Inquiry Search
Rec-ID | Code | Recommendation |
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REC308-2465 | 29 - Operational Health and Safety | Fatigue management strategies and guidance should be improved to ensure sustainable staffing practices are incorporated into disaster management planning. |
REC308-2459 | 14 - Incident Mgt Teams | Significant effort should be invested to provide disaster decision-makers at every level with a shared understanding of risks, the situation, and capability, so that they can agree on the best decisions for the communities they serve. |
REC308-2457 | 8 - Communications and warnings | Efforts are made to improve the timeliness, accuracy and targeting of Emergency Alert messaging by: |
REC308-2449 | 25 - Inquiry, audit, lessons management and after action review | Queensland should implement and maintain a system-wide lesson management program. |
Rec-ID | Code | Recommendation |
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REC002-4007 | 40 - Equipment and consumables | A measure of safety may be found in the use of high explosives combined with wet tamping, or, still better, water cartridges, instead of powder under any of its modifications. Encouragement ought also to be given to the use of patent multiple wedges and applicances of a like nature, for supplanting the use of explosives. Under all circumstances and conditions some provision should be adopted for compelling workmen to thoroughly undercut, shear, or nick, and generally to work the coal as directed by the Manager. |
REC002-4005 | 40 - Equipment and consumables | Where safety-lamps are used the lock should be of such a character as to prevent any workman opening it. If the "Protector" type of lamp be employed the necessity for a lock is the less necessary, as the unscrewing of this type of lamp extinguishes the light. |
Rec-ID | Code | Recommendation |
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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. |
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. |
REC258-2560 | 29 - Operational Health and Safety | The Civil Aviation Safety Authority devolve to Designated Aviation Medical Examiners the ability to renew aviation medical certificates (for Classes 1, 2, and 3) where the applicant meets the required standard at the time of the medical examination. |
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. |
Rec-ID | Code | Recommendation |
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REC236-2795 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that a short inquiry be conducted by the Senate Standing Committee on Rural and Regional Affairs and Transport into the current status of aviation regulatory reform to assess the direction, progress and resources expended to date to ensure greater visibility of the processes. |
REC236-2793 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that CASA processes in relation to matters highlighted by this investigation be reviewed. This could involve an evaluation benchmarked against a credible peer (such as FAA or CAA) of regulation and audits with respect to: non-RPT passenger carrying operations; approach to audits; and training and standardisation of FOI across regional offices. |
REC236-2792 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that the investigation be re-opened by the ATSB with a focus on organisational, oversight and broader systemic issues. |
REC236-2806 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that the relevant agencies investigate appropriate methods to ensure that information about the incidence of, and variable weather conditions at, Norfolk Island is available to assist flight crews and operators managing risk that may result from unforseen weather events. |
REC236-2805 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that the relevant agencies review whether any equipment or other changes can be made to improve the weather forecasting at Norfolk Island. The review would include whether the Unicom operator should be an approved meteorological observer. |
REC236-2801 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that the ATSB review its process to track the implementation of recommendations or safety actions to ensure it is an effective closed loop system. This should be made public, and provided to the Senate Regional and Rural Affairs and Transport Committee prior to each Budget Estimates. |
Rec-ID | Code | Recommendation |
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REC233-1592 | 8 - Communications and warnings | Department of Broadband, Communications and the Digital Economy will work with the Communications Sector Group within the Trusted Information Sharing Network to develop best practice guidance for owners of critical communications infrastructure regarding public messaging during a prolonged telecommunications outage covering: |
REC233-1590 | 25 - Inquiry, audit, lessons management and after action review | Department of Broadband, Communications and the Digital Economy seek regular updates from Telstra on the implementation of the recommendations of its inquiry into the Warrnambool exchange fire. |
REC233-1604 | 8 - Communications and warnings | Governments and other stakeholders consider reviewing their existing emergency management arrangements to ensure public communications are clear and the public is kept informed of the incident response. |
REC233-1603 | 8 - Communications and warnings | Department of Broadband, Communications and the Digital Economy (DBCDE) to work with the Triple Zero Awareness Work Group through Australian Communications and Media Authority's (ACMA) Emergency Service Advisory Committee to review Triple Zero awareness messages with regard to telecommunications outages. |
Rec-ID | Code | Recommendation |
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REC215-1879 | 25 - Inquiry, audit, lessons management and after action review | Regulators can help to achieve improved outcomes by auditing compliance with the BPEM guidelines on a regular basis |
REC215-1873 | 8 - Communications and warnings | Fire services can improve outcomes by implementing standard procedures that ensure the welfare and safety of crews and the public are not compromised |
REC215-1871 | 14 - Incident Mgt Teams | Fire services can improve outcomes by developing a checklist for use by incident controllers |
Rec-ID | Code | Recommendation |
---|---|---|
REC208-0524 | 8 - Communications and warnings | That the Premier issue clear and unambiguous guidelines to all Government Ministers specifying the timing of notifications to the public of any matters that may affect public health or safety. |
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. |
REC208-0525 | 7 - Inter-agency communication | That the Office of Environment and Heritage amend its operating procedures for the Environment Line to ensure that there are clear obligations to pass on information relevant to other agencies, to those agencies in a timely manner. |
Rec-ID | Code | Recommendation |
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REC204-1916 | 25 - Inquiry, audit, lessons management and after action review | Local Emergency Management Committee (LEMC) processes should be reviewed to ensure that: |
REC204-1913 | 25 - Inquiry, audit, lessons management and after action review | The Department of the Attorney General consider conducting a review of the Civil Liability Act 2002 (WA) in light of the 2011 Kimberley Ultramarathon. Such a review should consider issues such as the effectiveness given to competitor waivers under the Act and the potential difficulties of establishing proceedings and enforcing a judgement against foreign‐based providers of recreational activities. |
Rec-ID | Code | Recommendation |
---|---|---|
REC198-2905 | 14 - Incident Mgt Teams | The Fire Services Commissioner ensures that there is a single standard for the tabards worn by the IMT on the fireground and in control centres to ensure consistency and aid interoperability. |
REC198-2902 | 14 - Incident Mgt Teams | The Fire Services Commissioner clarifies the role of regional controller for major fires and incidents other than bushfire. |
Rec-ID | Code | Recommendation |
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REC197-1733 | 25 - Inquiry, audit, lessons management and after action review | That a review of the Country Fire Authority Act 1958 and the Country Fire Authority Regulations 2004 be undertaken. |
Rec-ID | Code | Recommendation |
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REC189-2911 | 29 - Operational Health and Safety | The review team recommend that: |
REC189-2907 | 29 - Operational Health and Safety | a) For the purposes of designing and implementing its regulatory activities, National Offshore Petroleum Safety Authority (NOPSA) should continue to identify priority hazards and risks and their underlying causes, in consultation with the NOPSA Advisory Board and stakeholders (see Theme 9, Stakeholder engagement). |
REC189-2912 | 29 - Operational Health and Safety | The review team recommend that the safety case system be strengthened by including provisions for a design notification scheme along the lines of that under the British Offshore Safety Case Regulations. |
Rec-ID | Code | Recommendation |
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REC166-3009 | 25 - Inquiry, audit, lessons management and after action review | That the Tasmania Fire Service conduct an audit of all shopping centres to ensure that there exists within those centres adequate fire protection and evacuation systems. |
Rec-ID | Code | Recommendation |
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REC158-3452 | 25 - Inquiry, audit, lessons management and after action review | That the nominated marine safety authority undertakes a further assessment to determine the recommendations from this Review that may also be applicable to State waters outside commercial port waters. |
Rec-ID | Code | Recommendation |
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REC156-3491 | 8 - Communications and warnings | The Victoria State Emergency Service improve its communication with local governments, especially in relation to severe weather and storm warning information. |
REC156-3515 | 8 - Communications and warnings | The electricity distribution businesses enhance power outage information on their websites which are accessible to electricity retail businesses, the media and the public and also consider improving their capacity to communicate with customers. |
REC156-3509 | 8 - Communications and warnings | The Victoria State Emergency Service, Department of Primary Industries, Energy Safe Victoria and the energy sector develop a coordinated set of safety messaging about preparedness for storm events and clearly outline the responsibilities for delivering these messages before during and after an emergency. |
REC156-3507 | 8 - Communications and warnings | Victoria progress, as a matter of priority, a telephony based public emergency notification system to reduce demand on Triple Zero and other emergency telephone lines during a major emergency. |
REC156-3503 | 8 - Communications and warnings | Emergency Service Organisations review their use of Emergency Alerting System paging message categories to ensure that priority messages are not compromised by inappropriate use. An education program may be required to ensure that all users understand message categories, their intended use and ramifications of each category on network and message delivery sequence. |
REC156-3497 | 8 - Communications and warnings | Emergency Service Organisations work with government departments, local governments and private industry to identify and implement a model for communication flow during an emergency incident. |
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. |
REC149-3144 | 29 - Operational Health and Safety | The Safety Case proponent should be allowed some flexibility to involve appropriate experience matched with the proposed workforce competencies to enable the Safety Case to be developed with value adding processes. Subsequent to the hiring of the workforce Final Government Response Offshore Petroleum Safety Regulation Inquiry and 2008 Review of NOPSA Operational Activities and preferably before the commencement of operations a review of the Safety Case should take place with the new workforce to ensure they understand the accepted Safety Case, its risks and Safety Management Plan. |
REC149-3135 | 29 - Operational Health and Safety | The initial acceptance of a new facility Safety Case should be in conjunction with inspection of a facility upon commencement of operations. |
REC149-3128 | 29 - Operational Health and Safety | National Offshore Petroleum Safety Authority (NOPSA) should develop guidelines in consultation with stakeholders to provide clarity and consistency to the process which ultimately will result in better safety outcomes. |
REC149-3147 | 29 - Operational Health and Safety | As all stakeholders have responsibility for safe outcomes, decisions regarding target subjects for safety promotion need to have the support of all stakeholders including NOPSA and the workforce. Industry, which ultimately has the responsibility for managing risk as well as funding the promotion, should take a leadership role in implementation. |
Rec-ID | Code | Recommendation |
---|---|---|
REC136-3528 | 8 - Communications and warnings | An early and high priority task in recovery from a natural disaster should be the development of a coordinated, succinct, practical and flexible public communications plan. |
REC136-3527 | 8 - Communications and warnings | In any future large-scale disaster or event, consideration be given to a centrally located Media Operations Centre. |
REC136-3526 | 8 - Communications and warnings | That consideration be given to additional ways and means to improve broadcast capability into disaster-affected regions, particularly for the early aftermath of any disaster when a loss of power characterises the event. |
Rec-ID | Code | Recommendation |
---|---|---|
REC121-3666 | 14 - Incident Mgt Teams | The rail commander should have complete authority to direct and control any rail employees attending the site of a rail accident, in accordance with directions given or arrangements put in place by the site controller, until the rescue phase of the emergency response to the rail accident has been completed. |
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. |
REC121-3757 | 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. |
REC121-3738 | 29 - Operational Health and Safety | All passenger trains must be fitted with an internal passenger emergency door release. |
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. |
REC121-3707 | 29 - Operational Health and Safety | The safety document management system should provide for the distribution of electronic versions of safety documentation to relevant staff. |
REC121-3747 | 29 - Operational Health and Safety | All trains should have windows available through which passengers can escape. |
REC121-3665 | 14 - Incident Mgt Teams | The role of the rail commander should be to provide support and assistance to the site controller and emergency services personnel until the rescue phase of the emergency response to any rail accident is completed. |
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: |
REC121-3755 | 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. |
REC121-3682 | 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. |
REC121-3737 | 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. |
REC121-3765 | 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. |
REC121-3706 | 29 - Operational Health and Safety | RailCorp should establish a comprehensive safety document management system. |
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”. |
REC121-3663 | 14 - Incident Mgt Teams | The incident command system should clearly identify the roles of the rail commander, site controller, police commander and commanders of the other emergency services, and the way in which each is to work together during the recovery phase of any rail accident. |
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. |
REC121-3754 | 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. |
REC121-3681 | 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. |
REC121-3735 | 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. |
REC121-3764 | 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. |
REC121-3702 | 29 - Operational Health and Safety | Random alcohol testing should be continued. |
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. |
REC121-3652 | 14 - Incident Mgt Teams | A designated staff member at the RMC should act as the rail emergency management co-ordinator. He or she should be the sole point of contact at the RMC with other rail personnel involved in the rail accident and emergency services personnel during the rescue phase of the emergency response. |
REC121-3713 | 25 - Inquiry, audit, lessons management and after action review | Recommendations one to seven of the final report of the Special Commission of Inquiry into the Glenbrook Rail Accident should be fully implemented, save that the random auditing referred to in recommendations five and seven should be carried out by ITSRR. |
REC121-3753 | 25 - Inquiry, audit, lessons management and after action review | The RailCorp Board should establish independent external safety auditing processes to regularly audit and report to the Board on the implementation of an integrated safety management system by RailCorp and on safety performance generally. |
REC121-3680 | 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. |
REC121-3734 | 29 - Operational Health and Safety | RailCorp should integrate its management of occupational health and safety into its overall safety management. |
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: |
REC121-3694 | 25 - Inquiry, audit, lessons management and after action review | The ITSRR should conduct random audits of accredited rail organisations for compliance with communications protocols. |
REC121-3740 | 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. |
REC121-3711 | 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. |
REC121-3749 | 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”. |
REC121-3676 | 14 - Incident Mgt Teams | A direct line of communication should be established between the RMC and Emergency Services Operations Control Centre by a “tie line” or otherwise, so as to ensure that in the case of a serious rail accident there is an open line of communication between the officer in charge of the management of the incident at the RMC and the various emergency response services. |
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. |
REC121-3758 | 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. |
REC121-3739 | 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. |
REC121-3709 | 29 - Operational Health and Safety | RailCorp should provide access to electronic versions of safety documentation for all operational staff at their workplace. |
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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC061-3423 | 25 - Inquiry, audit, lessons management and after action review | The Committee recommends that the Metropolitan Fire Brigades Board be reviewed five years from the tabling of this report in Parliament. |
REC061-3258 | 25 - Inquiry, audit, lessons management and after action review | The Committee recommends that the Metropolitan Fire Brigades Board be reviewed five years from the tabling of this report in Parliament. |
Rec-ID | Code | Recommendation |
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REC008-3988 | 40 - Equipment and consumables | The Commission recommends that buckets of sand or other apparatus for extinguishing fire be kept in any chamber where high powered electricity is used. |
Rec-ID | Code | Recommendation |
---|---|---|
REC004-3997 | 40 - Equipment and consumables | That suitable metal receptacles be fitted under the spittoons of all smoking compartments of country trains, to receive pipe ashes, lighted tobacco, cigars, cigarettes, matches, or other inflammable matter used by smokers. |