Inquiry Search
Rec-ID | Code | Recommendation |
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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: |
REC324-4296 | 1 - Land-use and building regs | Caravan parks and manufactured home estates: That, to ensure that permanent residents of caravan parks and mobile housing estates are protected from flood, Government: • prohibit permanent residency in caravan parks and mobile housing estates situated below the risk-based flood planning level. Caravan parks for holiday makers could still be on the floodplain with the provision that, if a flood is imminent, they need to be evacuated • address the issues raised in the 2015 Discussion Paper (Improving the regulation of manufactured homes, caravan parks, manufactured home estates and camping grounds). |
REC324-4308 | 26 - Research | Compound mental helath studies: That, to inform Government policies and programs for mental health and disasters, Government commission a longitudinal study on the effect of consecutive disasters on community mental health. |
REC324-4299 | 1 - Land-use and building regs | Relocating communities most at risk with good homes and amenities: That, to empower vulnerable people and communities to relocate, Government through the NSWRA: |
REC324-4310 | 41 - Emergency Management exercises | Task Force Hawk: That, to ensure disaster readiness, Government establish a high-level Government standing committee, Task Force ‘Hawk’, comprising key Cabinet Ministers, Secretaries and Commissioners that meets, trains and exercises to ensure Government is prepared to respond to any emergency. Task Force ‘Hawk’ should resonate with the community in difficult times to ensure the highest level of confidence in Government’s response. |
REC324-4300 | 1 - Land-use and building regs | Simplify the planning system disaster provisions: That, to simplify and improve the state planning processes especially when anticipating and recovering from a disaster, Government: |
REC324-4312 | 17 - Assets and technology | Impact to essential services: That, to minimise disruption to essential services, including outages which compromise basic communication coverage, and to ensure access to safe water supply and power during flood events, Government work directly or together with the Australian and other state governments and/or their relevant power and telecommunications regulatory, policy and market bodies to: |
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. |
REC324-4319 | 26 - Research | Climate and weather research: That, to enable effective mitigation and adaptation measures in response to changing climate risks, Government establish NSW as a world centre of disaster research and technology development. This should include: |
REC324-4304 | 1 - Land-use and building regs | Landholders can access information on previous disasters: That, to ensure there is a single source of ground truth to prepare for and respond to emergencies, and to provide people with a better understanding of their individual property and community risk exposure, an online visualisation tool be developed to display, for all land parcels (land titles) in NSW, the extent of known disasters that have affected each piece of land in NSW in the past. This information should be made available through the Planning Portal and, particularly in light of climate change, the data involved should be revised and updated at least every two years and after each major natural disaster. |
REC324-4293 | 17 - Assets and technology | Essential services and floodplain infrastructure: That, to minimise disruption to essential services (power, communications, water, sewerage) and to ensure flood infrastructure is fully serviceable before flooding, Government ensure: |
Rec-ID | Code | Recommendation |
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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. |
REC297-1271 | 1 - Land-use and building regs | That the organisations responsible for construction, maintenance and ownership of bridges review their design guidelines and, if necessary, update them to specifically include consideration of debris and flood impacts on bridge design. A review of existing bridges by the responsible organisations could also be undertaken to highlight any potential issues. |
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. |
REC297-1265 | 13 - Mapping and data quality | That BoM and the Flood Warning Consultative Committee, in consultation with gauge owners, review flood gauges and develop a program to update data used to support hydrologic modelling. This should include reviewing gauge maintenance before and after floods. |
REC297-1254 | 13 - Mapping and data quality | That Government: |
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. |
REC297-1253 | 13 - Mapping and data quality | That agencies undertaking flood studies adopt a standardised approach, based on Australia Handbook 7, maintain public ownership of underlying data sets to support future modelling, and ensure open access to these studies. |
REC297-1263 | 13 - Mapping and data quality | Subject to funding, that the Flood Warning Consultative Committee investigates the hydrological matters and advice received during this Review and detailed in this Report in Sections 4.1.9 and 4.1.11. |
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. |
REC297-1252 | 13 - Mapping and data quality | That SES uploads current flood studies and plans to the Common Operating Platform as a flood plan layer and that councils, subject to resolving licence restrictions, arrange to have appropriate access. |
REC297-1262 | 13 - Mapping and data quality | That the Flood Warning Consultative Committee considers the merits of delineating the Ouse River as a separate catchment from the Derwent River Basin. |
REC297-1272 | 1 - Land-use and building regs | That, to provide greater clarity for building development, design and approval within tolerable risk levels, the Tasmanian Planning Scheme, including a relevant Riverine Flood Hazard Code, is finalised and approved as soon as practicable. |
Rec-ID | Code | Recommendation |
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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. |
REC258-2548 | 17 - Assets and technology | The Civil Aviation Safety Authority shares the risk assessment outputs of Sky Sentinel, its computerised risk assessment system, with the applicable authorisation holder. |
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. |
REC258-2556 | 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. |
REC258-2541 | 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: |
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. |
REC258-2534 | 16 - Training and behaviour | The Civil Aviation Safety Authority develops a staff exchange program with industry. |
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. |
REC258-2528 | 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. |
Rec-ID | Code | Recommendation |
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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 |
REC199-0485 | 1 - Land-use and building regs | the state: • adopt a strategy to expedite incorporation of updated flood mapping or modelling into planning schemes • reconsider in what circumstances the ‘1 in 100 year event’ is the appropriate design event • actively support the Australian Building Code Board in its development of a new national standard for residential buildings in flood prone areas. Until such time as any new standard is incorporated into Victorian law, provide advice to householders about appropriate building materials for flood prone areas and ways that houses can be designed or adapted to mitigate flood risk; and • retain the ability of a Catchment Management Authority to require a council to refuse a planning permit or impose particular conditions when the Catchment Management Authority considers the flooding risk to be unacceptable. |
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. |
REC199-0450 | 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 |
REC199-0410 | 17 - Assets and technology | the state take the necessary measures to upgrade existing manual stream and rain gauges and ensure that all future gauges provide a seamless transfer of data from the gauges to the Bureau of Meteorology. |
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. |
REC199-0420 | 13 - Mapping and data quality | the state establish standards for flood mapping to ensure they are kept contemporary and meet the purposes of landuse risk planning and emergency response. In doing so, maps should extend where appropriate to include Probable Maximum Flood, over a range of Annual Exceedence Probability levels and be explicitly linked to a stream gauge. |
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. |
REC199-0408 | 13 - Mapping and data quality | the state, in consultation with Bureau of Meteorology and Melbourne Water, take the necessary action to ensure that all flood warnings issued are linked to the geographical location of the gauge the data was derived from. |
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. |
REC199-0417 | 13 - Mapping and data quality | the state ensure that regional and local flood plans incorporate all available flood mapping and intelligence, including assessments of levees and flood consequence information. |
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. |
REC199-0407 | 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. |
REC199-0463 | 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. |
REC199-0416 | 26 - Research | the state establish appropriate arrangements to ensure the capacity to maintain technical expertise for flood intelligence is initiated, including appropriate agreements with commercial experts. |
REC199-0441 | 4 - Fire season preparation | the state undertake further trials to explore the opportunity for greater use of social media as a credible source of information to and from the public during an emergency |
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. |
REC199-0462 | 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. |
REC199-0415 | 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. |
REC199-0429 | 13 - Mapping and data quality | the state take into account any outcomes from the Commonwealth Government’s flood mapping reviews in the continual development of the Victorian flood database and to incorporate into the database flood data currently held by Melbourne Water. |
REC199-0452 | 17 - Assets and technology | the state ensure that any new systems and equipment purchased by state emergency management agencies are interoperable with other relevant agencies to the fullest extent possible. This should involve the state establishing a procurement gateway process with input from the Emergency Services Commissioner. |
Rec-ID | Code | Recommendation |
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REC197-1754 | 16 - Training and behaviour | The CFA proceed with the update of facilities and infrastructure at Fiskville to enable its better utilisation by volunteers and employees for training. Where necessary, the Government support this update when determining CFA funding. |
REC197-1762 | 16 - Training and behaviour | The CFA provide greater opportunities for leadership training for volunteers at all levels but particularly at the brigade level. The CFA, as far as practicable, endeavour to ensure that persons appointed to positions of leadership have the necessary capability. |
REC197-1748 | 16 - Training and behaviour | The CFA establish forward strategic planning initiatives for training with resource allocation covering short term, mid term, and long term. |
REC197-1768 | 16 - Training and behaviour | The CFA, in consultation with the VFBV and volunteers, explore and develop initiatives whereby more volunteers are qualified to participate in Incident Management Teams. |
REC197-1753 | 16 - Training and behaviour | The CFA continue the Mobile Training Infrastructure Project and the Fixed Training Infrastructure Project. Where necessary, the Government support these initiatives in determining CFA funding. |
REC197-1761 | 16 - Training and behaviour | The CFA continue the development of key principles in relation to training, in consultation with volunteers and paid personnel. In the development of those principles, account should be taken of matters raised by volunteers to this Inquiry and the comments that I have made about training delivery. Account should also be taken of principles contained in any statement of Vision, Mission and Values adopted by the CFA. |
REC197-1747 | 16 - Training and behaviour | The CFA, in consultation with the VFBV and volunteers, review its arrangements with respect to First Aid training and maintenance of currency of qualifications, with a view to the delivery of such training and maintenance best meeting brigade needs. |
REC197-1767 | 16 - Training and behaviour | Consideration be given to the establishment of a dedicated CFA training academy. |
REC197-1752 | 16 - Training and behaviour | The CFA take initiatives to improve the accessibility of Field Training Grounds, including Fiskville, to volunteers for training. |
REC197-1757 | 16 - Training and behaviour | The CFA, in consultation with the VFBV and volunteers, examine options to enable the engagement of an adequate instructor strength to serve the training needs of volunteers. Those options should include making more use of volunteers as instructors. |
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. |
REC197-1765 | 16 - Training and behaviour | The CFA continue the development of Vector Command Training and its availability and utilisation by volunteers. The feasibility of this training being provided online be explored by the CFA as part of the consideration of the use of the NBN. |
REC197-1751 | 16 - Training and behaviour | The CFA ensure that there is transparency with respect to training budgets and, in particular, with respect to what relates to volunteer training and what relates to career staff training. |
REC197-1756 | 16 - Training and behaviour | CFA develop an individual training pathway for operational volunteers to enable volunteers to be able to better identify their career and training options and pursue a pathway that meets their expectation. |
REC197-1764 | 16 - Training and behaviour | A. The CFA, in consultation with volunteers, employees, the VFBV and the UFU, examine the feasibility of utilising the TAFE system for training delivery. |
REC197-1750 | 16 - Training and behaviour | The CFA ensure that there is transparency with respect to the identification and meeting of training demand, and plans to meet such demand. |
REC197-1755 | 16 - Training and behaviour | The CFA examine options to enable sufficient training materials to be available to ensure effective training delivery. As part of this examination, the CFA explore the feasibility of utilising the TAFE system. |
REC197-1763 | 16 - Training and behaviour | The CFA, in consultation with the VFBV and volunteers, review the process for RCC and RPL with the view to making that process transparent, efficient and fair. |
REC197-1749 | 16 - Training and behaviour | The CFA proceed with a review of the Minimum Skills training program. |
Rec-ID | Code | Recommendation |
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REC177-3330 | 39 - Disaster Risk Management | Decision‐making about well control issues should be professionalised. Industry participants must recognise that decision‐makers owe independent duties to the public, not just their employer or principal, in relation to well control. Risk management in the context of well control needs to be understood as an ethical/professional duty. Self‐regulation contemplates self‐regulation by the industry, not just by individual licensees and operators. |
REC177-3356 | 39 - Disaster Risk Management | The regulator should pre‐assess and review in a generic sense, and in conjunction with the offshore petroleum industry, available options for well control in the event of a blowout. Being ‘match fit’ in this sense will enable a quicker and more effective response in terms of safety assessment, and will ensure that expectations of both operator and regulator are more readily aligned. |
REC177-3289 | 39 - Disaster Risk Management | The use/type of barriers (including any change requests relating thereto) must be the subject of consultation between licensees and rig operators prior to installation. A proper risk assessment should be carried out, agreed upon, and documented in writing before installation. Joint written certification as to the appropriateness of the use of particular barriers should take place before installation. Senior onshore representatives of stakeholder entities should be involved in that certification process. |
REC177-3329 | 17 - Assets and technology | Logistics management of well control equipment should be conducted in such a way as to operate as a check against deficient well control practices, for example, use of serial numbers to track availability, testing, and deployment of well control equipment. |
REC177-3344 | 25 - Inquiry, audit, lessons management and after action review | There should be a review to determine whether it is appropriate to introduce a rigorous civil penalty regime and/or substantially increase some or all of the penalties that can be imposed for breaches of legislative requirements relating to well integrity and safety. |
REC177-3286 | 39 - Disaster Risk Management | Problems which arise in the course of installing barriers must be the subject of consultation between licensees, rig operators, and contractors (if used). A proper risk assessment should then be carried out and remedial steps (including further testing/verification) should be agreed upon, and documented in writing before the performance of remedial work whenever practicable. Joint written certification as to resolution of the problem should take place before resumption of drilling operations. Senior onshore representatives of stakeholder entities should be involved in that certification process. |
REC177-3333 | 16 - Training and behaviour | Licensees and rig operators (and third party contractors involved in well control operations) should specifically assess, and document, the nature and extent of knowledge/skills of relevant personnel in relation to well control (including familiarity of personnel with agency‐specific requirements and procedures). Training needs and opportunities should be identified. This process should take place on engagement and at appropriate intervals. |
REC177-3285 | 39 - Disaster Risk Management | Pre‐drilling assessments should include a risk assessment of the worst‐case blowout scenario. |
REC144-3387 | 25 - Inquiry, audit, lessons management and after action review | In order that the ACT public can be reassured about the project management and financial planning in relation to the Fairbairn site as a proposed centralised accommodation facility for emergency services, the Auditor-General undertake a review of the project from a financial probity and project management perspective. |
REC177-3304 | 26 - Research | It is recommended that industry, regulators, and training/research institutions liaise with one another with a view to developing better techniques for testing and verifying the integrity of cemented casing shoes as barriers (particularly in atypical situations such as where the casing shoe is located within a reservoir in a horizontal or high angle position at great depth). |
REC177-3332 | 16 - Training and behaviour | A specific focus on well control training should be mandatory for key personnel involved in well control operations (including both on‐rig personnel and onshore personnel in supervisory capacities). |
REC177-3378 | 25 - Inquiry, audit, lessons management and after action review | In view of the numerous well integrity problems in all of the Montara Oilfield wells, the Minister should commission a detailed audit of all the other offshore wells operated by PTTEPAA to determine whether they too may suffer from well integrity problems. |
REC177-3291 | 39 - Disaster Risk Management | Removal of a barrier must be the subject of consultation between licensees and rig operators prior to removal. A proper risk assessment should be carried out and agreed upon, and documented in writing before removal. Joint written certification as to the appropriateness of removal should take place before removal. Senior onshore representatives of stakeholder entities should be involved in that certification process. |
REC177-3331 | 16 - Training and behaviour | Existing well control training programs should be reviewed by the industry, regulators and training providers, with a focus on well control accidents that have occurred (in Australia and overseas). |
REC177-3374 | 25 - Inquiry, audit, lessons management and after action review | The Minister should, as the JA for the offshore area of the Territory of Ashmore and Cartier Islands, undertake a review of PTTEPAA’s permit and licence to operate at the Montara Oilfield. |
Rec-ID | Code | Recommendation |
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REC164-0075 | 16 - Training and behaviour | SERCon consider development of an education program for other government and non-government agencies (with |
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 |
Rec-ID | Code | Recommendation |
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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. |
REC149-3136 | 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. |
REC149-3145 | 25 - Inquiry, audit, lessons management and after action review | NOPSA should consider an audit regime that targets Greenfields operations at commencement of operations. |
REC149-3139 | 39 - Disaster Risk Management | The industry should develop in conjunction with the Regulator a process for addressing the need to maintain the risk profile of a facility moving into extended life operation at the same risk profile as when it was within design life. |
Rec-ID | Code | Recommendation |
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REC121-3768 | 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. |
REC121-3670 | 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. |
REC121-3715 | 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. |
REC121-3683 | 39 - Disaster Risk Management | RailCorp should undertake risk assessments of each of its activities as follows: |
REC121-3724 | 13 - Mapping and data quality | The ITSRR should establish a data and information management system, containing all data and information that it requires, to continually monitor the safety of the New South Wales rail system. |
REC121-3751 | 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. |
REC121-3651 | 10 - Infrastructure | A dedicated telephone line should be established by RailCorp between the RMC and any Emergency Services Control Centre for use during any emergency. |
REC121-3694 | 25 - Inquiry, audit, lessons management and after action review | The ITSRR should conduct random audits of accredited rail organisations for compliance with communications protocols. |
REC121-3765 | 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. |
REC121-3669 | 16 - Training and behaviour | All operational rail staff should be trained by RailCorp in the action check list relevant to each. |
REC121-3714 | 16 - Training and behaviour | RailCorp should use its simulators in an interactive manner. |
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. |
REC121-3719 | 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. |
REC121-3650 | 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. |
REC121-3693 | 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. |
REC121-3746 | 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. |
REC121-3758 | 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. |
REC121-3657 | 10 - Infrastructure | All signal telephones must be maintained by RailCorp in proper working order. |
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. |
REC121-3675 | 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. |
REC121-3718 | 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. |
REC121-3691 | 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. |
REC121-3744 | 16 - Training and behaviour | All RailCorp operational personnel should be trained in the location and operation of external emergency door release mechanisms. |
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. |
REC121-3656 | 17 - Assets and technology | Satellite telephones should be provided by RailCorp to all rail commanders at any emergency. |
REC121-3710 | 39 - Disaster Risk Management | The ITSRR should have permanent access to the RailCorp intranet. |
REC121-3673 | 41 - Emergency Management exercises | Regular field training exercises should be conducted by RailCorp with the emergency services to ensure that the incident command system and rail displan are able to be fully implemented as quickly as possible and are reviewed and improved. |
REC121-3717 | 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. |
REC121-3687 | 10 - Infrastructure | There must be compatibility of communications systems throughout the rail network. It is essential that all train drivers, train controllers, signallers, train guards and supervisors of trackside work gangs in New South Wales be able to communicate using the same technology. |
REC121-3726 | 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. |
REC121-3756 | 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. |
REC121-3654 | 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. |
REC121-3700 | 39 - Disaster Risk Management | Maintenance plans on all trains should be revised annually. |
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. |
REC121-3716 | 16 - Training and behaviour | Train driver and guard training should encourage teamwork and discourage authority gradients. |
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. |
REC121-3725 | 13 - Mapping and data quality | The data and information management system should be compatible with any data and information management system established by the ATSB for the designated interstate rail network, provided that the establishment of a compatible system does not reduce the amount or quality of the information obtained by ITSRR below the optimum levels which it needs to conduct trend analysis, and otherwise properly manage the safety of rail operations in New South Wales. |
REC121-3753 | 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. |
REC121-3653 | 10 - Infrastructure | The RMC should be equipped by RailCorp with a transcriber system, or mimic board, or such other system as is necessary to enable identification of the precise location at any time of any train on the RailCorp network. |
REC121-3695 | 10 - Infrastructure | There should be interoperability of communications equipment between all trains operating on the New South Wales rail network. |