Inquiry Search
Rec-ID | Code | Recommendation |
---|---|---|
REC327-4348 | 38 - Agency/Department Reporting | By December 2023, the Rural Fire Service should: report annually on fleet allocations to RFS Districts, and identify the ways in which fleet resources align with district-level fire risks |
REC327-4349 | 38 - Agency/Department Reporting | By December 2023, the Rural Fire Service should: develop performance measures to assess the performance and capabilities of the fleet in each RFS District by recording and publicly reporting on: fire response times and fire response outcomes; and, completions of fire hazard reduction works. |
Rec-ID | Code | Recommendation |
---|---|---|
REC326-4342 | 24 - Govt responsibility | To promote integrity and transparency, the Department of Regional NSW should ensure that for all future grant programs it: ensures staff declare conflicts of interest prior to the commencement of a grants stream, and that these conflicts of interest are recorded and managed. |
REC326-4343 | 24 - Govt responsibility | To promote integrity and transparency, the Department of Regional NSW should ensure that for all future grant programs it: ensures a communications plan is in place, including the communication of guidelines to potential applicants. |
REC326-4344 | 24 - Govt responsibility | To promote integrity and transparency, the Department of Regional NSW should ensure that for all future grant programs it: establishes and follows guidelines that align with relevant good practice guidance including accountabilities, key assessment steps and clear assessment criteria. |
REC326-4340 | 24 - Govt responsibility | To promote integrity and transparency, the Department of Regional NSW should ensure that for all future grant programs it: documents all key decisions and approvals in line with record keeping obligations. |
REC326-4341 | 24 - Govt responsibility | To promote integrity and transparency, the Department of Regional NSW should ensure that for all future grant programs it: ensures regular monitoring is in place as part of funding deeds. |
Rec-ID | Code | Recommendation |
---|---|---|
REC315-3834 | 12 - EM agency and authority | That, in order to ensure all firefighters understand how local situational awareness reflects (or may not reflect) the broader scale situation presented by a large/extreme bush fire and the implications this may have on asset protection and fire suppression strategies, the NSW RFS: |
REC315-3800 | 13 - Mapping and data quality | That the NSW Government, along with other Australian governments, ask AFAC to establish a national bush fire database. This database would enable: |
REC315-3842 | 24 - Govt responsibility | That, in order to prioritise early suppression and keep fires small: |
REC315-3813 | 35 - Business and Industry in relation to industry | That, in order to ensure tourism businesses are prepared for natural disasters including bush fires, Resilience NSW work with NSW RFS and Destination NSW to develop bush fire preparedness support for tourism businesses, based on research into existing models. Over time, this support could be expanded to include other natural hazards. |
REC315-3859 | 25 - Inquiry, audit, lessons management and after action review | That, in order to ensure State Emergency Operations Centre (SEOC) interoperability during all natural disasters, Resilience NSW review the current SEOC arrangements and location including responsibilities for ongoing resourcing and maintenance. |
REC315-3833 | 3 - Biodiversity | That Government invest in long-term ecosystem and land management monitoring, modelling, forecasting, research and evaluation, and harness citizen science in this effort. This will include, among other things: |
REC315-3873 | 25 - Inquiry, audit, lessons management and after action review | That Resilience NSW review existing functional area arrangements to ensure they are closely aligned to agencies responsible for direct service delivery. |
REC315-3799 | 9 - Community education | That at the start of each fire season, based on advice from the Bush Fire Coordinating Committee, Government provide a public statement with an evaluation of the likely fire season risk and the effectiveness of the planning and preparation for the upcoming season. This should be based on sophisticated monitoring of the key risk factors and signals for an extreme fire season. It should form the basis for clear public communication about these risks on a regional basis and the actions that Government proposes in preparation. |
REC315-3841 | 12 - EM agency and authority | That, in order to ensure suitably skilled and experienced personnel operate as Divisional Commanders during major fire incidents, Bush Fire Management Committees identify appropriate personnel as part of their plan of operations. |
REC315-3812 | 25 - Inquiry, audit, lessons management and after action review | That Government commit to: |
REC315-3858 | 25 - Inquiry, audit, lessons management and after action review | That, in order to improve cross-agency communication and coordination during bush fires, the NSW RFS review Fire Control Centres (FCCs) in areas that were heavily affected by fire. The results should be combined with the Emergency Operations Centre (EOC) Facilities Review to identify areas that would benefit from a purpose-built FCC, enabling co-location with the EOC. |
REC315-3828 | 9 - Community education | That, in order to improve bush fire planning and protection of road infrastructure and to ensure communities, freight movers and fire fighting agencies have appropriate access and egress in a bush fire event, Government, working with local government as needed: |
REC315-3869 | 42 - Culture and Heritage | That, in order to ensure Aboriginal people can access appropriate support during evacuation, Resilience NSW work with Local Emergency Management Committees and Aboriginal Affairs to ensure: |
REC315-3798 | 25 - Inquiry, audit, lessons management and after action review | That, in order to ensure recommendations accepted by the Government are implemented in a timely and transparent manner, Government establish a central accountability mechanism to track implementation of recommendations from bush fire-related reviews and inquiries and consider expanding this to other policy areas. |
REC315-3840 | 29 - Operational Health and Safety | That, in order to ensure firefighter sustenance is of sufficient volume and quality, the NSW RFS reviews food standards and procedures in consultation with volunteers. The review should include catering service standards, including food safety, as well as the viability of sourcing commercial contracts and providing 12-hour food packs to firefighters. |
REC315-3810 | 24 - Govt responsibility | That, to ensure updated resource-sharing arrangements are in place, the NSW and Victorian Governments progress and finalise a multi-agency Memorandum of Understanding before the 2020-21 fire season commences. |
REC315-3857 | 12 - EM agency and authority | That, in order to ensure timely payment and maintain positive ongoing supplier relationships during large-scale bush fires, the NSW RFS implements an automated logistics solution, informed by the outcomes of the Emergency Logistics Project. |
REC315-3823 | 42 - Culture and Heritage | That, in order to increase the respectful, collaborative and effective use of Aboriginal land management practices in planning and preparing for bush fire, Government commit to pursuing greater application of Aboriginal land management, including cultural burning, through a program to be coordinated by Aboriginal Affairs and Department of Planning, Industry and Environment working in partnership with Aboriginal communities. This should be accompanied by a program of evaluation alongside the scaled-up application of these techniques. |
REC315-3868 | 33 - Relief and recovery | That, in order to ensure people only need to tell their story once to access government agency support following an emergency, Resilience NSW and Service NSW jointly design an inclusive, person-centred approach to information collection at evacuation centres. This should be supported by an opt-in scheme enabling personal information to be shared between NSW government agencies, local councils and non-governmental organisations administering support services for disaster-affected people. |
REC315-3839 | 29 - Operational Health and Safety | That, to ensure firefighters can access mental health support through GPs, Government work with the Commonwealth Government to: |
REC315-3808 | 22 - Role of local Gvt | That, in order to strengthen the capability of local councils in future emergency events: |
REC315-3850 | 3 - Biodiversity | That Government develop and implement a policy on injured wildlife response, rescue and rehabilitation including: |
REC315-3822 | 42 - Culture and Heritage | That Government adopt the principle that cultural burning is one component of a broader practice of traditional Aboriginal land management and is an important cultural practice, not simply another technique of hazard reduction burning. |
REC315-3864 | 9 - Community education | That, in order to ensure people can access clear information on cross-border fires, the NSW RFS: |
REC315-3838 | 29 - Operational Health and Safety | That, in order to ensure all NSW RFS members can access the mental health support they need, the NSW RFS expands in-house mental health support for members. |
REC315-3801 | 13 - Mapping and data quality | That, in order to improve capability to detect ignitions and monitor accurately all fire edge intensity and progression automatically across the State in near real time, Government establish a spatial technology acceleration program to maximise the information available from the various remote sensing technologies currently in use and to plan for inclusion of new remote sensing systems that can sense precisely and rapidly through heavy smoke, cloud, fog and dust. This will require work within the State and with partners nationally and internationally. |
REC315-3846 | 12 - EM agency and authority | That, in order to maximise the efficiency and effectiveness of heavy plant used in dry fire fighting techniques, the NSW RFS expand and introduce the following in respect to heavy plant: |
REC315-3819 | 13 - Mapping and data quality | That, as part of the spatial technology acceleration program, Government support deployment of remote sensing and picture processing technologies to monitor and audit how well Asset Protection Zones and defendable space are being maintained, especially around towns. |
REC315-3860 | 25 - Inquiry, audit, lessons management and after action review | That, in order to ensure the guiding principles and approval processes are contemporary, streamlined and more flexible, the NSW and Commonwealth Governments review the Defence Assistance to the Civil Community (DACC) arrangements. This review should include the circumstances in which the State can request Commonwealth assistance, and the level of information provided by the ADF to the State on available resources and capabilities. |
Rec-ID | Code | Recommendation |
---|---|---|
REC304-2405 | 24 - Govt responsibility | Retain the Bushfires Council as a Ministerial advisory body. |
REC304-2413 | 12 - EM agency and authority | Authorise the Director of Bushfires NT to intervene in volunteer brigade affairs where necessary to maintain an effective fire management capacity in a brigade area. |
REC304-2412 | 12 - EM agency and authority | Maintain independence of volunteer brigades as community-based organisations and clarify the status and role of volunteers within the chain of command. |
REC304-2411 | 12 - EM agency and authority | Create new seasonal paid positions to coordinate and support groups of volunteer brigades. |
REC304-2419 | 28 - Personal responsibility | Further define the principle of landholder responsibility for fire management and strengthen its fundamental place in the Act. This should include a clear requirement for landholders to prevent fire on their land from spreading to neighbouring properties. |
REC304-2410 | 12 - EM agency and authority | Authorise Bushfires NT to establish volunteer bushfire brigades and to give authority to volunteer firefighters to take part in fire suppression and mitigation operations. |
REC304-2414 | 12 - EM agency and authority | Clarify and streamline the allocation of powers to Bushfires NT staff and volunteers involved in bushfire management operations, using a system of delegation through a chain of command similar to the arrangements described in the NT Fire and Emergency Act. |
REC304-2406 | 12 - EM agency and authority | Retain the Regional Bushfires Committees as regional planning and consultative bodies tasked with monitoring, reviewing and making recommendations on fire management in a Fire Control Region. |
REC304-2414 | 12 - EM agency and authority | Clarify and streamline the allocation of powers to Bushfires NT staff and volunteers involved in bushfire management operations, using a system of delegation through a chain of command similar to the arrangements described in the NT Fire and Emergency Act. |
Rec-ID | Code | Recommendation |
---|---|---|
REC302-2403 | 12 - EM agency and authority | Take steps to ensure that both fire commissioners are seeking opportunities to engender a culture in their respective organisations that seeks to attract and foster the volunteer ethos and experience |
REC302-2401 | 12 - EM agency and authority | While the proposal to establish an integrated call and dispatch centre is being implemented, Fire and Rescue NSW should take steps to civilianise ComCen and maintain experienced senior officers from both agencies as supervisors similar to how the NSW Police Force and Ambulance Service of NSW operate |
REC302-2399 | 24 - Govt responsibility | Implement a fully integrated civilianised single call and dispatch centre, that includes a redundancy option outside the Sydney CBD, which will adopt an agnostic approach to deploy the quickest most suitable resource to an emergency. Such a centre should be managed by either a non uniformed public servant staffed organisation like the Office for Emergency Management, or the NSW Police Force |
REC302-2397 | 12 - EM agency and authority | Use the model and system in place at the Ambulance Service of NSW as a benchmark for call taking, dispatch and the provision of situational awareness when deploying resources. This will overcome the lack of a feedback loop in current bushfire operations |
Rec-ID | Code | Recommendation |
---|---|---|
REC002-4010 | 35 - Business and Industry in relation to industry | The Commission do not approve of removing any responsibility from the management by increasing the power or number of the Inspectors. The visits of these officials should, so far as possible, be visits of surprise. |
REC002-4008 | 35 - Business and Industry in relation to industry | Where dust exists in quantity, and under conditions favourable for ignition, it should be periodically and sufficiently dampened by water |
REC002-4004 | 35 - Business and Industry in relation to industry | Where safety-lamps are used, and the obligation is laid upon the men to cleanse the same, all examinations, tests, and repairs to these should be done by the owners. |
REC002-4003 | 35 - Business and Industry in relation to industry | Where gas exists, and no provisions are made for its constant removal, no shots should be fired, and, where permitted in a gassy mine, shots should be fired only by a man specially appointed, and at such hours when the miners are not within the mine. All shots should be tamped by stone well damped, and only copper or wooden tools should be employed. As far as possible the use of explosives should be discouraged, and skilful mining encouraged. Danger-boards should be placed further from the faces whence gas issues (say), where practicable, 50 yards. |
REC002-4013 | 19 - Offences | Infringement of the regulations by either party should be followed by a summary form of justice, instituted before two Magistrates. |
REC002-4002 | 19 - Offences | Where safety-lamps are necessary - gas being present for (say) one month after being found in dangerous quantity - they should be securely locked by a man duly appointed, and tampering with them must be punishable by a simple and inexpensive process of law. |
REC002-4012 | 38 - Agency/Department Reporting | Complete sets of daily-report books should be provided, and kept in the mine or office, to be overlooked by the Inspector during his periodical visits. |
REC002-4001 | 35 - Business and Industry in relation to industry | The Commission consider that in all mines where gas exists the course of the air should be directed to sweep along the working-faces; in mines worked by Pillar and Stall, bratticing must be resorted to to carry the gas from the face as it issues, and so prevent any accumulation of explosive gases or of gases inimical to life. In cases where gas exists it would be better that no bords should be broken off the back or return heading or supplied with air fouled by dangerous gases. The panel system of working by confining and localising districts, or some modification thereof, might be pursued with advantage. |
Rec-ID | Code | Recommendation |
---|---|---|
REC280-1380 | 13 - Mapping and data quality | That the NSW Rural Fire Service investigate mechanisms to enhance the predictability of megafires and how this information is communicated easily to the public. |
REC280-1396 | 25 - Inquiry, audit, lessons management and after action review | That the Minister for Police and Emergency Services review the communications technologies used by the NSW Rural Fire Service, Fire and Rescue NSW, the NSW National Parks and Wildlife Service and Forestry NSW during fire fighting operations, to ensure that systems are standardised and effective. Within this context, the potential value of satellite phone technology should be investigated. |
REC280-1379 | 9 - Community education | That the NSW Rural Fire Service develop and implement a comprehensive community education campaign aimed at increasing community understanding of and support for hazard reduction burns. |
REC280-1394 | 12 - EM agency and authority | That the Minister for Police and Emergency Services examine the feasibility of relocating the NSW Rural Fire Service headquarters to a rural or regional location. |
REC280-1388 | 25 - Inquiry, audit, lessons management and after action review | That the NSW Rural Fire Service: |
REC280-1387 | 12 - EM agency and authority | That the NSW Rural Fire Service: |
REC280-1384 | 12 - EM agency and authority | That the NSW National Parks and Wildlife Service examine its staffing policy for periods of extreme and catastrophic weather conditions to ensure that sufficient staff are available on site on fire watch. |
Rec-ID | Code | Recommendation |
---|---|---|
REC261-1508 | 25 - Inquiry, audit, lessons management and after action review | That the NSW Rural Fire Service review its procedures, systems and infrastructure for notifying community members of bush fires, both when a fire has broken out and as it proceeds, to ensure the provision of timely and adequate information. |
REC261-1507 | 24 - Govt responsibility | That the NSW Government consider enabling the default position during catastrophic and extreme fire danger periods to be the same as for section 44 fires, so that fire control centres have the same systems and resources ready to deploy should a fire break out. |
REC261-1505 | 25 - Inquiry, audit, lessons management and after action review | That the NSW Rural Fire Service: |
REC261-1504 | 12 - EM agency and authority | That the NSW Rural Fire Service: |
REC261-1520 | 33 - Relief and recovery | That the Ministry for Police and Emergency Services urgently review its policies for the provision of disaster welfare services to ensure that in the event of a bush fire emergency and the declaration of a fire under section 44 of the Rural Fires Act 1997, adequate funding and services, especially recovery centres and mental health services, are provided for an adequate length of time, with gradual transition to normal service delivery when those services are no longer required. |
REC261-1501 | 12 - EM agency and authority | That the NSW National Parks and Wildlife Service examine its staffing policy for periods of extreme and catastrophic weather conditions to ensure that sufficient staff are available on site on fire watch. |
REC261-1511 | 12 - EM agency and authority | That the Minister for Police and Emergency Services examine the feasibility of relocating the NSW Rural Fire Service headquarters to a rural or regional location. |
REC261-1496 | 9 - Community education | That the NSW Rural Fire Service develop and implement a comprehensive community education campaign aimed at increasing community understanding of and support for hazard reduction burns. |
Rec-ID | Code | Recommendation |
---|---|---|
REC260-1049 | 13 - Mapping and data quality | That the Rural Fire Service consider proposing an arrangement with the Bureau of Meteorology to deploy weather balloons specifically for the purpose of assessing atmospheric instability during periods of severe to catastrophic fire danger in locations most likely to be severely affected, for example, areas in which a very high C-Haines index reading is registered and local fires have been identified. |
REC260-1058 | 28 - Personal responsibility | That NPWS and the RFS consider developing a land management policy that requires active engagement with property owners adjoining the Park to ensure that hazard reduction and asset protection is encouraged and undertaken before the bush fire season commences |
REC260-1054 | 2 - Emergency powers | That the Rural Fire Service consider extending pre-emptive section 44 to whole of Castlereagh RFS/Warrumbungle Shire area. |
REC260-1050 | 13 - Mapping and data quality | Alternatively, I recommend that the RFS consider developing such capacity to deploy weather balloons itself, in conjunction with mobile weather stations, for this purpose. |
Rec-ID | Code | Recommendation |
---|---|---|
REC259-1046 | 33 - Relief and recovery | That prior to the commencement of any major clean-up, firm policy be established and made known to the extent to which material removal will be the responsibility of the home owner, the Council or the State led recovery effort. |
REC259-1045 | 9 - Community education | That recovery policy incorporates the need for regular public meetings which give access to officials and representatives of agencies, as required |
REC259-1044 | 9 - Community education | That where, in the future a similar process for land clearing is adopted, the rationale and process is better explained and widely promulgated. |
REC259-1043 | 33 - Relief and recovery | That a single victim registration form be designed, which captures all relevant details required for use by any support agency both in the Response Phase at Evacuation centres and during the Recovery Phase. That such documents when completed form part of a wider database which can be accessed by all relevant agencies |
Rec-ID | Code | Recommendation |
---|---|---|
REC209-1665 | 12 - EM agency and authority | Develop a long term forecast of volunteer requirements, by region, and then review the adequacy of volunteer operational grants, equipment and facilities to meet this forecast. |
REC209-1647 | 9 - Community education | A comprehensive pre bushfire season communications strategy, that supplements and extends the information provided on the DNRETAS website, be implemented to inform and educate landholders. |
REC209-1656 | 9 - Community education | Ensure educational material is available prior to the commencement of each fire season in each region. |
REC209-1664 | 12 - EM agency and authority | Review Bushfires NT brigade boundaries to increase the catchment for possible volunteers and maximise the availability and allocation of equipment. |
REC209-1646 | 28 - Personal responsibility | Spreading the message of enforcement of landholder’s obligations and responsibilities through active consultation and ultimately the issuing of infringement notices be adopted as a planned strategic intervention to promote the importance of compliance with the Bushfires Act. |
REC209-1655 | 9 - Community education | Professional communications and educational resources be contracted to develop an integrated communications and engagement strategy and program for implementation by Bushfires NT. |
REC209-1663 | 12 - EM agency and authority | Review Bushfires CRC initiatives as the basis for the implementation of a recruitment drive in the Territory. |
REC209-1643 | 25 - Inquiry, audit, lessons management and after action review | An evaluation be conducted into the integration of the appropriate elements of the South Australian Country Fire Service “Crimson” networking system into Bushfires NT ICT. |
REC200-1693 | 22 - Role of local Gvt | The Fire and Emergency Services Authority and local governments ensure that the ability to: |
REC209-1654 | 24 - Govt responsibility | That the Director Bushfires NT NOT be appointed as a member of Council. |
REC209-1661 | 9 - Community education | Arrange a forum that includes all stakeholders in large scale fire management for the purposes of aligning the various stakeholder strategies across the Territory. |
REC209-1676 | 19 - Offences | Increase the emphasis on the issuing of infringement notices to reinforce the responsibilities of landholder’s in the management of bushfires in the Territory. |
REC209-1653 | 9 - Community education | Develop a continuing education program for new members of the Bushfires Council, the Regional Committees and stakeholders’ representatives, to ensure that all stakeholders clearly understand the role and processes involved in the Bushfires Council advisory function. |
REC209-1660 | 24 - Govt responsibility | Better alignment between divisions within DNRETAS be achieved through the development of an integrated strategy that addresses the combined objectives of weed management, land management, carbon farming and biodiversity management using fire across the Territory. |
REC209-1668 | 12 - EM agency and authority | Maintain DNRETAS as the lead agency for all aspects of Bushfires NT’s role and maintain Bushfires NT as the lead organisation for both fire prevention and fire fighting operations in its specified districts and zones. |
REC209-1649 | 12 - EM agency and authority | Regular rotation of staff across other regions of the Territory to increase knowledge, skills and expertise that can be called upon to increase response effectiveness. |
REC209-1657 | 9 - Community education | Information for all landholders, in appropriate cultural and language formats be developed and distributed through events and multiple media. |
Rec-ID | Code | Recommendation |
---|---|---|
REC208-0526 | 25 - Inquiry, audit, lessons management and after action review | That OEH’s testing procedures for determining the impact of pollution incidents incorporate additional requirements for the checking and verification of results before those results are released. |
REC208-0527 | 35 - Business and Industry in relation to industry | That the Office of Environment and Heritage require Orica to engage and fund appropriate independent experts to oversee any modifications to the plant in the next major maintenance overhaul of the plant in 2016 and in any upgrades to the plant prior to that date. |
Rec-ID | Code | Recommendation |
---|---|---|
REC163-1935 | 19 - Offences | The prescribed penalty notice penalty amount for section 99(6) of the Rural Fires Act 1997 be increased to $1,100. |
REC163-1940 | 19 - Offences | That legislation be prepared by the Criminal Law Review Division of the Attorney General’s Department allowing designated officers of the Rural Fire Service to apply for a warrant in certain circumstances. |
REC163-1934 | 19 - Offences | The prescribed penalty notice penalty amount for section 100(2) of the Rural Fires Act 1997 be increased to $1,100. |
REC163-1939 | 2 - Emergency powers | That the Rural Fires Act 1997 be amended to provide to designated Fire Investigation Officers of the Rural Fire Service the power to enter any land upon which a bushfire has occurred for the purposes of investigation for a period of up to 24 hours after a fire has been declared out. |
REC163-1938 | 12 - EM agency and authority | That appropriate officers of the Rural Fire Service be granted the same powers as granted to officers of NSW Fire Brigades under section 19 of the Fire Brigades Act 1989. |
REC163-1937 | 19 - Offences | That the Attorney General’s Department’s Crime Prevention Division consider the causes of, and any solution to, the high number of juveniles involved in causing bushfires. |
REC163-1936 | 19 - Offences | The prescribed penalty notice penalty amount for section 66(7) of the Rural Fires Act 1997 be increased to $1,100. |
REC163-1941 | 19 - Offences | A working group be established to consider methods of preventing criminal firestarting. |
Rec-ID | Code | Recommendation |
---|---|---|
REC121-3774 | 38 - Agency/Department Reporting | The ITSRR must provide a quarterly report to the Minister for Transport Services on the progress made by RailCorp in implementing these recommendations, including: |
REC121-3693 | 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. |
REC121-3723 | 38 - Agency/Department Reporting | All ATSB accident investigation reports should be made public. |
REC121-3743 | 29 - Operational Health and Safety | All passenger trains operating in New South Wales must have the external emergency door release clearly marked with the words “Emergency Door Release”. |
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. |
REC121-3704 | 28 - Personal responsibility | RailCorp should continue its system of voluntary self-identification and rehabilitation of employees with alcohol or drug related problems. |
REC121-3731 | 29 - Operational Health and Safety | RailCorp should develop a plan to be submitted to ITSRR to address the deficiencies in the safety culture of RailCorp, including: |
REC121-3759 | 29 - Operational Health and Safety | A Safety Reform Program Director (hereafter referred to as SRPD), reporting directly to the Chief Executive of RailCorp, should be retained to manage, as head of a Safety Reform Program Office, any safety reform program being undertaken by RailCorp. The SRPD should work with the Chief Executive and senior management to ensure the implementation of an integrated safety management system and the cultural change required. The SRPD must have qualifications suitable for recognition by the Australian Institute of Project Management as a master program director. He or she should report to and be under the control of the Chief Executive, to ensure that the accountability of the Chief Executive is not reduced. The SRPD should co-ordinate and integrate any existing rail safety reform programs and, in consultation with and with the authority of the Chief Executive he or she should: |
REC121-3678 | 35 - Business and Industry in relation to industry | All railway owners and operators should have a quality assurance program for the design and construction of rolling stock and regular review of construction to ensure that the rolling stock satisfies the original functional performance specifications. |
REC121-3711 | 29 - Operational Health and Safety | The ITSRR should establish an electronic document control system to enable effective and reliable information to be gathered for monitoring the safety of the New South Wales rail system. |
REC121-3737 | 29 - Operational Health and Safety | There must be a minimum of two independent methods of self-initiated emergency escape for passengers from all trains at all times. |
REC121-3768 | 25 - Inquiry, audit, lessons management and after action review | The ITSRR, when considering a re-application for accreditation, should conduct a field audit of the organisation to ensure that it is carrying on its activities in accordance with the basis upon which it seeks accreditation. |
REC121-3691 | 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. |
REC121-3722 | 38 - Agency/Department Reporting | The ATSB should deliver any report of any such rail accident which it investigates to the Board of any rail organisation involved in the accident, ITSRR and the Minister for Transport Services. |
REC121-3742 | 19 - Offences | The risk of abuse of internal passenger emergency door releases should be further reduced by introducing significant penalties for any improper use of such an emergency facility. It should be a criminal offence for anyone to use or tamper improperly with an emergency escape facility in a train. |
REC121-3752 | 12 - EM agency and authority | RailCorp should establish clear safety accountability statements and reporting lines for all management positions. |
REC121-3702 | 29 - Operational Health and Safety | Random alcohol testing should be continued. |
REC121-3729 | 38 - Agency/Department Reporting | All reports of the Chief Investigator of OTSI should be delivered, upon completion and without being reviewed, to ITSRR and the Minister for Transport Services. |
REC121-3758 | 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. |
REC121-3658 | 12 - EM agency and authority | All emergency services stations should be provided with access keys to, and maps showing, all gates providing access to RailCorp tracks within their geographic area of responsibility. |
REC121-3709 | 29 - Operational Health and Safety | RailCorp should provide access to electronic versions of safety documentation for all operational staff at their workplace. |
REC121-3735 | 29 - Operational Health and Safety | Risk assessments of occupational health and safety issues by RailCorp should include an analysis of broader public safety risks and not be confined to narrow occupational health and safety issues. |
REC121-3767 | 24 - Govt responsibility | All accredited rail organisations should be required to re-apply every three years to ITSRR for accreditation. |
REC121-3689 | 12 - EM agency and authority | All RMC communications related staff should be selected upon the basis of the ability to convey information clearly, accurately and concisely and to follow strict communications protocols. |
REC121-3721 | 24 - Govt responsibility | The ITSRR should ensure that OTSI, as a division of ITSRR, co-operates and assists the ATSB in the conduct of any independent investigation by the ATSB of any rail accident or incident in New South Wales. |
REC121-3741 | 29 - Operational Health and Safety | The operation of the train doors should have an override facility whereby the train driver or the guard can override an internal passenger emergency door release system if the door release is interfered with when there is no emergency. There should be an alarm, together with an intercom, in the train guard’s compartment so that, if a passenger attempts to initiate an emergency door release, there is an appropriate delay during which time an alarm sounds in the train guard’s compartment and the guard can then, after first attempting to speak via the intercom to the person concerned, if necessary, override the door release, and make an appropriate announcement over the intercom system in the train. |
REC121-3749 | 29 - Operational Health and Safety | All new rolling stock must be designed with an area of the roof through which emergency services personnel can access a rail car without encountering wiring or other equipment. That access point must be clearly marked with words such as “emergency services cut here”. |
REC121-3700 | 12 - EM agency and authority | The RailCorp defects unit should be combined with the passenger fleet maintenance division of RailCorp. |
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. |
REC121-3757 | 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. |
REC121-3708 | 12 - EM agency and authority | RailCorp should employ a Chief Safety Information Officer to manage the collection, collation, and dissemination of safety information within RailCorp. |
REC121-3734 | 29 - Operational Health and Safety | RailCorp should integrate its management of occupational health and safety into its overall safety management. |
REC121-3766 | 12 - EM agency and authority | Staffing arrangements for ITSRR should be reviewed by it to ensure that adequate staff are employed in field positions, actively monitoring the safety of rail operations and compliance with conditions of accreditation. |
REC121-3682 | 29 - Operational Health and Safety | All new rolling stock should be designed to be compatible with at least level 2 automatic train protection discussed in chapter 7 of this report. |
REC121-3720 | 24 - Govt responsibility | The New South Wales Government should make the necessary arrangements with the Australian Government, including any necessary legislation, for the Australian Transport Safety Bureau (ATSB) to have the power to investigate all rail accidents occurring on the New South Wales rail network the investigation of which may advance the knowledge of the causes of rail accidents in Australia. |
REC121-3740 | 29 - Operational Health and Safety | The internal passenger emergency door release should be fitted with a facility which prevents it from operating unless the train is stationary. |
REC121-3748 | 29 - Operational Health and Safety | All new rail cars must have appropriate signage and lighting identifying escape routes in the case of emergency. |
REC121-3776 | 38 - Agency/Department Reporting | The Minister for Transport Services should retain, independently of ITSRR, safety auditors to provide a report to the Minister confirming or qualifying the contents of each such ITSRR quarterly report. |
REC121-3697 | 38 - Agency/Department Reporting | All train drivers’ defects reports should be entered by RailCorp into a computerised record and tracked to finalisation. |
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. |
REC121-3755 | 29 - Operational Health and Safety | The RailCorp Board should require a full review of the safety competence of RailCorp managers to ensure that each has the ability to bring about those safety reforms recommended in this report which are applicable to his or her position. |
REC121-3707 | 29 - Operational Health and Safety | The safety document management system should provide for the distribution of electronic versions of safety documentation to relevant staff. |
REC121-3733 | 29 - Operational Health and Safety | RailCorp’s approach to occupational health and safety should be proactive and involve the systematic analysis of all current hazards, risks and controls and an assessment of their adequacy to reduce the risk of injury to, or death of, employees to an acceptable level. |
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. |
REC121-3681 | 29 - Operational Health and Safety | RailCorp should progressively implement, within a reasonable time, level 2 automatic train protection with the features identified in chapter 8 of this report. |
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. |
REC121-3739 | 29 - Operational Health and Safety | All passenger trains operating in New South Wales must be fitted with external emergency door releases which do not require any special key or other equipment to operate. |
REC121-3775 | 38 - Agency/Department Reporting | The Minister for Transport Services must table in Parliament, each such quarterly report by ITSRR. |
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. |
REC121-3747 | 29 - Operational Health and Safety | All trains should have windows available through which passengers can escape. |
REC121-3754 | 29 - Operational Health and Safety | The RailCorp Board should ensure that RailCorp has an adequate and integrated safety management system, including adequate systems for risk assessment, clearly defined safety responsibilities and accountabilities for persons holding management positions, and specific performance criteria against which evaluations can be made of safety performance and accountability for safety performance of all managers. |
REC121-3706 | 29 - Operational Health and Safety | RailCorp should establish a comprehensive safety document management system. |
REC121-3732 | 29 - Operational Health and Safety | If ITSRR accepts such a plan as an appropriate response to the existing weak safety culture, ITSRR should approve it and monitor the effectiveness of the plan. |
REC121-3764 | 29 - Operational Health and Safety | The ITSRR should not grant accreditation to any rail organisation unless it has an integrated safety management system in accordance with any safety management system regulation and the guidelines published from time to time by ITSRR. |
REC121-3680 | 29 - Operational Health and Safety | All trains must be fitted with a minimum of two independent engineering defences to minimise the risk of derailment or collision in the event of train driver incapacitation. |
REC121-3712 | 38 - Agency/Department Reporting | RailCorp and ITSRR should co-operate with national programs for the collection, collation, trend analysis and dissemination of safety critical information. |
REC121-3738 | 29 - Operational Health and Safety | All passenger trains must be fitted with an internal passenger emergency door release. |
Rec-ID | Code | Recommendation |
---|---|---|
REC013_3963 | 12 - EM agency and authority | The establishment of a Board, to be called "The Bush Fires Control Board" which shall operate in conjunction with the shire councils in connection with the prevention of bush fires and control of bush-fire organisations. |
REC013_3968 | 22 - Role of local Gvt | Any number of persons, wishing to form a Bush Fire Brigade, may, by a majority vote of the ratepayers in the particular area, requisition the Shire Council to proclaim such area a Bush Fire Brigade area, and the Council may then impose, with the concurrence of a majority of such ratepayers, a special levy for the purpose of equipping such brigades and carrying out its neccessary functions. |
REC013_3983 | 19 - Offences | To prohibit persons throwing lighted cigarettes, cigars and tobacco among any straw, stubble, grass or herbage during the months of September to March in any Bush Fire area, under a penalty not exceeding $10. |
REC013_3967 | 22 - Role of local Gvt | Each Shire Council shall divide the lands within their respective shires into suitable areas for the formation of Bush Fire Brigades as requested. |
REC013_3982 | 19 - Offences | To prohibit persons taking into a harvest field or through any grass or bush lands any motor, tractor, harvester, &c., which is not supplied with an approved fire extinguisher or without the exhaust being properly fitted and protected, under a penalty not exceeding $50. |
REC013_3966 | 12 - EM agency and authority | Each member of the Board to act in an honorary capacity. |
REC013_3981 | 3 - Biodiversity | To prohibit the preparation of baits for the destruction of rabbits and other noxious animals in which stick phosphorus is used at the time of mixing on any farm, pastoral or grazing area. |
REC013_3965 | 12 - EM agency and authority | The Minister to have power to make regulations for the purpose of all proceedings of the Board, including the summoning and attendance of members, and the enforcement of orders of the Board. |
REC013_3971 | 12 - EM agency and authority | To elect necessary officers. |
REC013_3964 | 12 - EM agency and authority | The Board shall consist of a Chairman and four other members, one member to be nominated each by the Graziers', Farmers and Settlers' and Agricultural Bureau Associations, one by the Fire Underwriters' Association, and one by the Government. |
REC013_3970 | 12 - EM agency and authority | The Board may, at any time, require the Bush Fire Committees to report on the condition of their fire-fighting equipment, and on any other matter, which in their opinion, will tend to greater efficiency in their operations. |