
REC121-3768 | 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. |