Inquiry Search
Rec-ID | Code | Recommendation |
---|---|---|
REC325-4335 | 16 - Training and behaviour | The Inspector-General of Emergency Management recommends Queensland Fire and Emergency Services update and deliver training on the workflow reviewed (as per Recommendation 3) of the current Emergency Alert system to all persons responsible at a local, district and state level by 1 November 2022. Training should address system constraints and system complexities in addition to the process of requesting, composing (including Clear Explicit Translatable Language [CETL]), authorising and issuing Emergency Alerts. |
REC325-4325 | 32 - Doctrine, standards, and reform | The Inspector-General of Emergency Management recommends Queensland Fire and Emergency Services review and implement State Emergency Service (SES) protocol by 1 November 2023 outlining procedures to be undertaken to ensure persons uplifted from places of immediate danger or risk are transferred to a place of safety. |
REC325-4336 | 8 - Communications and warnings | The Inspector-General of Emergency Management recommends Queensland Fire and Emergency Services, in consultation with the Queensland Police Service, incorporate into the workflow of the current Emergency Alert system a process that ensures the inclusion of an ‘urgent approval and distribution without delay’ process for Emergency Alert messages by 1 November 2022. |
REC325-4329 | 8 - Communications and warnings | The Inspector-General of Emergency Management recommends Queensland Fire and Emergency Services implement the Australian Warning System for all nationally agreed hazards by 1 November 2023. Implementation should include guidance and training to all local governments and agencies operationally involved in disaster management, with emphasis on those agencies with hazard specific responsibility. |
REC325-4337 | 8 - Communications and warnings | The Inspector-General of Emergency Management recommends Queensland Fire and Emergency Services lead an urgent multi-agency (including but not limited to the Queensland Police Service and Brisbane City Council) review of the workflow, of the current Emergency Alert system, including requesting, composing, authorising and issuing of Emergency Alerts by 1 November 2022. |
REC325-4332 | 8 - Communications and warnings | The Inspector-General of Emergency Management recommends that all local governments that do not have pre-formatted messages and polygons engage with Queensland Fire and Emergency Services and determine whether their local disaster management group capability could be improved through the development of pre-formatted polygons and messages. |
REC325-4334 | 32 - Doctrine, standards, and reform | The Inspector-General of Emergency Management recommends Queensland Fire and Emergency Services develop and publish an operationally based quick reference guide that complements the training offered (as per Recommendation 5) by 1 November 2022. The guide will identify key and critical aspects of the Emergency Alert system in relation to the development, composition, request for and authorising of Emergency Alerts and will include a template and an example of ‘good’ messaging using concise, minimal language and Clear Explicit Translatable Language (CETL). |
REC325-4321 | 25 - Inquiry, audit, lessons management and after action review | The Inspector-General of Emergency Management recommends this report be returned to the Office of the Inspector-General of Emergency Management to monitor, evaluate, and report on progress and implementation of the recommendations that are accepted in whole or in part by government. |
REC325-4332 | 8 - Communications and warnings | The Inspector-General of Emergency Management recommends that all local governments that currently use pre-formatted messages within the Emergency Alert system review and, where necessary, redraft messages using the principles of Clear Explicit Translatable Language (CETL). |
REC325-4324 | 32 - Doctrine, standards, and reform | The Inspector-General of Emergency Management recommends Queensland Fire and Emergency Services review the tasking protocols used to manage State Emergency Service (SES) tasks undertaken in the response phase of a disaster to enable more complete recording of details for all ‘jobs of opportunity’ (including the personal details of those assisted and/or rescued) to enable better coordination of tasks and reflect outcomes of activities by 1 November 2023. |
Rec-ID | Code | Recommendation |
---|---|---|
REC324-4305 | 39 - Disaster Risk Management | Cost benefit framework:That, to enable a more systematic prioritisation of investment options in risk mitigation before, during and immediately following a natural disaster event, Government adopt and utilise a Disaster Cost Benefit Framework. This Framework will enable Government to estimate the investment required for any given disaster, starting with flood events, and will enable the fast allocation of funding based on detailed and rapid analysis of flood and property modification, mitigation, preparation, response and finance related options including: |
REC324-4313 | 8 - Communications and warnings | NSW disaster app: That, to improve community confidence in government messaging and warnings, the SEOCON and DCS develop a single ‘NSW disaster app’. This: |
REC324-4314 | 8 - Communications and warnings | PIFAC function: That, to ensure the community can better understand the threat of flood, storm and tsunami activity, the Department of Customer Service (DCS) be made accountable for PIFAC in all emergencies. This will improve access to clear, reliable and consistent messaging prior to and during emergencies. This transfers the PIFAC role from NSW Police Force to Service NSW. Under this PIFAC function, DCS would be responsible for: |
REC324-4301 | 32 - Doctrine, standards, and reform | Floodplains as assets: That, to establish the capacity and maximise the economic, social and environmental potential and consequently unlock the value of NSW floodplains, Government adopt the following guiding principles for floodplain management: |
REC324-4317 | 32 - Doctrine, standards, and reform | Flood rescue capability: That, to help improve the protection of life across NSW in flood events: |
REC324-4302 | 32 - Doctrine, standards, and reform | Disaster adaptation plans for all towns: That, to establish realistic expectations of safe spaces to live and deliver much needed housing quickly, Government through NSWRA working with local government: |
REC324-4303 | 39 - Disaster Risk Management | Risk-based approach to calculating flood planning: That, to take account of greater knowledge of climate change, Government reinforce its adoption of a risk-based approach to calculating the flood planning level for planning purposes and, through the NSWRA, immediately start a process of revising all flood planning level calculations in the state’s high-risk catchments. Flood planning level re-determinations for all high-risk catchments should be completed within 3 years. These revised flood planning levels will need to be factored into all development applications (in-progress and new) in those high-risk catchments. The risk profile of high-risk catchments should be revisited at appropriate time intervals to check that levels are current. A review should take place if there has been a significant trigger event (i.e. changed rainfall, development) or at least every 5 years. As well as reviewing the flood planning level, this 5-yearly review should include reviewing any floodplain lease conditions and adjusting them as necessary in the light of better knowledge of climate change impacts. In working out a tolerable, risk-based flood planning level, consideration should be given to the PMF, 1% AEP, 0.02% AEP, existing development, approved but not yet constructed developments, and existing and approved but not yet constructed evacuation routes. |
Rec-ID | Code | Recommendation |
---|---|---|
REC311-2505 | 25 - Inquiry, audit, lessons management and after action review | This report be returned to the InspectorGeneral Emergency Management to monitor, evaluate and report on progress and implementation of the recommendation(s) that are accepted in whole or in part by government. |
REC311-2490 | 39 - Disaster Risk Management | To enable entities to have a shared understanding of forecast information for dam failure events during a flood, including flood wave travel time, speed and height, Emergency Action Plans contain protocols and responsibilities of relevant stakeholders for these aspects. |
REC311-2504 | 25 - Inquiry, audit, lessons management and after action review | To enable entities in the sector to proactively work to achieve better results for the community, the recommendations and lessons of this review should be evaluated through the lessons management processes of entities involved in dam safety for their value and relevance. |
REC311-2499 | 39 - Disaster Risk Management | To ensure enhanced capability integration and enable timely community messaging Bundaberg LDMG in consultation with Sunwater develop additional Emergency Alerts and associated polygons for a Paradise Dam failure and load these on to the disaster management portal. |
REC311-2498 | 39 - Disaster Risk Management | To enhance shared capacity and collaboratively manage risk, the Chair of the Bundaberg DDMG use the QERMF process to determine if dam failure for Paradise Dam should be reported as a residual risk in this instance due to known changes in the risk profile to: |
REC311-2497 | 39 - Disaster Risk Management | To increase shared understanding of risks, ensure the coordination of plans and manage risks, dam failure for Paradise Dam be included as a separate risk within the Bundaberg District Disaster Management Plan (DDMP). |
REC311-2492 | 39 - Disaster Risk Management | To increase understanding of hazards and manage risks, dam failure for Paradise Dam be included as a separate risk within the North Burnett Local Disaster Management Plan (LDMP). |
Rec-ID | Code | Recommendation |
---|---|---|
REC308-2453 | 32 - Doctrine, standards, and reform | Business continuity planning should feature permanently in disaster management doctrine. |
REC308-2452 | 39 - Disaster Risk Management | Planning and warnings for storm tide should be based on modelling that shows the chances of an event occurring (probabilistic). |
REC308-2464 | 16 - Training and behaviour | The provision of system-wide education, guidance and testing to enhance requests for Assistance is strengthened. |
REC308-2449 | 25 - Inquiry, audit, lessons management and after action review | Queensland should implement and maintain a system-wide lesson management program. |
REC308-2458 | 39 - Disaster Risk Management | A strategy should be developed to improve the availability of information to decision-makers and other audiences. Information should be searchable, more specific, timely, and allow stake-holders to find what they want. |
REC308-2457 | 8 - Communications and warnings | Efforts are made to improve the timeliness, accuracy and targeting of Emergency Alert messaging by: |
REC308-2455 | 32 - Doctrine, standards, and reform | The Queensland Offers of Assistance Policy, particularly for corporate donations, should be updated and exercised prior to the next season. |
Rec-ID | Code | Recommendation |
---|---|---|
REC297-1266 | 8 - Communications and warnings | That Government supports the anticipated SES State Flood Warning proposals aimed at improving public warnings and communication, and that the proposed warning system is consistent with the National Frameworks. |
REC297-1264 | 25 - Inquiry, audit, lessons management and after action review | That the Flood Warning Consultative Committee reviews flood classification levels in the Service Level Specifications with BoM specifically relating to flood level triggers on gauges. |
REC297-1260 | 32 - Doctrine, standards, and reform | That DPIPWE clarifies responsibility for river restoration and riparian management and, having done so, communicates this to councils, landowners and other owners of relevant infrastructure. |
REC297-1259 | 25 - Inquiry, audit, lessons management and after action review | That DPIPWE examines the Forest Practice Code 2015 for relevance of its concepts to farming and other business activities near rivers, streams and naturally occurring dams and makes recommendations to Government accordingly. |
REC297-1273 | 25 - Inquiry, audit, lessons management and after action review | That the State Emergency Management Committee allocates resources to reviewing all findings and recommendations in the Productivity Commission Report No. 74 relevant to Tasmania and, for those identified as relevant, actions taken and, if none, why not. |
REC297-1258 | 25 - Inquiry, audit, lessons management and after action review | That DPIPWE examines the WMAwater report along with its own, analyses the differences, consults with the Forest Practices Authority and Environment Protection Authority, and proposes an appropriate course of action to Government. |
REC297-1267 | 8 - Communications and warnings | That emergency management authorities react with heightened awareness and action when BoM issues flood watches and related warnings. |
Rec-ID | Code | Recommendation |
---|---|---|
REC258-2554 | 32 - Doctrine, standards, and reform | Recreational Aviation Administration Organisations, in coordination with the Civil Aviation Safety Authority, develop mechanisms to ensure all aircraft to be regulated under CASR Part 149 are registered. |
REC258-2533 | 32 - Doctrine, standards, and reform | The Civil Aviation Safety Authority: |
REC258-2538 | 32 - Doctrine, standards, and reform | The Department of Infrastructure and Regional Development and Department of Defence (and appropriate agencies) establish an agreed policy position on safety oversight of civil operations into joint user and military airports. |
REC258-2552 | 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. |
REC258-2531 | 32 - Doctrine, standards, and reform | The Civil Aviation Safety Authority’s Board exercises full governance control. The nonexecutive directors should possess a range of appropriate skills and backgrounds in aviation, safety, management, risk, regulation, governance and government. |
REC258-2537 | 32 - Doctrine, standards, and reform | The Civil Aviation Safety Authority delegates responsibility for the day-to-day operational management of airspace to Airservices Australia, including the designation of air routes, short term designations of temporary Restricted Areas, and temporary changes to the classification of airspace for operational reasons. |
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. |
REC258-2529 | 32 - Doctrine, standards, and reform | The Australian Transport Safety Bureau and the Civil Aviation Safety Authority utilise the provision in their bilateral Memorandum of Understanding to accredit CASA observers to ATSB investigations. |
REC258-2562 | 32 - Doctrine, standards, and reform | The Civil Aviation Safety Authority amends the current Terms of Reference of the Industry Complaints Commissioner so that: |
REC258-2536 | 32 - Doctrine, standards, and reform | The Australian Transport Safety Bureau and the Civil Aviation Safety Authority amend the wording of their existing Memorandum of Understanding to make it more definitive about interaction, coordination, and cooperation. |
REC258-2549 | 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. |
REC258-2556 | 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. |
REC258-2535 | 32 - Doctrine, standards, and reform | Airservices Australia, in conjunction with the Department of Infrastructure and Regional Development and the Civil Aviation Safety Authority, reconsiders the policy on ‘Assessment of Priorities’ that stipulates that air traffic controllers sequence arriving aircraft based on category of operation, rather than on the accepted international practice of ‘first come, first served’. |
REC258-2542 | 16 - Training and behaviour | The Civil Aviation Safety Authority publishes and demonstrates the philosophy of ‘just culture’ whereby individuals involved in a reportable event are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training. However, actions of gross negligence, wilful violations and destructive acts should not be tolerated. |
REC258-2527 | 32 - Doctrine, standards, and reform | The Department of Infrastructure and Regional Development plays a stronger policy role in the State Safety Program. |
REC258-2555 | 32 - Doctrine, standards, and reform | The Civil Aviation Safety Authority changes the current two-tier regulatory framework (act and regulations) to a three-tier structure (act, regulations and standards), with: |
REC258-2534 | 16 - Training and behaviour | The Civil Aviation Safety Authority develops a staff exchange program with industry. |
REC258-2541 | 16 - Training and behaviour | The Civil Aviation Safety Authority finalises its Capability Framework and overhauls its training program to ensure identified areas of need are addressed, including: |
Rec-ID | Code | Recommendation |
---|---|---|
REC238-0802 | 25 - Inquiry, audit, lessons management and after action review | Review the NSW state-wide governance arrangements for flood risk management so that broader issues identified by this Review can be most effectively addressed. |
REC238-0798 | 32 - Doctrine, standards, and reform | Optimise the configuration of a raised Warragamba Dam for flood mitigation of the full range of flood events and water supply, with due consideration of upstream impacts. |
REC238-0797 | 32 - Doctrine, standards, and reform | Determine the appropriateness and the steps required to allow the reduction of full supply level by up to five metres and/or the implementation of alternative gate operation at Warragamba Dam for the mitigation of minor to moderate flood events in the short-term. |
REC238-0803 | 32 - Doctrine, standards, and reform | Ensure effective flood gauging arrangements in the Hawkesbury-Nepean Valley |
Rec-ID | Code | Recommendation |
---|---|---|
REC216-2870 | 8 - Communications and warnings | Efficient and effective supporting tools and processes: streamlining the authorisation processes for urgent warnings. |
REC216-2869 | 8 - Communications and warnings | Efficient and effective supporting tools and processes: developing tools and workflows to quickly and reliably transform technical data into intelligence that can be used to construct messages for community information that are timely, relevant, tailored and effective. |
Rec-ID | Code | Recommendation |
---|---|---|
REC199-0423 | 21 - Role of Commonwealth Government | the Bureau of Meteorology expand its volunteer amateur weather watch groups to enhance its weather and flood information gathering procedures. |
REC199-0454 | 32 - Doctrine, standards, and reform | the State Emergency Response Coordinator further develop the Strategic Emergency Management Assurance Team process by involving subject matter experts from relevant emergency management control agencies who are the subject of Strategic Emergency Management Assurance Team focus. |
REC199-0487 | 32 - Doctrine, standards, and reform | the state develop and incorporate into emergency management planning regimes plans based on geographic risk, such as sub-regional plans |
REC199-0402 | 8 - Communications and warnings | the state develop a flood warning system for each basin and location with community input and make relevant documents publicly available. Each warning system should include key performance indicators. |
REC199-0435 | 8 - Communications and warnings | the state put in place appropriate measures to inform the community of the intended purpose of the Emergency Alert warning system. |
REC199-0462 | 16 - Training and behaviour | the state introduce a joint emergency management leadership training program that will deliver critical core competencies for all levels of management of major emergencies. Future appointments to senior operational emergency management positions should require successful accreditation at the appropriate level. |
REC199-0409 | 21 - Role of Commonwealth Government | the Bureau of Meteorology should present water levels in both local datum and Australian Height Datum (gauge zero) for all its published information and warnings |
REC199-0440 | 8 - Communications and warnings | the state actively pursue the use of social media as part of its emergency warning and public information system. |
REC199-0470 | 21 - Role of Commonwealth Government | the commonwealth consider including (as part of its review of standards for aged care services) requirements for: • robust ‘all hazards’ evacuation plans that include current after-hour contact details of people who are able to make authoritative decisions during an emergency; and • rehearsal of those plans. |
REC199-0419 | 21 - Role of Commonwealth Government | the Bureau of Meteorology provide Incident Control Centres with real-time access to flood data held by the Bureau of Meteorology. This will require Bureau of Meteorology staff making themselves available to respond to enquiries from Incident Control Centres during a flood event. |
REC199-0450 | 25 - Inquiry, audit, lessons management and after action review | the state ensure that appropriate record management processes are developed and implemented and that these processes also provide record accountability for multi-agency operations. Agency processes should be standardised to the fullest extent possible |
REC199-0484 | 32 - Doctrine, standards, and reform | the state: • assess current risk and risk mitigation strategies for essential services, with a focus on ensuring that risks are appropriately identified at all levels of emergency planning; and • ensure that the responsible authority or owner/ operator of essential services put in place appropriate strategies to mitigate any risk to service continuity |
REC199-0401 | 25 - Inquiry, audit, lessons management and after action review | the state task the Emergency Services Commissioner with the responsibility to establish an effective audit regime of the total flood warning system. |
REC199-0434 | 8 - Communications and warnings | the state require that agencies operate in compliance with the guidelines of the Victorian Warning Protocol to ensure efficacy of warning messages. |
REC199-0461 | 32 - Doctrine, standards, and reform | the state ensure: • water rescue/swift water rescue definitions, roles and responsibilities are clarified and communicated to all stakeholders to ensure common understanding • appropriate training, equipment and support is provided to those required to perform water rescue/swift water rescue. Common training programs, standards and accreditation should be utilised wherever possible to increase potential for joined up operations and maximised capability • that based upon the experiences of these flood events, an appropriate level of water rescue capacity and capability is established and maintained • flood plans (all levels) and flood emergency response planning incorporate consideration of pre-positioning of appropriate water rescue capability in the event that such services should be required; and • that revised water rescue roles, responsibilities and arrangements are clearly defined in the Emergency Management Manual Victoria and such definitions are replicated in all individual agency planning and operational documents |
REC199-0407 | 25 - Inquiry, audit, lessons management and after action review | the state: • undertake a strategic review to identify areas at risk from flash or riverine flooding. Shortcomings in the flood gauging networks identified in the review should then be the focus of remedial action • seek to address as a priority any notable gaps in the total flood warning system as apparent in the 2010–11 floods (including south west Victoria, Wimmera and north central region) by enhancing mapping, gauging and education programs; and • seek a commitment from the Bureau of Meteorology to ensure any new gauges installed are utilised to enhance flood prediction capability and coverage. |
REC199-0439 | 8 - Communications and warnings | the state review its Memoranda of Understanding with official emergency broadcasters to take account of increased usage of internet based information, including social media and the ability to broadcast community meetings |
REC199-0469 | 32 - Doctrine, standards, and reform | the state update the current fire specific guidelines and resources for evacuation planning to take an ‘all hazards’ approach |
REC199-0415 | 16 - Training and behaviour | the state ensure that all personnel who are likely to become involved in incident management teams for floods receive basic flood awareness training prior to such involvement. |
REC199-0448 | 16 - Training and behaviour | the state ensure that sector wide familiarity and understanding of the various systems for incident management is developed and maintained. Primarily, this should be achieved through multi-agency emergency management training and exercising involving usage of the various agency incident management systems. |
REC199-0482 | 25 - Inquiry, audit, lessons management and after action review | the state task the Emergency Services Commissioner with the responsibility to develop and undertake the regular audit of emergency management plans at all levels. |
REC199-0433 | 8 - Communications and warnings | the state develop and implement standards for Emergency Alert to ensure consistent use, training and application by accredited operators within agencies across ‘all hazards’. |
REC199-0459 | 32 - Doctrine, standards, and reform | the state undertake a complete review of emergency management legislation. This should include agencyspecific emergency management legislation and should focus on service interoperability and securing an ‘all hazards, all agencies’ capability |
REC199-0405 | 21 - Role of Commonwealth Government | the state and the Bureau of Meteorology liaise to ensure the existence of appropriate quality control processes for gauges and contingency measures in the event that gauges are damaged during flood events. |
REC199-0438 | 8 - Communications and warnings | the state investigate the ability to refine the Flood and Storm Information Line to enable it to receive as well as provide information. |
REC199-0467 | 32 - Doctrine, standards, and reform | the state review and align all policies and procedures for evacuation, such as the interim evacuation guidelines and the State Health Emergency Response Plan, to ensure consistency and to clarify roles and responsibilities. |
REC199-0414 | 16 - Training and behaviour | the state ensure that all personnel who, because of their particular flood expertise, are likely to be potential participants in an Incident Control Centre are familiar with the requirements of the Australasian Inter-service Incident Management System structure |
REC199-0445 | 25 - Inquiry, audit, lessons management and after action review | the state develop and implement operational performance standards for each state agency involved in emergency management response and recovery and that: • each agency be assessed by the Emergency Services Commissioner periodically against these performance standards for both capability and capacity; and • where performance against these standards for either capability or capacity cannot be demonstrated by any agency – appropriate advice is communicated to the relevant Minister, departmental/agency head and State Emergency Response Coordinator; and – an action plan is developed and implemented to address the relevant capability or capacity deficiency in both the short and longer term. |
REC199-0477 | 21 - Role of Commonwealth Government | the state review the potential for National Registration and Inquiry System 6 to provide a single point of information collection to both register individuals and plan the delivery of recovery services. If the review determines National Registration and Inquiry System 6 is unable to fulfil this function, the state should work with the commonwealth and other states to implement the necessary changes to National Registration and Inquiry System 6. If National Registration and Inquiry System 6 is unable to be developed as a single information collection system: the state should develop and implement a single point of information collection system, including how information obtained from outreach activities can be incorporated into this system and how such information may be linked into the Rapid Impact Assessment process. |
REC199-0432 | 8 - Communications and warnings | the state develop and implement a single web portal as a means of providing emergency information to communities and local government on an ‘all hazards’ basis, including the information referred to in recommendations 74, 89 and 92. |
REC199-0457 | 32 - Doctrine, standards, and reform | the state: • revise the Emergency Management Team Practice Note to include a template to ensure an appropriate and consistent approach to Emergency Management Team operations • provide the revised Emergency Management Team Practice Note to all stakeholders to enable familiarisation; and • ensure that there is regular exercising of Emergency Management Teams with an `all hazards’ focus. |
REC199-0404 | 21 - Role of Commonwealth Government | the state engage with the Bureau of Meteorology to establish a joint initiative to review existing flash flood warning systems in Victoria and identify where additional systems are needed, with a particular focus on urban centres with a history of flash flooding. This review should seek to achieve outcomes similar to those implemented in NSW. Subject to those outcomes being implemented, the state should determine which agency is responsible for flash flood warnings. |
REC199-0437 | 8 - Communications and warnings | the state engage with local government to ensure emergency services’ public information and warnings reflect the community demographic. |
REC199-0464 | 32 - Doctrine, standards, and reform | the state develop and implement a strategy that maximises the flexibility and united capacity of the Country Fire Authority and Victoria State Emergency Service to respond to emergencies. |
REC199-0412 | 21 - Role of Commonwealth Government | the Bureau of Meteorology adjust its flood prediction models to incorporate water storage conditions (to enable it to issue more timely and useful flood predictions for communities based downstream of water storages). |
REC199-0443 | 32 - Doctrine, standards, and reform | the state reconfigure the Victorian Emergency Management Council and the supportive committee arrangements to ensure a comprehensive, accountable, effective and integrated approach to the development of emergency management arrangements is in place for Victoria. The process should also include consideration of the Security and Emergencies Committee and Central Government Response Committee roles, functions, reporting arrangements and relationships with other state level emergency management groups. Settled arrangements must be clearly articulated to ensure stakeholder understanding. |
REC199-0475 | 16 - Training and behaviour | the Department of Planning and Community Development review the volunteer register and examine additional options to support councils in volunteer management, including the development of tools and staffing support. |
REC199-0428 | 25 - Inquiry, audit, lessons management and after action review | the state clarify which agency is responsible for collecting post-flood extent and related data. This should include: • the development of guidelines to ensure consistent standards are applied to post-flood data collection; and • an appropriate process to ensure funding availability for such activities. |
REC199-0456 | 32 - Doctrine, standards, and reform | the state: • ensure an ‘all hazards, all agencies’ approach to Incident Action Plan compilation is developed and implemented to enable the timely issue of functional Incident Action Plans. All agency incident action planning processes should be standardised to the fullest extent possible, including consideration of a library of pro-forma Incident Action Plans; and • develop and implement mechanisms to test and ensure that agencies possess satisfactory incident action planning capability and capacity for ‘all hazards’ at all levels of operations. |
REC199-0403 | 21 - Role of Commonwealth Government | the state and commonwealth undertake a review into the appropriate institutional arrangements for the forecasting and predictions function currently undertaken by Melbourne Water for the Port Phillip and Westernport region. |
REC199-0436 | 8 - Communications and warnings | the state develop a standard approach to the provision of emergency warnings and information in formats – spoken and written – that recognise diverse community needs, including language and disability |
REC199-0463 | 16 - Training and behaviour | the state: • ensure an appropriate regime of regular emergency management training and exercising is introduced. This must be ‘all hazards’ and multi-agency focused and include all relevant stakeholders • designate an accountable officer to hold ongoing responsibility for conducting such exercises; and • designate the Emergency Services Commissioner as holding ongoing responsibility for auditing and reviewing this training and exercising. |
REC199-0411 | 21 - Role of Commonwealth Government | the Bureau of Meteorology undertake a review of its radar coverage in the context of flash and riverine flood warnings for Victoria, with a particular focus on known gap areas such as the Horsham/Nhill region. |
REC199-0442 | 32 - Doctrine, standards, and reform | the state appoint a state emergency controller who is ultimately accountable for all major emergencies. |
REC199-0471 | 8 - Communications and warnings | the state and the commonwealth, during a flood event, make information available on providers who have capacity to accommodate patients and residents who require evacuation. |
Rec-ID | Code | Recommendation |
---|---|---|
REC189-2913 | 21 - Role of Commonwealth Government | In developing and improving its policies and practices for stakeholder engagement, NOPSA should ensure that: |
REC189-2910 | 21 - Role of Commonwealth Government | NOPSA should: |
REC189-2909 | 32 - Doctrine, standards, and reform | Equipping the regulator with a wider range of compliance tools under the legislation should continue to be a policy priority. The aim should be to enhance the regulator’s capacity to secure compliance in an appropriately graduated way. The opportunity should be taken to ensure that the regulator and inspectors can, in appropriate cases, bring proceedings that do not require referral to the Commonwealth Director of Public Prosecutions, such as actions for civil penalties or injunctions. |
REC189-2908 | 21 - Role of Commonwealth Government | To ensure that NOPSEMA is in a strong position to perform its functions effectively: |
REC189-2906 | 21 - Role of Commonwealth Government | In order to improve the effectiveness of National Offshore Petroleum Safety and Environmental Management Authority (NOPSEMA), with similar benefits for State or Territory regulators, attention should be given to the following actions. |
REC189-2914 | 32 - Doctrine, standards, and reform | The review team recommend that: |
Rec-ID | Code | Recommendation |
---|---|---|
REC187-2946 | 21 - Role of Commonwealth Government | That a national agency sponsored by the Commonwealth Government be established to undertake national coordination of flood risk management and to operate the system of premium discounts and the flood risk reinsurance facility. The Agency would: |
REC187-2918 | 21 - Role of Commonwealth Government | That an agency sponsored by the Commonwealth Government be created to manage the national coordination of flood risk management and to operate a system of premium discounts and a flood risk reinsurance facility, supported by a funding guarantee from the Commonwealth. |
Rec-ID | Code | Recommendation |
---|---|---|
REC164-0073 | 25 - Inquiry, audit, lessons management and after action review | SERCon consider that the proposed State Recovery Committee provide an interim report to government on these and |
REC164-0072 | 32 - Doctrine, standards, and reform | SERCon consider that the proposed State Recovery Committee review the recommended considerations arising from |
REC164-0071 | 32 - Doctrine, standards, and reform | SERCon consider the establishment of a body, such as a State Recovery Committee, with responsibility for the |
REC164-0077 | 32 - Doctrine, standards, and reform | SERCon consider the continued development of a State Recovery Sub-Plan (including complementary local and district |
REC164-0076 | 32 - Doctrine, standards, and reform | SERCon consider meeting with the State Emergency Management Committee, Directors General and agency heads to |
REC164-0075 | 16 - Training and behaviour | SERCon consider development of an education program for other government and non-government agencies (with |
Rec-ID | Code | Recommendation |
---|---|---|
REC158-3426 | 32 - Doctrine, standards, and reform | That the nominated marine safety authority, in consultation with the Emergency Services Commissioner, senior emergency services personnel and relevant port stakeholders, is responsible for establishing appropriate performance standards, risk management guidelines and good practice guidelines for marine emergency management. |
REC158-3437 | 32 - Doctrine, standards, and reform | That port/channel managers coordinate marine emergency planning for the port and are required to ensure that marine emergency arrangements are integrated with whole of port emergency management plans. |
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. |
REC158-3425 | 32 - Doctrine, standards, and reform | Consequential or complementary amendments to the Emergency Management Act are required to ensure that: |
REC158-3436 | 32 - Doctrine, standards, and reform | That Harbour Masters are the designated principle marine specialists within the port and work directly with emergency services to provide advice and the interface with the marine legislative powers, to manage a marine emergency. |
REC158-3441 | 32 - Doctrine, standards, and reform | That, where practical, risk assessments, emergency planning, training and exercising are integrated to minimise duplication of effort. |
REC158-3424 | 32 - Doctrine, standards, and reform | That legislation is prepared by the Department of Transport to ensure marine emergency management arrangements are clarified and provide: |
REC158-3435 | 32 - Doctrine, standards, and reform | That Harbour Masters have the appropriate powers, authority, accountability, skills, responsibility and indemnity to provide a coordinated response of marine resources in support of emergency services, except where the nominated marine safety authority is the control agency for a marine pollution or marine casualty emergency. |
REC158-3440 | 32 - Doctrine, standards, and reform | That the Water Division Emergency Response Plan is amended, by the Water Division emergency response coordinator, to provide a framework to coordinate a marine response that crosses declared port water boundaries and requires resource coordination and prioritisation. |
REC158-3434 | 32 - Doctrine, standards, and reform | That the accountability relationship between Harbour Masters and the Director of Marine Safety is strengthened in the relevant legislation. |
REC158-3439 | 32 - Doctrine, standards, and reform | That the port marine emergency management arrangements are integrated with the Victorian Water Division Emergency Response Plan. |
REC158-3427 | 32 - Doctrine, standards, and reform | That the standards and guidelines determined by the nominated marine safety authority require port/channel managers to conduct a marine emergency risk assessment using AS/NZ 4360:2004 Risk Management and, in addition, must require port/channel managers to: |
REC158-3438 | 32 - Doctrine, standards, and reform | That the port/channel managers coordinate marine emergency management planning in the port and are required to ensure that individual port stakeholder marine emergency management arrangements plans are integrated with the whole of port marine emergency management arrangements. |
REC158-3453 | 32 - Doctrine, standards, and reform | That, where applicable, consideration is given to legislative amendment that will enable the findings of this report to be applied to areas inside State waters but outside commercial port waters. |
Rec-ID | Code | Recommendation |
---|---|---|
REC156-3496 | 21 - Role of Commonwealth Government | The Bureau of Meteorology contact list for severe weather warning be strategically managed in consultation with Emergency Service Organisations, to identify critical contacts. The Bureau of Meteorology must ensure the detail for these critical contacts remains up to date. |
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. |
REC156-3509 | 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. |
REC156-3495 | 16 - Training and behaviour | The Department of Primary Industries should work through the appropriate Ministerial Councils to seek alignment of competency standards for line workers across jurisdictions. |
REC156-3501 | 32 - Doctrine, standards, and reform | The Country Fire Authority review their procedures regarding receipt of Triple Zero calls on the Brigade Spectrum Preset Conference including training material, testing procedures and interface back to the Emergency Services Telecommunications Authority Computer Aided Dispatch system. |
REC156-3508 | 32 - Doctrine, standards, and reform | The Australian Broadcast Corporation and Emergency Services Organisations redevelop the protocols for the use of the Memorandum of Understanding; and all relevant emergency services and ABC staff are trained in the use of the protocols. |
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. |
REC156-3499 | 32 - Doctrine, standards, and reform | The Department of Primary Industries clearly document responsibilities within the Department to ensure better co-ordination of public information during emergencies. |
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. |
REC156-3489 | 32 - Doctrine, standards, and reform | The Department of Primary Industries responsibility for emergency management within the energy sector needs to be reinforced consistent with Recommendation 5. |
REC156-3513 | 32 - Doctrine, standards, and reform | The Department of Primary Industries in consultation with the energy sector develop and implement a Memorandum of Understanding or similar authorising instrument that provides a single contact for emergency |
REC156-3498 | 32 - Doctrine, standards, and reform | The Department of Primary Industries, Department of Premier and Cabinet, and the Office of the Emergency Services Commissioner review and clarify energy sector emergency event trigger points for the activation of Central Government Response Committee. |
REC156-3505 | 32 - Doctrine, standards, and reform | The Emergency Service Organisations and the Emergency Services Telecommunications Authority agree on the direct telephone numbers to be used for contacting the Emergency Services Telecommunications Authority in relation to emergency incidents. The Emergency Service Organisations need to ensure an effective process is in place to educate their personnel in relation to the use of these numbers. |
REC156-3484 | 32 - Doctrine, standards, and reform | The Victoria State Emergency Service finalise its development of strategic emergency response management plans including severe weather and storm events. |
REC156-3511 | 32 - Doctrine, standards, and reform | The operational protocols of the Emergency Management Joint Public Information Committee be formally endorsed by the State Emergency Response Planning Committee and the Victorian Emergency Management |
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. |
REC156-3504 | 32 - Doctrine, standards, and reform | The Emergency Services Telecommunications Authority develop a protocol to direct the suspension or cessation of scheduled telecommunication maintenance or testing to emergency alert systems during an emergency event. |
REC156-3510 | 32 - Doctrine, standards, and reform | Victoria’s emergency management arrangements as they relate to the Emergency Management Joint Public Information Committee be enhanced to include greater clarity of its operational role in the Emergency Management Manual Victoria. |
Rec-ID | Code | Recommendation |
---|---|---|
REC149-3134 | 32 - Doctrine, standards, and reform | Improved and agreed guidelines for Safety Case application and assessment, including suggested structure and content, would alleviate many current problems related to Safety Case processes. |
REC149-3141 | 32 - Doctrine, standards, and reform | NOPSA should complete the next revision of Safety Case guidelines in consultation and agreement with stakeholders and continue its program to achieve consistency with a firmer hand from the CEO and management. |
REC149-3130 | 32 - Doctrine, standards, and reform | The regulations pertaining to vessels of opportunity or their interpretation should be changed to facilitate a risk based approach to regulation. This approach will be consistent with the approach taken in other jurisdictions. |
REC149-3140 | 32 - Doctrine, standards, and reform | The industry should provide advice to NOPSA on where the regulations do not provide sufficient clarity and consider developing broad policy/process guidelines in consultation with the regulator to provide clarity and consistency. Regulators should not take personal views or preferences. |
REC149-3129 | 32 - Doctrine, standards, and reform | The consequences of the disapplication of the Navigation Act 1912 should be analysed, the actual consequences identified and unintended consequences addressed. |
REC149-3139 | 39 - Disaster Risk Management | The industry should develop in conjunction with the Regulator a process for addressing the need to maintain the risk profile of a facility moving into extended life operation at the same risk profile as when it was within design life. |
REC149-3137 | 16 - Training and behaviour | As professional competency is one of the key pillars of any Safety Case, commitment to training for current and future needs remains a fundamental requirement for achieving best practice outcomes in safety. Industry should be encouraged to build on its training commitment now being made to achieve a competent and fully accredited workforce over the next five years. |
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. |
REC149-3136 | 16 - Training and behaviour | There is a need for industry in consultation with NOPSA to establish a priority programme of accredited education modules in the Safety Case regime targeting stakeholders in the regime at their respective levels to improve the understanding of the Safety Case and correspondent responsibilities. |
REC149-3143 | 21 - Role of Commonwealth Government | The role of the advisory Board, namely to give advice to Ministers and NOPSA when asked, should be made clear to Board members and all stakeholders. The Board and NOPSA should consider the need for a clear description of who does what based on the legislated responsibilities of the NOPSA CEO. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC121-3675 | 16 - Training and behaviour | All rail employees should be trained by their employer to commence any emergency communication with the words “Emergency, emergency, emergency”, thereafter to identify themselves, the train, its location, what has occurred, the approximate passenger load and whether death or injuries have occurred. |
REC121-3700 | 39 - Disaster Risk Management | Maintenance plans on all trains should be revised annually. |
REC121-3744 | 16 - Training and behaviour | All RailCorp operational personnel should be trained in the location and operation of external emergency door release mechanisms. |
REC121-3771 | 32 - Doctrine, standards, and reform | RailCorp should establish an integrated safety management system which includes the following: |
REC121-3659 | 32 - Doctrine, standards, and reform | A railway disaster plan, or rail displan, should be developed by RailCorp and the emergency services to ensure co-ordinated inter-agency response to rail accidents and incidents on the RailCorp network. |
REC121-3685 | 32 - Doctrine, standards, and reform | The ITSRR should impose a standard in relation to the collection and use of data from data loggers. |
REC121-3714 | 16 - Training and behaviour | RailCorp should use its simulators in an interactive manner. |
REC121-3756 | 16 - Training and behaviour | RailCorp should ensure that where the safety competency of any manager is deficient such manager is required to undertake professional development courses to raise his or her safety competency level to an adequate standard. |
REC121-3668 | 32 - Doctrine, standards, and reform | The RailCorp emergency response plan should include action checklists of the steps that each employee is required to take, and the order for specific employees to follow in case of emergency. |
REC121-3692 | 32 - Doctrine, standards, and reform | Communications protocols and procedures should be standardised and mandated by regulations making them a condition of accreditation. |
REC121-3719 | 16 - Training and behaviour | The position of team leader should be created by RailCorp to be responsible for a group of approximately 30 train drivers, with responsibility to ensure that each train driver’s training needs are being met and that any safety concerns of train drivers are being properly addressed. The team leaders are to have direct access to the Chief Executive of RailCorp if any safety concerns they have are not addressed. |
REC121-3762 | 32 - Doctrine, standards, and reform | The Chief Executive of ITSRR should have sole accountability and responsibility for the regulation of rail safety in New South Wales. |
REC121-3674 | 32 - Doctrine, standards, and reform | Uniform verbal descriptions identifying that power has been isolated should be developed by RailCorp and utilised by all railway personnel, electrical service providers and all emergency response personnel. |
REC121-3699 | 32 - Doctrine, standards, and reform | All reported train defects should be certified by a person in a supervisory position in RailCorp as having been rectified. |
REC121-3736 | 32 - Doctrine, standards, and reform | The RailCorp passenger containment policy must be abandoned. |
REC121-3770 | 32 - Doctrine, standards, and reform | A safety management system regulation should be promulgated, specifying the requirements of safety management systems in all accredited organisations, using Annexure I to this report as a guide |
REC121-3655 | 32 - Doctrine, standards, and reform | Procedures should be put in place by RailCorp to ensure that electrical power supply to the area of an accident can be immediately isolated, if necessary, in the event of a rail accident, so as to reduce any risk of exposure of emergency response personnel to injury or harm. |
REC121-3684 | 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. |
REC121-3713 | 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. |
REC121-3667 | 32 - Doctrine, standards, and reform | RailCorp should develop and implement an emergency response plan for management of all rail accidents. Such a plan should be subsumed by the rail displan in the case of serious accidents or incidents. |
REC121-3691 | 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. |
REC121-3718 | 16 - Training and behaviour | Training should be based upon a needs analysis, to determine what skills a particular person will require to carry out the tasks of any position safely and efficiently, and instruction and practice, to acquire and demonstrate those skills. |
REC121-3761 | 32 - Doctrine, standards, and reform | Legislative changes should be enacted to ensure the complete independence of ITSRR from the Minister for Transport Services. |
REC121-3672 | 16 - Training and behaviour | All emergency response personnel should be specifically trained in the features of railways which are relevant to their work, such as the location and means of operation of all emergency door releases on trains, the location and use of signal telephones, the methods by which electrical power can be isolated and the means by which they can readily identify and obtain information from the on-site rail commander. |
REC121-3698 | 32 - Doctrine, standards, and reform | No RailCorp train should enter into revenue service or remain in service if, in the opinion of the driver in charge of that train, any defect in it creates a risk of injury. |
REC121-3730 | 32 - Doctrine, standards, and reform | Legislation should be enacted and any necessary arrangements made, to enable the ATSB to review any reports of any investigation by a rail organisation or the OTSI into any serious incident or accident in New South Wales. |
REC121-3769 | 32 - Doctrine, standards, and reform | The ITSRR should continue to participate in the development of a national system for rail safety regulation, provided that any ultimate agreement between the States and Territories and the Australian Government does not produce a safety outcome for New South Wales that is less than would be achieved by the implementation of all the recommendations contained in this report. |
REC121-3654 | 16 - Training and behaviour | All train guards should be trained by RailCorp in the use of the Metronet radio and instructed to use it in any emergency. |
REC121-3683 | 39 - Disaster Risk Management | RailCorp should undertake risk assessments of each of its activities as follows: |
REC121-3710 | 39 - Disaster Risk Management | The ITSRR should have permanent access to the RailCorp intranet. |
REC121-3751 | 16 - Training and behaviour | RailCorp should make it a condition of employment that all level 2 managers have or obtain a formal qualification in system safety management. |
REC121-3662 | 32 - Doctrine, standards, and reform | The rail displan should provide for the site controller to have complete control of the site, with other agencies co-ordinating with and supporting him or her, until the rescue phase of the emergency response has been completed. |
REC121-3690 | 32 - Doctrine, standards, and reform | All communications protocols must be strictly enforced by all accredited rail organisations. |
REC121-3717 | 16 - Training and behaviour | RailCorp must establish a task analysis for particular categories of employees, to identify the specific skills and responsibility of those employees or groups of employees, and thereafter undertake a training needs analysis, to develop the skills required in particular areas. |
REC121-3760 | 32 - Doctrine, standards, and reform | The Advisory Board established under the Transport Legislation Amendment (Safety and Reliability) Act 2003 must be abolished. |
REC121-3671 | 32 - Doctrine, standards, and reform | The RailCorp emergency response plan should include a requirement for the debriefing of all senior rail and emergency response personnel involved in any rail accident, so as to determine the way or ways in which emergency response arrangements for rail accidents can be continually improved, and thereafter implement such improvements. |
REC121-3696 | 32 - Doctrine, standards, and reform | Defects reporting, recording and rectification should be integrated with the RailCorp regimes for train maintenance. |
REC121-3728 | 32 - Doctrine, standards, and reform | Any barriers to communication between OTSI and ITSRR should be removed, so as to ensure that any findings made by OTSI in relation to any investigation it conducts are reported immediately to ITSRR. |
REC121-3768 | 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. |
REC121-3650 | 16 - Training and behaviour | Staff at the Rail Management Centre (RMC) should receive training from RailCorp to enable them to quickly and accurately assess that an emergency has occurred and to provide precise and reliable information to emergency response personnel about the location of the emergency, the available access to the site and the resources necessary. |
REC121-3679 | 32 - Doctrine, standards, and reform | The rail safety regulator should set standards for the design, manufacture, testing and commissioning of rolling stock to ensure that the rolling stock is fit for its purpose. |
REC121-3705 | 32 - Doctrine, standards, and reform | The ITSRR should develop standards for periodic medical examinations which include the following: |
REC121-3750 | 32 - Doctrine, standards, and reform | ITSRR should initiate and/or participate in the development of a national standard for crashworthiness of all passenger trains. |
REC121-3773 | 32 - Doctrine, standards, and reform | The ITSRR should ensure that RailCorp establishes a safety management system containing the 29 elements identified in the SMSEP report, and ensure the ongoing monitoring and improvement of the safety management system established. |
REC121-3661 | 32 - Doctrine, standards, and reform | The rail displan should include provision for the appointment of a rail emergency management co-ordinator at the RMC, and an on-site rail commander with the sole function of assisting and supporting the emergency services during the rescue phase of the emergency response. |
REC121-3688 | 32 - Doctrine, standards, and reform | Communications procedures must be standardised throughout the rail network, so that all railway employees describe the same subject matter in an identical way. |
REC121-3716 | 16 - Training and behaviour | Train driver and guard training should encourage teamwork and discourage authority gradients. |
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. |
REC121-3670 | 16 - Training and behaviour | The RailCorp emergency response plan should be provided to all emergency response agencies. The officers of each emergency service should be trained in any rail specific features of the plan, so as to better ensure inter-agency co-ordination in the circumstances of an emergency. |
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. |
REC121-3727 | 32 - Doctrine, standards, and reform | The relevant legislation should be amended to provide expressly that OTSI and the Chief Investigator have the power to initiate a rail accident or incident investigation. |
REC121-3765 | 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. |
REC121-3677 | 16 - Training and behaviour | A training centre for emergency services personnel should be established by RailCorp. The emergency services personnel should be required to undertake training at such a centre, which should be equipped with features replicating railway infrastructure and rolling stock. |
REC121-3701 | 32 - Doctrine, standards, and reform | Train inspections should be carried out at the time of stabling RailCorp trains, as well as a part of train preparation prior to entering service. |
REC121-3746 | 16 - Training and behaviour | All emergency services personnel should be trained in the location and operation of emergency door release mechanisms on all rail cars. |
REC121-3772 | 32 - Doctrine, standards, and reform | RailCorp should establish a safety management system containing the 29 elements identified in the SMSEP report which is in volume 2 of this report. |
REC121-3660 | 32 - Doctrine, standards, and reform | The rail displan should include the use by all emergency response personnel of a uniform incident command system, involving procedures for such matters as the establishment of inner and outer perimeters, control of access to the site, orderly evacuation of injured passengers and the establishment of a staging area remote from the accident site, in a unified command structure with the site controller co-ordinating the various emergency services through representatives of each service. |
REC121-3686 | 32 - Doctrine, standards, and reform | The standard in relation to the collection and use of data from data loggers should provide that such information must be accessed in the circumstances of any accident or incident and can be accessed to monitor driver performance generally. |
REC121-3715 | 16 - Training and behaviour | RailCorp should use its simulators to train drivers and guards in methods of dealing with degraded operations on the rail network. |
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. |
REC121-3669 | 16 - Training and behaviour | All operational rail staff should be trained by RailCorp in the action check list relevant to each. |
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. |
REC121-3726 | 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. |
REC121-3763 | 32 - Doctrine, standards, and reform | The ITSRR should publish guidelines to be followed by accredited organisations. |