Inquiry Search
Rec-ID | Code | Recommendation |
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REC002-4011 | 32 - Doctrine, standards, and reform | The Commission feel that the 4th clause in the present Act, relating to the spacing of cut-throughs, should be amended to admit of any convenient or safe system of mining being pursued. This is a matter of detail that would be better out of the Act. The Commission would advise that the word should not occur at all, and that, if bratticing be used, or the air by some other satisfactory device be conveyed to the face, scope would be given to Managers to introduce systems of mining adapted to the circumstance of each particular coal-seam, with advantage to all concerned. |
REC002-4009 | 16 - Training and behaviour | In gassy mines the Manager should be specially competent, and one possessing a thorough knowledge of the principles and practice of mining, the properties of gases, and systems of ventilation; and, above all, he must be prudent and cautious, yet resolute, possessing sound judgement. He must have absolute and supreme control over the whole operations, and of the men within the mine, to maintain rigid discipline, and be perfectly free and untrammelled by any outside influences. The competency of a manager should be certified by an examination before a specially-appointed Board. The Commission consider that better results may be obtained if such examinations be oral, and probably assume a more practical form than those hitherto conducted in Great Britain for the same object. |
REC002-4007 | 40 - Equipment and consumables | A measure of safety may be found in the use of high explosives combined with wet tamping, or, still better, water cartridges, instead of powder under any of its modifications. Encouragement ought also to be given to the use of patent multiple wedges and applicances of a like nature, for supplanting the use of explosives. Under all circumstances and conditions some provision should be adopted for compelling workmen to thoroughly undercut, shear, or nick, and generally to work the coal as directed by the Manager. |
REC002-4005 | 40 - Equipment and consumables | Where safety-lamps are used the lock should be of such a character as to prevent any workman opening it. If the "Protector" type of lamp be employed the necessity for a lock is the less necessary, as the unscrewing of this type of lamp extinguishes the light. |
REC002-4012 | 38 - Agency/Department Reporting | Complete sets of daily-report books should be provided, and kept in the mine or office, to be overlooked by the Inspector during his periodical visits. |
Rec-ID | Code | Recommendation |
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REC292-2344 | 32 - Doctrine, standards, and reform | I recommend that the New South Wales Police Force review the division of tasks among the various officers responsible for responding to major high-risk situations to enable Police Forward Commanders to focus exclusively on their primary goals and that officers engaged in matters not directly related to the resolution of the incident be required to report to an officer other than the Police Forward Commander |
REC292-2362 | 32 - Doctrine, standards, and reform | I recommend that the New South Wales Police Force review its policies to ensure that the usual arrangements for placing a sniper coordinator in the Police Forward Command Post are departed from only for sound operational reasons that are recorded. |
REC292-2350 | 32 - Doctrine, standards, and reform | I recommend that the Secretariat of the Australia–New Zealand Counter-Terrorism Committee prepare guidelines regarding the interpretation and scope of the restrictions contained Clause 92 of the National Counter Terrorism Plan 2012. The Secretariat should also update relevant Australia–New Zealand Counter-Terrorism Committee documents and the New South Wales Police Force should update State Protection Group documents to refer to the latest versions of the National Counter-Terrorism Plan |
REC292-2367 | 32 - Doctrine, standards, and reform | I recommend that the Australia New Zealand Policing Advisory Agency liaise with the Australia–New Zealand Counter-Terrorism Committee to determine whether policies requiring the consideration of more proactive intervention should be developed for responding to terrorist sieges. |
REC292-2355 | 12 - EM agency and authority | I recommend that the New South Wales Police Force review its procedures to ensure that handovers between negotiation teams are staggered so that a fully briefed officer is always available to receive a call from the stronghold. |
REC292-2373 | 32 - Doctrine, standards, and reform | I recommend that the ADF Review confer with state and territory governments about the criteria governing applications for the ADF to be called out pursuant to the Defence Act 1903(Cth) with a view to determining: whether further guidance is required on the criteria to be used by states and territories in determining whether to apply for Commonwealth assistance; and if so, what criteria ought to be stipulated. |
REC292-2343 | 32 - Doctrine, standards, and reform | I recommend that the New South Wales Police Force remedy the lack of detailed guidance on how State Protection Group officers should interact and communicate with the Police Forward Commander, and that such guidance be included in policy documents and reinforced with training. |
REC292-2361 | 32 - Doctrine, standards, and reform | I recommend that the Minister for Police consider whether the provisions of the Terrorism (Police Powers) Act2002 should be amended to ensure that police officers have sufficient legal protection to respond to terrorist incidents in a manner most likely to minimise the risk to members of the public. |
REC292-2349 | 12 - EM agency and authority | I recommend that the New South Wales Police Force review its personnel arrangements and structures for the monitoring of surveillance devices, including the number of officers allocated to a listening or viewing post for monitoring purposes, and the demarcation of roles, including primary monitor, scribe/log keeper, and disseminator. I also recommend that clear communication channels be established for reporting data captured during such surveillance, including via integrated electronic intelligence sharing platforms or applications. |
REC292-2366 | 16 - Training and behaviour | I recommend that the New South Wales Police Force review the training provided to officers in relation to DA planning and approval. |
REC292-2354 | 12 - EM agency and authority | I recommend that the New South Wales Police Force consider expanding the panel of psychological advisers it retains and the range of disciplines it consults. |
REC292-2372 | 32 - Doctrine, standards, and reform | I recommend that the New South Wales Police Force review its policies, procedures and training to ensure the rapid identification of persons killed or injured in high-risk situations. Those policies should provide appropriate guidance on how and when death messages ought to be conveyed following such incidents. |
REC292-2341 | 32 - Doctrine, standards, and reform | I recommend that the New South Wales Police Force review the Management Operational Guidelines to resolve any inconsistency between them and relevant counter terrorism protocols. |
REC292-2359 | 32 - Doctrine, standards, and reform | I recommend that the New South Wales Police Force develop policies that require the recording of negotiation strategies and tactics, demands made by a hostage taker, and any progress towards resolution (or lack thereof ) in a form readily accessible by commanders and negotiators. |
REC292-2382 | 32 - Doctrine, standards, and reform | I recommend that the Minister for Police undertake a review of the Law Enforcement Conduct Commission Act 2016 with a view to enabling the Law Enforcement Conduct Commission to facilitate urgent debriefs and confidential internal reviews of critical incidents focused on improving current practice. |
REC292-2347 | 32 - Doctrine, standards, and reform | I recommend that the New South Wales Police Force consider developing a pro forma debriefing sheet containing standard questions relevant to all or most high risk situations, which can be supplemented by the negotiation coordinator and the tactical commander to maximise the likelihood of all available relevant information being obtained during hostage debriefings. Such measures would also aid contemporaneous documentation of information derived from debriefs and assist in relaying all relevant information to command. |
REC292-2365 | 32 - Doctrine, standards, and reform | I recommend that the Australia New Zealand Policing Advisory Agency and the Australia–New Zealand Counter-Terrorism Committee review the Australia New Zealand Guidelines for Deployment of Police to High Risk Situations and the Police Tactical Group Operations Manual to ensure that they adequately describe all aspects of the DA planning and approval pro-cess and present commanders with appropriate guidance on relevant considerations. |
REC292-2353 | 32 - Doctrine, standards, and reform | I recommend that the New South Wales Police Force develop a comprehensive policy that describes the role and function of a psychological adviser engaged to assist in responses to high-risk situations and that all those involved be made familiar with that policy. |
REC292-2371 | 32 - Doctrine, standards, and reform | I recommend that the New South Wales Police Force develop a comprehensive policy and set of procedures in relation to family liaison capability for high-risk situations. Those policies and procedures should ensure that: The capability is scalable depending on the nature of the incident, An appropriately senior officer is responsible for overseeing the liaison process, He or she should have direct access to officers in the Police Forward Command Post for the purpose of conveying and receiving information in a timely manner, A dedicated family liaison officer (or officers) is assigned to the family of each victim and given responsibility for managing the needs of that family Officers are given guidance on communi-cating with families, including the appropriate frequency and content of briefings both during and after an incident, Officers are advised of the proper process for gathering and disseminating intelligence from family members. |
REC292-2340 | 32 - Doctrine, standards, and reform | I recommend that the Director of Public Prosecutions develop a policy for overseeing lawyers' exercise of the discretion not to oppose bail that takes into account the seriousness of the offences involved; the experience of the prosecutor appearing; and the views of the police officer in charge of the investigation, insofar as those views are based on facts relevant to bail determinations. |
REC292-2358 | 16 - Training and behaviour | I recommend that the New South Wales Police Force develop a cadre of counterterrorist negotiators and provide them with appropriate training to equip them to respond to a terrorist siege. |
REC292-2376 | 32 - Doctrine, standards, and reform | I recommend that the Commonwealth Attorney-General, in consultation with states and territories, review existing arrangements for information sharing between federal, state and territory agencies during terrorist events to determine whether those arrangements (and the guidance provided to officers in respect of them) adequately facilitate the efficient identification and transfer of pertinent information between agencies. |
REC292-2346 | 12 - EM agency and authority | I recommend that the New South Wales Police Force investigate the development of an integrated intelligence system that allows selected officers secure access to all information platforms and to record and share operational decisions. |
REC292-2364 | 32 - Doctrine, standards, and reform | I recommend that the Australia New Zealand Policing Advisory Agency and the Australia–New Zealand Counter-Terrorism Committee review the Australia–New Zealand Guidelines for Deployment of Police to High-Risk Situations and the Police Tactical Group Operations Manual to ensure that those documents give commanders guidance on how to assess imminent or immediate risk. |
REC292-2352 | 16 - Training and behaviour | The New South Wales Police Force should consider drawing on international experience when reviewing its negotiator training |
REC292-2370 | 25 - Inquiry, audit, lessons management and after action review | I recommend that the New South Wales Police Force undertake a formal assessment of alternatives to the TOU’s current soft-point ammunition to determine whether a more appropriate form of ammunition is reasonably available. |
REC292-2338 | 32 - Doctrine, standards, and reform | I recommend that the Commissioner of Police issue guidelines to assist officers to determine when they should exercise their powers of arrest and take an accused into custody rather than proceeding by way of a court attendance notice. |
REC292-2357 | 12 - EM agency and authority | I recommend that the New South Wales Police Force review its policy of requiring negotiators to relinquish that role when they are promoted to commissioned officer rank |
REC292-2375 | 32 - Doctrine, standards, and reform | I recommend that the ADF Review, in consultation with the police forces of the states and territories, examine the guidance available to ADF officers and state and territory police regarding: the role of ADF liaison officers; the availability of ADF assistance in the absence of a call-out; and the procedures to apply in relation to requests for, and the provision of, equipment or advice by the ADF. |
REC292-2345 | 12 - EM agency and authority | I recommend that the New South Wales Police Force establish procedures and the technical capability to ensure that phone calls from hostages in sieges or the victims of other ongoing high-risk situations are expeditiously transferred to officers involved in responding to the incident. |
REC292-2363 | 32 - Doctrine, standards, and reform | I recommend that New South Wales Police Force policies be amended to require documentation of triggers for Emer-gency Actions. Consideration should be given to stipulating that “contingency triggers”—specific events that will require initiation of an EA or some other agreed response—should also be recorded. |
REC292-2351 | 16 - Training and behaviour | The sections above dealing with negotiators’ attempts to engage with Monis, their responses to his demands, and their assessment of progress demonstrate deficiencies in current practice. To respond to those deficiencies, I recommend that the New South Wales Police Force conduct a general review of the training afforded to negotiators and the means by which they are assessed and accredited. Specifically, the review should consider the training provided regarding: measuring progress in negotiations; recording of information, including the systems by which that occurs; the use of third-party intermediaries; additional approaches to securing direct contact with a person of interest; and handovers. |
REC292-2368 | 32 - Doctrine, standards, and reform | I recommend that the New South Wales Police Force develop a policy regarding the use of distraction devices and the training of officers in their use. |
REC292-2337 | 16 - Training and behaviour | I recommend that the Director of Public Prosecutions initiate reviews of the training in file management given to lawyers employed by the Office of the Director of Public Prosecutions to ensure important original documents are not discarded and that the files accurately reflect relevant events. |
REC292-2356 | 12 - EM agency and authority | I recommend that the New South Wales Police Force review the number, rank and function of the officers comprising the Negotiation Unit |
REC292-2374 | 32 - Doctrine, standards, and reform | I recommend that the ADF Review give consideration to amending the Australia–New Zealand Counter-Terrorism Committee protocols to ensure that they provide sufficient guidance as to the respective roles of the ADF and state police tactical groups. Such guidance should accord with the legislative framework in Part IIIAAA of the Defence Act 1903 (Cth). |
Rec-ID | Code | Recommendation |
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REC258-2528 | 25 - Inquiry, audit, lessons management and after action review | The Australian Transport Safety Bureau investigates as many fatal accidents in the sport and recreational aviation sector as its resources will allow. |
REC258-2551 | 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. |
REC258-2534 | 16 - Training and behaviour | The Civil Aviation Safety Authority develops a staff exchange program with industry. |
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: |
REC258-2527 | 32 - Doctrine, standards, and reform | The Department of Infrastructure and Regional Development plays a stronger policy role in the State Safety Program. |
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. |
REC258-2533 | 32 - Doctrine, standards, and reform | The Civil Aviation Safety Authority: |
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: |
REC258-2538 | 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. |
REC258-2547 | 12 - EM agency and authority | The Civil Aviation Safety Authority establishes small offices at specific industry centres to improve monitoring, service quality, communications and collaborative relationships. |
REC258-2532 | 12 - EM agency and authority | The next Director of Aviation Safety has leadership and management experience and capabilities in cultural change of large organisations. Aviation or other safety industry experience is highly desirable. |
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. |
REC258-2537 | 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. |
REC258-2562 | 32 - Doctrine, standards, and reform | The Civil Aviation Safety Authority amends the current Terms of Reference of the Industry Complaints Commissioner so that: |
REC258-2546 | 12 - EM agency and authority | The Civil Aviation Safety Authority changes its organisational structure to a client-oriented output model. |
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. |
REC258-2553 | 12 - EM agency and authority | The Civil Aviation Safety Authority establishes a safety oversight risk management hierarchy based on a categorisation of operations. Rule making and surveillance priorities should be proportionate to the safety risk. |
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. |
REC258-2560 | 29 - Operational Health and Safety | The Civil Aviation Safety Authority devolve to Designated Aviation Medical Examiners the ability to renew aviation medical certificates (for Classes 1, 2, and 3) where the applicant meets the required standard at the time of the medical examination. |
REC258-2545 | 12 - EM agency and authority | The Australian Transport Safety Bureau transfers its safety education function to the Civil Aviation Safety Authority. |
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. |
REC258-2552 | 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. |
REC258-2535 | 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’. |
REC258-2558 | 12 - EM agency and authority | The Civil Aviation Safety Authority applies a project management approach to the completion of all Civil Aviation Safety Regulation Parts not yet in force, with drafting to be completed within one year and consultation completed one year later, with: |
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. |
Rec-ID | Code | Recommendation |
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REC236-2791 | 37 - Funding | The committee recommends that the government develop a process by which the ATSB can request access to supplementary funding via the minister. |
REC236-2807 | 32 - Doctrine, standards, and reform | The committee recommends that the Aeronautical Information Package (AIP) En Route Supplement Australia (ERSA) is updated to reflect the need for caution with regard to Norfolk Island forecasts where the actual conditions can change rapidly and vary from forecasts. |
REC236-2796 | 32 - Doctrine, standards, and reform | The committee recommends that the ATSB-CASA Memorandum of Understanding be re-drafted to remove any ambiguity in relation to information that should be shared between the agencies in relation to aviation accident investigations, to require CASA to: |
REC236-2785 | 32 - Doctrine, standards, and reform | The committee recommends that the ATSB move away from its current approach of forecasting the probability of future events and focus on the analysis of factors which allowed the accident under investigation to occur. This would enable the industry to identify, assess and implement lessons relevant to their own operations. |
REC236-2801 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that the ATSB review its process to track the implementation of recommendations or safety actions to ensure it is an effective closed loop system. This should be made public, and provided to the Senate Regional and Rural Affairs and Transport Committee prior to each Budget Estimates. |
REC236-2790 | 12 - EM agency and authority | The committee recommends that an expert aviation safety panel be established to ensure quality control of ATSB investigation and reporting processes along the lines set out by the committee. |
REC236-2806 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that the relevant agencies investigate appropriate methods to ensure that information about the incidence of, and variable weather conditions at, Norfolk Island is available to assist flight crews and operators managing risk that may result from unforseen weather events. |
REC236-2795 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that a short inquiry be conducted by the Senate Standing Committee on Rural and Regional Affairs and Transport into the current status of aviation regulatory reform to assess the direction, progress and resources expended to date to ensure greater visibility of the processes. |
REC236-2784 | 32 - Doctrine, standards, and reform | The committee recommends that the minister, in issuing a new Statement of Expectations to the ATSB, valid from 1 July 2013, make it clear that safety in aviation operations involving passengers (fare paying or those with no control over the flight they are on, e.g. air ambulance) is to be accorded equal priority irrespective of flight classification. |
REC236-2800 | 38 - Agency/Department Reporting | The committee recommends that where a safety action has not been completed before a report being issued that a recommendation should be made. If it has been completed the report should include details of the action, who was involved and how it was resolved. |
REC236-2789 | 32 - Doctrine, standards, and reform | The committee recommends that the Transport Safety Investigation Act 2003 be amended to require that the Chief Commissioner of the ATSB be able to demonstrate extensive aviation safety expertise and experience as a prerequisite for the selection process. |
REC236-2805 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that the relevant agencies review whether any equipment or other changes can be made to improve the weather forecasting at Norfolk Island. The review would include whether the Unicom operator should be an approved meteorological observer. |
REC236-2794 | 32 - Doctrine, standards, and reform | The committee recommends that CASA, in consultation with an Emergency Medical Services industry representative group (eg. Royal Flying Doctor Service, air ambulance operators, rotary wing rescue providers) consider the merit, form and standards of a new category of operations for Emergency Medical Services. The minister should require CASA to approve the industry plan unless there is a clear safety case not to. Scope for industry to assist as part of an audit team should also be investigated where standardisation is an issue. This should be completed within 12 months and the outcome reported publicly. |
REC236-2799 | 38 - Agency/Department Reporting | The committee recommends that the ATSB prepare and release publicly a list of all its identified safety issues and the actions which are being taken or have been taken to address them. The ATSB should indicate its progress in monitoring the actions every 6 months and report every 12 months to Parliament. |
REC236-2788 | 16 - Training and behaviour | The committee recommends that, as far as available resources allow, ATSB investigators be given access to training provided by the agency's international counterparts. Where this does not occur, resultant gaps in |
REC236-2804 | 32 - Doctrine, standards, and reform | The committee recommends that Airservices Australia discuss the safety case for providing a hazard alert service with Fijian and New Zealand ATC (and any other relevant jurisdictions) and encourage them to adopt this practice. |
REC236-2793 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that CASA processes in relation to matters highlighted by this investigation be reviewed. This could involve an evaluation benchmarked against a credible peer (such as FAA or CAA) of regulation and audits with respect to: non-RPT passenger carrying operations; approach to audits; and training and standardisation of FOI across regional offices. |
REC236-2798 | 32 - Doctrine, standards, and reform | The committee recommends that, where relevant, the ATSB include thorough human factors analysis and discussion in future investigation reports. Where human factors are not considered relevant, the ATSB should include a statement explaining why. |
REC236-2787 | 16 - Training and behaviour | The committee recommends that the training offered by the ATSB across all investigator skills sets be benchmarked against other agencies by an independent body by, for example, inviting the NTSB or commissioning an industry body to conduct such a benchmarking exercise. |
REC236-2803 | 32 - Doctrine, standards, and reform | The committee recommends that the government consider setting a time limit for agencies to implement or reject recommendations, beyond which ministerial oversight is required where the agencies concerned must report to the minister why the recommendation has not been implemented or that, with ministerial approval, it has been formally rejected. |
REC236-2792 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that the investigation be re-opened by the ATSB with a focus on organisational, oversight and broader systemic issues. |
REC236-2808 | 38 - Agency/Department Reporting | The committee recommends that in relation to mandatory and confidential reporting, the default position should be that no identifying details should be provided or disclosed. However, if there is a clear risk to safety then the ATSB, CASA and industry representatives should develop a process that contains appropriate checks and balances. |
REC236-2797 | 12 - EM agency and authority | The committee recommends that all meetings between the ATSB and CASA, whether formal or informal, where particulars of a given investigation are being discussed be appropriately minuted. |
REC236-2786 | 32 - Doctrine, standards, and reform | The committee recommends that the ATSB be required to document investigative avenues that were explored and then discarded, providing detailed explanations as to why. |
REC236-2802 | 32 - Doctrine, standards, and reform | The committee recommends that where the consideration and implementation of an ATSB recommendation may be protracted, the requirement for regular updates (for example 6 monthly) should be included in the TSI Act. |
Rec-ID | Code | Recommendation |
---|---|---|
REC233-1590 | 25 - Inquiry, audit, lessons management and after action review | Department of Broadband, Communications and the Digital Economy seek regular updates from Telstra on the implementation of the recommendations of its inquiry into the Warrnambool exchange fire. |
Rec-ID | Code | Recommendation |
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REC227-2856 | 12 - EM agency and authority | I recommend that BPC establish an onshore presence as recommended by Lieutenant Commander Livingstone. |
REC227-2855 | 32 - Doctrine, standards, and reform | I recommend that arrangements be put in place which would remove the requirements for Masters of Volunteer Marine Rescue vessels to hold a commercial certificate of competency. Operators could then be qualified through the FESA Volunteer Marine Rescue Training pathway as skippers and crew. This would increase the number of available skippers in the event of a search and rescue incident and would make appropriate training easier to arrange. |
REC227-2854 | 12 - EM agency and authority | I recommend that the Christmas Island VMRS be given autonomy to maintain operational readiness for the VMRS rescue vessel(s) and an appropriate budget be provided to allow this to take place. |
Rec-ID | Code | Recommendation |
---|---|---|
REC215-1879 | 25 - Inquiry, audit, lessons management and after action review | Regulators can help to achieve improved outcomes by auditing compliance with the BPEM guidelines on a regular basis |
REC215-1878 | 32 - Doctrine, standards, and reform | Regulators can help to achieve improved outcomes by acknowledging that changes to legislation and the BPEM guidelines may be required to help address the identified issues |
REC215-1872 | 32 - Doctrine, standards, and reform | Fire services can improve outcomes by implementing standard procedures that ensure the welfare and safety of crews and the public are not compromised |
REC215-1870 | 12 - EM agency and authority | Fire services can improve outcomes by using a pre-planned response to provide appropriate resources |
Rec-ID | Code | Recommendation |
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REC208-0529 | 32 - Doctrine, standards, and reform | That, when developing requirements concerning pollution incident response management plans pursuant to the recent legislative amendments, the Office of Environment and Hertiage include appropriate definitions as to the meaning of ‘immediately’, and when ‘material harm to the environment is caused or threatened’. |
REC208-0528 | 32 - Doctrine, standards, and reform | That, as part of the Pollution Incident Management Response Plan to be developed for Orica’s Kooragang Island site, or by another appropriate mechanism, the Office of Environment and Heritage ensure that Orica’s incident-response procedures address the need to consider all relevant factors when assessing potential impacts, including the height and force of emissions as well as the location of any onsite fallout and whether there are off-site impacts following all serious incidents. |
REC208-0526 | 25 - Inquiry, audit, lessons management and after action review | That OEH’s testing procedures for determining the impact of pollution incidents incorporate additional requirements for the checking and verification of results before those results are released. |
REC208-0525 | 7 - Inter-agency communication | That the Office of Environment and Heritage amend its operating procedures for the Environment Line to ensure that there are clear obligations to pass on information relevant to other agencies, to those agencies in a timely manner. |
REC208-0530 | 32 - Doctrine, standards, and reform | That, if necessary, regulation be amended to require Health to approve any script used by any party concerned, for door knocking or other information dissemination, if Health is not the first source of information to affected residents. |
Rec-ID | Code | Recommendation |
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REC204-1907 | 32 - Doctrine, standards, and reform | The Department of Sport and Recreation facilitate the development of an Adventure Activity Standard for ultramarathons in order to determine a minimum safety standard for the sport. |
REC204-1921 | 32 - Doctrine, standards, and reform | The Coroner’s Act 1996 should be amended to give the Coroner jurisdiction to investigate fires that do not cause death, and that the Coroner should be suitably resourced to undertake investigations of the kind the subject of this Report. |
REC204-1917 | 32 - Doctrine, standards, and reform | The review of the Health Act 1911 (WA) should include the following amendments: |
REC204-1916 | 25 - Inquiry, audit, lessons management and after action review | Local Emergency Management Committee (LEMC) processes should be reviewed to ensure that: |
REC204-1913 | 25 - Inquiry, audit, lessons management and after action review | The Department of the Attorney General consider conducting a review of the Civil Liability Act 2002 (WA) in light of the 2011 Kimberley Ultramarathon. Such a review should consider issues such as the effectiveness given to competitor waivers under the Act and the potential difficulties of establishing proceedings and enforcing a judgement against foreign‐based providers of recreational activities. |
REC204-1912 | 38 - Agency/Department Reporting | The Board of Tourism WA should take action to ensure that it reviews the quality of Board papers that are submitted to it by the executive of Tourism WA. |
Rec-ID | Code | Recommendation |
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REC198-2901 | 12 - EM agency and authority | The Fire Services Commissioner ensures that policy, operational procedures, systems and training relating to information and warnings that have been applied to bushfires are now also applied to other emergencies. In particular: |
REC198-2904 | 16 - Training and behaviour | The CFA, in collaboration with the other agencies develop a case study of the response to and recovery from the TriTech fire as a training and development opportunity. |
Rec-ID | Code | Recommendation |
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REC197-1773 | 12 - EM agency and authority | The CFA continue, in consultation with volunteers, paid personnel and their representatives, its review of disciplinary arrangements and as part of that review consider the concept of the establishment of a Volunteer Ombudsman. |
REC197-1740 | 36 - Volunteers | The CFA, in consultation with the VFBV and volunteers, develop and introduce an arrangement whereby a volunteer can transfer from one brigade to another and still remain a member of the CFA, without the need to resign. |
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. |
REC197-1762 | 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. |
REC197-1746 | 12 - EM agency and authority | The CFA revisit with the UFU the arrangements relating to the employment of part‐time and casual employees. |
REC197-1767 | 16 - Training and behaviour | Consideration be given to the establishment of a dedicated CFA training academy. |
REC197-1734 | 36 - Volunteers | A. Consideration be given to the VFBV being funded directly by Government rather than by the CFA. |
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. |
REC197-1772 | 12 - EM agency and authority | The CFA, in relation to developing any process for brigade support or career structure or position description for Brigade Administrative Support Officers, as referred to in Clause 8 of the 2010 Deed, consult with the VFBV and volunteers before reaching any decision on those matters. |
REC197-1739 | 36 - Volunteers | The CFA, in consultation with the VFBV and volunteers, develop a systemic exit strategy, which ensures that relevant information is captured consistently across all brigades. |
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. |
REC197-1761 | 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. |
REC197-1745 | 36 - Volunteers | The CFA revisit with the UFU the arrangements relating to Community Education Firefighters/Fire Officers and the use of volunteers in this role. |
REC197-1766 | 12 - EM agency and authority | The CFA as part of any examination of the utilisation of the NBN give priority to the establishment of internet access for brigades. |
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. |
REC197-1750 | 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. |
REC197-1771 | 12 - EM agency and authority | The CFA, in consultation with the VFBV and volunteers, develop a comprehensive strategy for the administrative support of volunteer brigades to ensure that such brigades can operate efficiently and effectively. |
REC197-1738 | 12 - EM agency and authority | A. The CFA, in consultation with its volunteers and employees, determine and adopt a statement of Vision, Mission and Values. |
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. |
REC197-1744 | 12 - EM agency and authority | The CFA revisit with the UFU the arrangements relating to lateral entry and secondment. |
REC197-1760 | 12 - EM agency and authority | The CFA continue with its initiatives to implement the Garnock Report, keeping volunteers and paid personnel fully informed of progress and consulting with them in relation to the implementation. This implementation should be given priority, having regard to its importance. |
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. |
REC197-1749 | 16 - Training and behaviour | The CFA proceed with a review of the Minimum Skills training program. |
REC197-1770 | 36 - Volunteers | The CFA, in consultation with the VFBV and volunteers, review the arrangements for the reimbursement of volunteer expenses. This review could be done in conjunction with the review of possible reimbursement of employers of CFA volunteers as recommended in Recommendation 5. |
REC197-1737 | 12 - EM agency and authority | A. The CFA, in consultation with employers and volunteers, explore the establishment of employer consultation and support mechanisms along the lines of those developed by the Australian Defence Force. |
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. |
REC197-1743 | 12 - EM agency and authority | The CFA revisit with the UFU the arrangement relating to the recruitment of volunteer firefighters as an employee. |
REC197-1759 | 12 - EM agency and authority | The CFA continue its consultations with the UFU to establish a satisfactory and workable process for the use of sessional instructors. |
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. |
REC197-1748 | 16 - Training and behaviour | The CFA establish forward strategic planning initiatives for training with resource allocation covering short term, mid term, and long term. |
REC197-1769 | 12 - EM agency and authority | The CFA, in consultation with the VFBV and volunteers, explore and develop initiatives whereby qualified volunteers may be more utilised in Incident Management Teams. |
REC197-1736 | 12 - EM agency and authority | The CFA and the Chief Officer continue to develop the initiatives outlined in relation to service delivery and standards, decision‐making and allocation of resources. |
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. |
REC197-1742 | 36 - Volunteers | The CFA, in consultation with the VFBV and volunteers, develop initiatives and strategies that will maximise the involvement of young people as volunteers and their retention as volunteers. |
REC197-1758 | 12 - EM agency and authority | The CFA revisit with the UFU the arrangements contained in industrial agreements relating to the engagement of instructors with a view to increasing the ability and flexibility of the CFA to fill instructor positions and thereby ensure maximum training capacity to the benefit of CFA members, both volunteer and paid. |
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. |
REC197-1747 | 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. |
REC197-1768 | 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. |
REC197-1735 | 36 - Volunteers | A. The CFA continue to explore and develop initiatives with modern information and communication technologies to maximise the benefits that they may bring to volunteer involvement in the CFA. |
REC197-1752 | 16 - Training and behaviour | The CFA take initiatives to improve the accessibility of Field Training Grounds, including Fiskville, to volunteers for training. |
Rec-ID | Code | Recommendation |
---|---|---|
REC189-2912 | 29 - Operational Health and Safety | The review team recommend that the safety case system be strengthened by including provisions for a design notification scheme along the lines of that under the British Offshore Safety Case Regulations. |
REC189-2911 | 29 - Operational Health and Safety | The review team recommend that: |
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. |
REC189-2907 | 29 - Operational Health and Safety | a) For the purposes of designing and implementing its regulatory activities, National Offshore Petroleum Safety Authority (NOPSA) should continue to identify priority hazards and risks and their underlying causes, in consultation with the NOPSA Advisory Board and stakeholders (see Theme 9, Stakeholder engagement). |
REC189-2914 | 32 - Doctrine, standards, and reform | The review team recommend that: |
Rec-ID | Code | Recommendation |
---|---|---|
REC188-2917 | 33 - Relief and recovery | The committee recommends that relevant Commonwealth agencies continue to monitor the wellbeing of their personnel and that counselling and support services should be provided for as long as necessary. |
REC188-2916 | 33 - Relief and recovery | The committee recommends that the Department of Regional Australia and DIAC liaise with the Christmas Island community to explore options for a permanent memorial to be erected on the island, at a site of the residents' choosing, for the victims of the tragedy. |
REC188-2915 | 33 - Relief and recovery | The committee recommends that Department of Immigration and Citizenship (DIAC) and its relevant contractors continue to monitor the wellbeing of the survivors and that counselling and support services should be provided for as long as is necessary. |
Rec-ID | Code | Recommendation |
---|---|---|
REC177-3288 | 29 - Operational Health and Safety | As soon as a risk of barrier failure arises, no other activities should take place in the well other than those directed to removal of the risk. |
REC177-3307 | 32 - Doctrine, standards, and reform | Any indication of a compromised cemented shoe which cannot be resolved with a high measure of confidence should result in the installation of additional well control barrier(s). |
REC177-3324 | 32 - Doctrine, standards, and reform | The mere fact that the rig is over the platform should not be regarded by licensees or regulators as sufficient justification for reliance on only one barrier. The default position should be that producible wells are shut‐in when a rig is moved on and off a platform, or when a drilling unit is moved between wells on a platform. |
REC177-3341 | 32 - Doctrine, standards, and reform | The definition of ‘good oilfield practice’ in the OPGGS Act is unduly narrow. The current definition is incapable of application except where things ‘are generally accepted as good and safe’. The definition should be amended such that ‘good oilfield practice includes…’. |
REC177-3368 | 32 - Doctrine, standards, and reform | The regulatory framework should provide that in respect of all activities in Commonwealth waters: |
REC177-3275 | 32 - Doctrine, standards, and reform | Well Operations Management Plan (WOMPs) submitted by licensees to the regulator(s) should continue to be the primary framework document for achieving well integrity. |
REC177-3295 | 29 - Operational Health and Safety | Wells drilled into hydrocarbon zones should be treated as live wells, with the potential to blowout unless a documented risk assessment establishes otherwise. |
REC177-3313 | 32 - Doctrine, standards, and reform | Barriers should not be installed or removed off‐line. The derrick should be located over a well at the time of removal and installation of any barrier. This will enable more decisive action to be taken in the event a problem arises. |
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). |
REC177-3352 | 32 - Doctrine, standards, and reform | The regulator, rather than the responsible Minister, should be given the power to direct an operator to use a particular rig for the purpose of well control operations, if appropriate in the circumstances, and the power should be used in the future if that rig is the best option available. This would necessarily involve the operator fully compensating for the use of the rig and any other associated costs. The Inquiry suggests that this power could be invoked and given effect as a condition of an operator’s licence. |
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. |
REC177-3280 | 32 - Doctrine, standards, and reform | Well construction and management plans should include provision for an independent compliance review of well integrity (i) in the event of stipulated triggers; and (ii) at least once in the period between perceived achievement of well integrity and production. The independent compliance review should be undertaken by an expert who is not involved in the day‐to‐day drilling operations. Reviews should be completed in sufficient time to enable results to be implemented in a meaningful manner. |
REC177-3300 | 32 - Doctrine, standards, and reform | Licensees and rig operators should install an additional barrier whenever (i) there is any real doubt as to the integrity of any barrier; (ii) whenever the risk of flow from a reservoir increases materially in the course of operations; and (iii) where the consequences of a blowout are grave (for example, for reef systems or shorelines). |
REC177-3318 | 32 - Doctrine, standards, and reform | Manufacturers should be consulted about how to address non‐routine operational problems affecting their well control equipment. |
REC177-3336 | 12 - EM agency and authority | Achievement and maintenance of well control should be written into the job responsibilities of key personnel, at every level up to and including CEOs. That is, a functional line of accountability for well control must exist up to, and including, CEOs. |
REC177-3361 | 32 - Doctrine, standards, and reform | The National Plan should be revised to ensure that it fully comprehends environmental matters and that it recognises the importance of the prompt implementation of Scientific Monitoring to facilitate the assessment of the environmental impacts of an incident. |
REC177-3287 | 38 - Agency/Department Reporting | Licensees should be subject to an express obligation to inform regulators of problems which arise in the course of installing barriers, even if they consider that well integrity is not thereby compromised. The information should be provided by way of special report, rather than included in a standard reporting document (such as a DDR). The information provided should include risk assessment details. |
REC177-3306 | 32 - Doctrine, standards, and reform | It should be standard industry practice to re‐test a cemented casing shoe (that is, after WOC) whenever the plugs do not bump or the float valves apparently fail. Standard industry practice should require consideration of other tests in addition to a repeat pressure test. |
REC177-3323 | 32 - Doctrine, standards, and reform | Where multiple wells are drilled, operations and occurrences at one well must be carefully assessed for any implications with respect to well control at other wells. |
REC177-3340 | 32 - Doctrine, standards, and reform | To better ensure that ‘risks’ are identified and managed in accordance with sound engineering principles and good oilfield practice, it is recommended that regulation 25(1)(a)(i) and (2)(a)(i) of the Management of Well Operations Regulations, be reworded as follows: ‘A titleholder must not commence / continue a well activity if…a well integrity hazard exists in relation to the well’. |
REC177-3367 | 32 - Doctrine, standards, and reform | Procedures and accountabilities should be established to ensure, in the event of a future incident, that: |
REC177-3294 | 29 - Operational Health and Safety | Perceived time and cost savings relating to any matters impacting upon well control should be subjected to rigorous safety assessment. |
REC177-3312 | 32 - Doctrine, standards, and reform | The BOP and rig should not move from a well until barrier integrity has been verified. |
REC177-3328 | 32 - Doctrine, standards, and reform | All communications between on‐rig and onshore personnel relating to well control should be documented in a timely manner. |
REC177-3350 | 32 - Doctrine, standards, and reform | The recommendations of the Inquiry in relation to suitable ways of achieving well integrity contained in Chapter 3 be included in a guidance manual that is issued for the assistance of industry and regulators. |
REC177-3377 | 32 - Doctrine, standards, and reform | The Minister consider legislative amendments to the OPGGS Act which make clear that |
REC177-3279 | 29 - Operational Health and Safety | Well construction and management plans, and drilling programs, should include provision for testing and verifying the integrity of all barriers as soon as practicable after installation. |
REC177-3299 | 29 - Operational Health and Safety | Regulatory approval to rely on only one barrier should not be given unless (i) a proper risk assessment is carried out; (ii) exceptional circumstances exist; and (iii) risks involved are reduced to ‘as low as reasonably practicable’. The default position must be that well integrity must be assured. |
REC177-3317 | 32 - Doctrine, standards, and reform | Any equipment (including PCCCs) used as, or to install, a barrier should be manufactured for that purpose and be generally recognised as fit for purpose. If equipment is designed in‐house by a licensee or rig operator it should not be approved for use unless and until it is subjected to expert external analysis. |
REC177-3335 | 32 - Doctrine, standards, and reform | Licensees, rig operators and relevant third party contractors should develop well control competency standards for key personnel in other entities involved in well control operations. |
REC177-3359 | 32 - Doctrine, standards, and reform | The National Plan should be reviewed to clarify the arrangements to apply in Commonwealth waters regarding key roles and responsibilities, including in relation to the ESC, in the event of an oil spill. This should also address any necessary training required. |
REC177-3284 | 32 - Doctrine, standards, and reform | Memoranda of Agreement should be entered into between operators in relation to provision of emergency assistance in the event of blowouts. |
REC177-3305 | 32 - Doctrine, standards, and reform | Cement integrity should be evaluated wherever practicable by way of cement evaluation tests, rather than relying on pre‐operational calculations of cement and displacement fluid volumes. |
REC177-3322 | 32 - Doctrine, standards, and reform | Batched drilling operations should only be undertaken after careful assessment of the special risks which such operations give rise to; well control must be maintained during the course of batched drilling operations. |
REC177-3339 | 32 - Doctrine, standards, and reform | The Inquiry supports the objective (rather than prescriptive) approach to regulation now followed in Australia. However, the pendulum has swung too far away from prescriptive standards. In some areas relating to well integrity there needs to be minimum standards. |
REC177-3366 | 32 - Doctrine, standards, and reform | The National Plan should be reviewed: |
REC177-3293 | 29 - Operational Health and Safety | If a dispute arises between a licensee and a rig operator in relation to a well control issue, and is not resolved between them, the matter must be raised with the relevant regulator before discretionary operations proceed. |
REC177-3311 | 32 - Doctrine, standards, and reform | Horizontal or high angle penetration of a reservoir should be avoided wherever practicable until such time as the apparent problems associated with the cementing of a casing shoe in these situations are satisfactorily overcome. If a casing string does penetrate a well horizontally or at a high angle, standard practice should be to install two secondary barriers in addition to the cemented casing shoe. |
REC177-3327 | 32 - Doctrine, standards, and reform | Information relevant to well control must be captured and communicated within and between licensees and rig operators (and relevant third party contractors), in a manner which ensures it comes to the attention of relevant personnel. In particular, protocols should be developed to ensure that changes in shift and hitch do not operate as communication barriers. |
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. |
REC177-3374 | 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. |
REC177-3278 | 29 - Operational Health and Safety | Well construction and management plans should include provision(s) for reviewing the integrity of barriers at safety‐critical times or milestones, such as (i) prior to suspension involving departure of the rig from the platform; (ii) prior to re‐entry of a well after suspension; (iii) prior to removal of any barrier. |
REC177-3298 | 32 - Doctrine, standards, and reform | Reliance upon one barrier against a blowout must not take place except with the prior written approval of the relevant regulator and then only in a true emergency situation (see below). |
REC177-3316 | 32 - Doctrine, standards, and reform | Wells should be re‐entered with a BOP in place unless a documented risk assessment indicates that well control can be maintained at all times. |
REC177-3334 | 32 - Doctrine, standards, and reform | Licensees, rig operators, and relevant third party contractors should develop well control competency standards for their key personnel. Wherever possible, the competencies of key personnel should be benchmarked against their roles and responsibilities. |
REC177-3355 | 32 - Doctrine, standards, and reform | The Inquiry also supports Bills and Agostini’s recommendation: ‘…in relation to safety case development and compliance overall, that NOPSA revise its approach to interacting with operators prior to the safety case assessment process and subsequently direct more resources into its advisory functions. We further recommend that NOPSA develop and implement a formal plan for supporting and guiding each operator prior to safety case acceptance, as well as for ongoing compliance with that safety case, recognising the unique experience, capabilities and assessed risk of that operator. Each plan needs to include advice, education and liaison meetings with the operators. The plan needs to be continuously reviewed and reassessed based on the latest information, including the interaction with the operator’. |
REC177-3283 | 32 - Doctrine, standards, and reform | A separate, identifiable barrier manual should be agreed upon and used by licensees, rig operators, and cementing contractors. These manuals should set out best industry practice in relation to achieving and maintaining well integrity. They should describe barrier types, barrier standards, general principles of well integrity, testing and verification methods and technologies, standard operating procedures (including procedures for the capture and communication of relevant information within and between relevant stakeholder entities). Barrier manuals should address blowout control during drilling, completion, re‐entry, tie‐back of casing strings and so on. Barrier manuals should be the subject of expert external review, and should be regularly updated. |
REC177-3303 | 29 - Operational Health and Safety | Tracking and analysis of cementing problems/failures should occur to assess industry trends, principal causes, remedial techniques and so on. |
REC177-3321 | 29 - Operational Health and Safety | Careful consideration must be given to equipment compatibility as part of well construction design. |
REC177-3338 | 12 - EM agency and authority | Licensees and rig operators should be astute in ensuring that corporate systems and culture encourage rather than discourage raising of well control issues. For instance, do performance bonuses or rewards actually encourage or discourage reporting of issues? Is there a system in place to enable anonymous reporting of well control concerns? What whistleblower protections are in place? |
REC177-3364 | 37 - Funding | The funding arrangements that support the National Plan should be reviewed to ensure that the costs associated with both preparedness and response capability are equitably shared between the shipping and offshore petroleum industries. |
REC177-3292 | 32 - Doctrine, standards, and reform | Licensees should be subject to an express obligation to inform regulators of the proposed removal of a barrier, even if they consider that well integrity is not thereby compromised. The information should be provided by way of special report, rather than included in a standard reporting document (such as a DDR). The information provided should include risk assessment details. Removal of a barrier should not take place without prior written approval of the relevant regulator(s). |
REC177-3309 | 32 - Doctrine, standards, and reform | If performance of barrier installation is outsourced by a licensee, the contractor (for example, the cementing company) should be engaged on terms which clearly require the provision of expert advisory services by the contractor with respect to barrier integrity. |
REC177-3326 | 32 - Doctrine, standards, and reform | Prior to commencement of drilling operations, senior representatives of the licensee and rig operator should exchange certificates to the effect that their respective key personnel and contractors have been informed in writing of agreed well control arrangements. |
REC177-3343 | 32 - Doctrine, standards, and reform | The OPGGS Act should be amended to allow for a power to suspend a petroleum production licence (in addition to the current power to cancel a licence or suspend its conditions). |
REC177-3373 | 32 - Doctrine, standards, and reform | Arrangements should be developed to minimise duplication between the EPBC Act and the OPGSS Act Environment Regulation. |
REC177-3277 | 32 - Doctrine, standards, and reform | The concept of ‘good oilfield practice’ should be supplemented by the requirement to incorporate into WOMPs non‐exhaustive minimum compliance standards in relation to well control: for example, stipulations as to when BOPs and/or well control systems must be in place and when they can be removed and minimum barrier requirements (a number of other factors that should be stipulated are outlined in other recommendations below). |
REC177-3297 | 32 - Doctrine, standards, and reform | A minimum of two barriers should be in place at all times (including during batched operations) whenever it is reasonably practicable to do so. |
REC177-3315 | 32 - Doctrine, standards, and reform | PCCCs should be installed in a timely manner (for example, to prevent corrosion in the MLS apparatus). Non‐installation in order to park a BOP is not acceptable. |
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. |
REC177-3354 | 32 - Doctrine, standards, and reform | NOPSA develop a policy of engagement with operators so as to enable experts (including safety experts) to canvas all available options for well control in the event of a blowout. |
REC177-3282 | 29 - Operational Health and Safety | If a risk assessment or compliance review is triggered by the happening of a predetermined event, specific consideration should be given to whether a ‘hold point’ should be introduced such that work must cease until the problem is resolved (and the subject of appropriate certification). |
REC177-3302 | 32 - Doctrine, standards, and reform | Industry, regulators, and training/research institutions should develop standards that address best practices for cementing operations (including liaising, as appropriate, with overseas regulators) with a view to overcoming problems which can effect the integrity of cemented casing shoes, annulus and cement plugs. |
REC177-3320 | 32 - Doctrine, standards, and reform | Any pro‐formas used by licensees, rig operators and contractors for recording information about installation of barriers should explicitly provide for ‘exception reporting’, that is, the form should include provision for recording any unforseen or untoward events which occur in the course of installation. |
REC177-3337 | 12 - EM agency and authority | Supervision/oversight of well control operations (within licensees, rig operators and by regulators) must occur without assuming adherence to good oilfield practice. The opposite assumption should prevail: namely adherence to good oilfield practice may well be compromised by the pursuit of time and cost savings. |
REC177-3363 | 32 - Doctrine, standards, and reform | DEWHA, in concert with AMSA and with expert input, should develop ‘off the shelf’ monitoring programs that can be speedily implemented following incidents in Commonwealth waters. In this context, the utility of the current Scientific Monitoring program should be peer reviewed to inform future policy. |
REC177-3290 | 38 - Agency/Department Reporting | The successful installation of every barrier should be the subject of written verification within and between licensees and rig operators; and should be the subject of explicit reporting to the relevant regulator(s). |
REC177-3308 | 32 - Doctrine, standards, and reform | Volumes of cement used in connection with barrier installation should be calculated with the assistance of a pro‐forma which records all relevant baseline data, which should be verified by onshore personnel. |
REC177-3325 | 32 - Doctrine, standards, and reform | Relevant personnel from licensees and rig operators should meet face to face to agree on, and document, well control issues/arrangements prior to commencement of drilling operations. Well control should be regarded as a so‐called SIMOP to signify its critical importance to both licensees and rig operators, and to ensure that they each take responsibility for achievement and maintenance of well control. |
REC177-3342 | 32 - Doctrine, standards, and reform | Written (rather than verbal) approval from the DA (or new regulator) should be obtained before the commencement of well activities that lead to a physical change of a wellbore, other than in a true emergency situation (requiring amendment to regulation 17 of the Management of Well Operations Regulations). |
REC177-3370 | 32 - Doctrine, standards, and reform | Environment plans and OSCPs should be made publicly available as a condition of approval of proposals under the OPGGS Act, and should clearly set out Scientific Monitoring requirements in the event of an oil spill. |
REC177-3276 | 32 - Doctrine, standards, and reform | WOMPs should be comprehensive and freestanding, rather than an overarching document cross‐referencing many other documents (although the Inquiry also recommends a freestanding well control manual; this should be a guide to rig and onshore personnel on good oilfield practice). |
REC177-3296 | 32 - Doctrine, standards, and reform | Use of single strings of intermediate casing to penetrate hydrocarbon bearing zones should be carefully risk assessed. Multiple strings of intermediate casing have the advantage of isolating lost circulation zones and sealing off anomalous pressure zones. If intermediate casing is set in a hydrocarbon zone it should be treated as production casing. |
REC177-3314 | 32 - Doctrine, standards, and reform | Secondary barriers (including PCCCs) should only be installed, tested, and removed with a BOP in place unless a documented risk assessment indicates that well control can be maintained at all times. |
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). |
REC177-3353 | 32 - Doctrine, standards, and reform | The regulatory regime should also impose an obligation on an operator to ascertain the availability, and provide details to the regulator, of any potential relief well rigs, prior to the commencement of drilling operations (including prior to each phase of a drilling operation where applicable). |
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. |
REC177-3281 | 29 - Operational Health and Safety | Wellbore gas bubbling should be regarded as a trigger for independent review of well integrity. Industry and regulators should identify and document other triggers. |
REC177-3301 | 32 - Doctrine, standards, and reform | The industry standard of two barriers should be replaced with the concept of ‘two or more barriers’ as a minimum standard. A minimum standard when operations proceed normally should never be regarded as a sufficient standard in other circumstances. |
REC177-3319 | 32 - Doctrine, standards, and reform | Drilling programs dealing with barrier installation should incorporate relevant aspects of manufacturer’s instructions. |
REC177-3336 | 12 - EM agency and authority | Achievement and maintenance of well control should be written into the job responsibilities of key personnel, at every level up to and including CEOs. That is, a functional line of accountability for well control must exist up to, and including, CEOs. |
REC177-3362 | 32 - Doctrine, standards, and reform | Procedures for the approval of development projects should ensure that conditions of approval are comprehensive and clearly set out the obligations of their proponents in relation to environmental matters (including expected monitoring and remediation obligations). |
Rec-ID | Code | Recommendation |
---|---|---|
REC169-2989 | 38 - Agency/Department Reporting | The Department of Premier and Cabinet should lead the development of a performance management framework for measuring, monitoring and reporting on the implementation of Part 6 of the Act and the CIP framework. The framework should include key indicators, targets and reporting arrangements for assessing the extent to which departments, agencies and industry have fulfilled their obligations, as well as measures for monitoring achievement of joint objectives. |
REC169-2988 | 32 - Doctrine, standards, and reform | The Department of Premier and Cabinet should establish clear oversight and coordination of the arrangements for both Part 6 of the Terrorism (Community Protection) Act 2003 and the CIP framework by an appropriate body, such as the Government Security and Continuity Network Coordination Group with expanded responsibilities. |
REC169-2998 | 38 - Agency/Department Reporting | Reports on the training exercises should be retained in an appropriately secured central repository so that consolidated results of the exercises can be drawn together effectively. |
REC169-2997 | 38 - Agency/Department Reporting | The Department of Premier and Cabinet and Victoria Police, in consultation with departments, should standardise reporting on training exercises conducted under Part 6 of the Act and the CIP framework to promote greater consistency and to enable better identification of lessons learned and continuous improvement. |
REC169-2996 | 32 - Doctrine, standards, and reform | The Department of Premier and Cabinet should provide clear guidance on terms such as ‘audit’, ‘auditor’ and ‘adequacy of the exercise’ to assist departments, Victoria Police and industry to implement requirements more reliably. |
Rec-ID | Code | Recommendation |
---|---|---|
REC166-3001 | 16 - Training and behaviour | That the Tasmania Fire Service provide further training in respect to sprinkler systems, namely: |
REC166-3000 | 32 - Doctrine, standards, and reform | That the Tasmania Fire Service establish clear systems and protocols for dealing with fires. |
REC166-3009 | 25 - Inquiry, audit, lessons management and after action review | That the Tasmania Fire Service conduct an audit of all shopping centres to ensure that there exists within those centres adequate fire protection and evacuation systems. |
REC166-3005 | 32 - Doctrine, standards, and reform | That the Coroner prepare a discussion paper and draft guidelines for the clarification of investigative roles of the Tasmania Police Service, the Tasmania Fire Service, and the Coroners Office for adoption in relation to future fires where a Coroner’s Inquest is established. |
REC166-3003 | 12 - EM agency and authority | That the Tasmania Fire Service provide additional training in power disconnection and improvements in communication between Tasmania Fire Service and Aurora: |
REC166-3002 | 16 - Training and behaviour | That the Tasmania Fire Service provide additional training in the use of thermal camera imaging: |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC158-3424 | 32 - Doctrine, standards, and reform | That legislation is prepared by the Department of Transport to ensure marine emergency management arrangements are clarified and provide: |
REC158-3449 | 37 - Funding | That port/channel managers are responsible for funding the preparation of marine emergency risk assessments and marine emergency response arrangements and ensuring the availability of identified marine resources in support of response to a marine emergency, to meet their statutory obligations. |
REC158-3429 | 38 - Agency/Department Reporting | That the nominated marine safety authority is required to ensure that incident notification and data recording requirements for Victorian commercial ports are consistent and adhered 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. |
REC158-3443 | 12 - EM agency and authority | That emergency services increase their capability/capacity to respond to marine emergencies by undertaking the necessary training, increasing their awareness of port and ship operations and ensuring knowledge of the roles/responsibilities of the relevant authorities and stakeholders. |
REC158-3428 | 38 - Agency/Department Reporting | That the nominated marine safety authority, in consultation with the Emergency Services Commissioner and senior emergency services personnel, is responsible for monitoring the implementation and auditing against appropriate performance standards, risk management guidelines and good practice guidelines. |
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. |
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. |
REC158-3442 | 12 - EM agency and authority | That emergency services continue to take the lead role in marine emergencies and operate under their respective legislation, the Emergency Management Act and the State’s emergency management arrangements. |
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: |
REC158-3452 | 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. |
REC158-3436 | 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. |
REC158-3426 | 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. |
REC158-3451 | 37 - Funding | That port/channel managers should be able, within the general context of the pricing/cost recovery arrangements established under the Port Services Act 1995 and pricing determinations made by the Essential Services Commission, to recover the reasonable costs of meeting their statutory obligations (as per recommendation 26) through charges for prescribed service applied to port users. |
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. |
REC158-3425 | 32 - Doctrine, standards, and reform | Consequential or complementary amendments to the Emergency Management Act are required to ensure that: |
REC158-3450 | 37 - Funding | That emergency services are responsible for funding the development of the emergency services marine emergency response capacity/capability to meet their statutory obligations. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC149-3128 | 29 - Operational Health and Safety | National Offshore Petroleum Safety Authority (NOPSA) should develop guidelines in consultation with stakeholders to provide clarity and consistency to the process which ultimately will result in better safety outcomes. |
REC149-3136 | 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. |
REC149-3144 | 29 - Operational Health and Safety | The Safety Case proponent should be allowed some flexibility to involve appropriate experience matched with the proposed workforce competencies to enable the Safety Case to be developed with value adding processes. Subsequent to the hiring of the workforce Final Government Response Offshore Petroleum Safety Regulation Inquiry and 2008 Review of NOPSA Operational Activities and preferably before the commencement of operations a review of the Safety Case should take place with the new workforce to ensure they understand the accepted Safety Case, its risks and Safety Management Plan. |
REC149-3135 | 29 - Operational Health and Safety | The initial acceptance of a new facility Safety Case should be in conjunction with inspection of a facility upon commencement of operations. |
REC149-3141 | 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. |
REC149-3134 | 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. |
REC149-3140 | 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. |
REC149-3130 | 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. |
REC149-3138 | 38 - Agency/Department Reporting | The current KPI measures used by the Regulator and industry need to be reassessed and the performance indicators need to be related to the risk profiles of the industry. The industry needs to develop the indicators, which need to be agreed and measured by the industry in discussion with other stakeholders. The KPI's selected should be published in comparison with the worldwide offshore industry and with other industries. NOPSA should continue discussions with Australian Safety and Compensation Council (ASCC) with a view to adopting their goals. |
REC149-3147 | 29 - Operational Health and Safety | As all stakeholders have responsibility for safe outcomes, decisions regarding target subjects for safety promotion need to have the support of all stakeholders including NOPSA and the workforce. Industry, which ultimately has the responsibility for managing risk as well as funding the promotion, should take a leadership role in implementation. |
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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC137-3531 | 32 - Doctrine, standards, and reform | I recommend that CASA consider creating firm guidelines that require consideration of workload, lines of authority, potential conflicts of interest and any other factors that impact upon the ability of “key personnel” to discharge their responsibilities within an aviation organisation when its officers are approving appointments to those positions. |
REC137-3530 | 16 - Training and behaviour | I recommend that Civil Aviation Safety Authority (CASA) expedite the introduction of mandatory crew resource management training. |
REC137-3532 | 16 - Training and behaviour | I recommend that CASA reconsider the introduction of measures to ensure the efficiency of training and checking organisations for air transport operations. I recommend that this include the way in which particular training needs of an air operator’s flight crew are to be identified (including recurrent training and CRM training) and how those needs are to be met by approved or certified training and checking organisations. |
Rec-ID | Code | Recommendation |
---|---|---|
REC121-3732 | 29 - Operational Health and Safety | If ITSRR accepts such a plan as an appropriate response to the existing weak safety culture, ITSRR should approve it and monitor the effectiveness of the plan. |
REC121-3750 | 32 - Doctrine, standards, and reform | ITSRR should initiate and/or participate in the development of a national standard for crashworthiness of all passenger trains. |
REC121-3766 | 12 - EM agency and authority | Staffing arrangements for ITSRR should be reviewed by it to ensure that adequate staff are employed in field positions, actively monitoring the safety of rail operations and compliance with conditions of accreditation. |
REC121-3670 | 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. |
REC121-3692 | 32 - Doctrine, standards, and reform | Communications protocols and procedures should be standardised and mandated by regulations making them a condition of accreditation. |
REC121-3712 | 38 - Agency/Department Reporting | RailCorp and ITSRR should co-operate with national programs for the collection, collation, trend analysis and dissemination of safety critical information. |
REC121-3717 | 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. |
REC121-3737 | 29 - Operational Health and Safety | There must be a minimum of two independent methods of self-initiated emergency escape for passengers from all trains at all times. |
REC121-3755 | 29 - Operational Health and Safety | The RailCorp Board should require a full review of the safety competence of RailCorp managers to ensure that each has the ability to bring about those safety reforms recommended in this report which are applicable to his or her position. |
REC121-3772 | 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. |
REC121-3650 | 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. |
REC121-3677 | 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. |
REC121-3698 | 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. |
REC121-3726 | 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. |
REC121-3743 | 29 - Operational Health and Safety | All passenger trains operating in New South Wales must have the external emergency door release clearly marked with the words “Emergency Door Release”. |
REC121-3760 | 32 - Doctrine, standards, and reform | The Advisory Board established under the Transport Legislation Amendment (Safety and Reliability) Act 2003 must be abolished. |
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. |
REC121-3685 | 32 - Doctrine, standards, and reform | The ITSRR should impose a standard in relation to the collection and use of data from data loggers. |
REC121-3705 | 32 - Doctrine, standards, and reform | The ITSRR should develop standards for periodic medical examinations which include the following: |
REC121-3731 | 29 - Operational Health and Safety | RailCorp should develop a plan to be submitted to ITSRR to address the deficiencies in the safety culture of RailCorp, including: |
REC121-3749 | 29 - Operational Health and Safety | All new rolling stock must be designed with an area of the roof through which emergency services personnel can access a rail car without encountering wiring or other equipment. That access point must be clearly marked with words such as “emergency services cut here”. |
REC121-3765 | 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. |
REC121-3691 | 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. |
REC121-3711 | 29 - Operational Health and Safety | The ITSRR should establish an electronic document control system to enable effective and reliable information to be gathered for monitoring the safety of the New South Wales rail system. |
REC121-3716 | 16 - Training and behaviour | Train driver and guard training should encourage teamwork and discourage authority gradients. |
REC121-3736 | 32 - Doctrine, standards, and reform | The RailCorp passenger containment policy must be abandoned. |
REC121-3754 | 29 - Operational Health and Safety | The RailCorp Board should ensure that RailCorp has an adequate and integrated safety management system, including adequate systems for risk assessment, clearly defined safety responsibilities and accountabilities for persons holding management positions, and specific performance criteria against which evaluations can be made of safety performance and accountability for safety performance of all managers. |
REC121-3771 | 32 - Doctrine, standards, and reform | RailCorp should establish an integrated safety management system which includes the following: |
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. |
REC121-3697 | 38 - Agency/Department Reporting | All train drivers’ defects reports should be entered by RailCorp into a computerised record and tracked to finalisation. |
REC121-3723 | 38 - Agency/Department Reporting | All ATSB accident investigation reports should be made public. |
REC121-3741 | 29 - Operational Health and Safety | The operation of the train doors should have an override facility whereby the train driver or the guard can override an internal passenger emergency door release system if the door release is interfered with when there is no emergency. There should be an alarm, together with an intercom, in the train guard’s compartment so that, if a passenger attempts to initiate an emergency door release, there is an appropriate delay during which time an alarm sounds in the train guard’s compartment and the guard can then, after first attempting to speak via the intercom to the person concerned, if necessary, override the door release, and make an appropriate announcement over the intercom system in the train. |
REC121-3759 | 29 - Operational Health and Safety | A Safety Reform Program Director (hereafter referred to as SRPD), reporting directly to the Chief Executive of RailCorp, should be retained to manage, as head of a Safety Reform Program Office, any safety reform program being undertaken by RailCorp. The SRPD should work with the Chief Executive and senior management to ensure the implementation of an integrated safety management system and the cultural change required. The SRPD must have qualifications suitable for recognition by the Australian Institute of Project Management as a master program director. He or she should report to and be under the control of the Chief Executive, to ensure that the accountability of the Chief Executive is not reduced. The SRPD should co-ordinate and integrate any existing rail safety reform programs and, in consultation with and with the authority of the Chief Executive he or she should: |
REC121-3776 | 38 - Agency/Department Reporting | The Minister for Transport Services should retain, independently of ITSRR, safety auditors to provide a report to the Minister confirming or qualifying the contents of each such ITSRR quarterly report. |
REC121-3659 | 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. |
REC121-3682 | 29 - Operational Health and Safety | All new rolling stock should be designed to be compatible with at least level 2 automatic train protection discussed in chapter 7 of this report. |
REC121-3702 | 29 - Operational Health and Safety | Random alcohol testing should be continued. |
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. |
REC121-3748 | 29 - Operational Health and Safety | All new rail cars must have appropriate signage and lighting identifying escape routes in the case of emergency. |
REC121-3764 | 29 - Operational Health and Safety | The ITSRR should not grant accreditation to any rail organisation unless it has an integrated safety management system in accordance with any safety management system regulation and the guidelines published from time to time by ITSRR. |
REC121-3668 | 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. |
REC121-3690 | 32 - Doctrine, standards, and reform | All communications protocols must be strictly enforced by all accredited rail organisations. |
REC121-3709 | 29 - Operational Health and Safety | RailCorp should provide access to electronic versions of safety documentation for all operational staff at their workplace. |
REC121-3715 | 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. |
REC121-3735 | 29 - Operational Health and Safety | Risk assessments of occupational health and safety issues by RailCorp should include an analysis of broader public safety risks and not be confined to narrow occupational health and safety issues. |
REC121-3753 | 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. |
REC121-3770 | 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 |
REC121-3674 | 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. |
REC121-3696 | 32 - Doctrine, standards, and reform | Defects reporting, recording and rectification should be integrated with the RailCorp regimes for train maintenance. |
REC121-3722 | 38 - Agency/Department Reporting | The ATSB should deliver any report of any such rail accident which it investigates to the Board of any rail organisation involved in the accident, ITSRR and the Minister for Transport Services. |
REC121-3740 | 29 - Operational Health and Safety | The internal passenger emergency door release should be fitted with a facility which prevents it from operating unless the train is stationary. |
REC121-3758 | 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. |
REC121-3775 | 38 - Agency/Department Reporting | The Minister for Transport Services must table in Parliament, each such quarterly report by ITSRR. |
REC121-3658 | 12 - EM agency and authority | All emergency services stations should be provided with access keys to, and maps showing, all gates providing access to RailCorp tracks within their geographic area of responsibility. |
REC121-3681 | 29 - Operational Health and Safety | RailCorp should progressively implement, within a reasonable time, level 2 automatic train protection with the features identified in chapter 8 of this report. |
REC121-3701 | 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. |
REC121-3729 | 38 - Agency/Department Reporting | All reports of the Chief Investigator of OTSI should be delivered, upon completion and without being reviewed, to ITSRR and the Minister for Transport Services. |
REC121-3747 | 29 - Operational Health and Safety | All trains should have windows available through which passengers can escape. |
REC121-3763 | 32 - Doctrine, standards, and reform | The ITSRR should publish guidelines to be followed by accredited organisations. |
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. |
REC121-3689 | 12 - EM agency and authority | All RMC communications related staff should be selected upon the basis of the ability to convey information clearly, accurately and concisely and to follow strict communications protocols. |
REC121-3708 | 12 - EM agency and authority | RailCorp should employ a Chief Safety Information Officer to manage the collection, collation, and dissemination of safety information within RailCorp. |
REC121-3714 | 16 - Training and behaviour | RailCorp should use its simulators in an interactive manner. |
REC121-3734 | 29 - Operational Health and Safety | RailCorp should integrate its management of occupational health and safety into its overall safety management. |
REC121-3752 | 12 - EM agency and authority | RailCorp should establish clear safety accountability statements and reporting lines for all management positions. |
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. |
REC121-3672 | 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. |
REC121-3694 | 25 - Inquiry, audit, lessons management and after action review | The ITSRR should conduct random audits of accredited rail organisations for compliance with communications protocols. |
REC121-3719 | 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. |
REC121-3739 | 29 - Operational Health and Safety | All passenger trains operating in New South Wales must be fitted with external emergency door releases which do not require any special key or other equipment to operate. |
REC121-3757 | 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. |
REC121-3774 | 38 - Agency/Department Reporting | The ITSRR must provide a quarterly report to the Minister for Transport Services on the progress made by RailCorp in implementing these recommendations, including: |
REC121-3655 | 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. |
REC121-3680 | 29 - Operational Health and Safety | All trains must be fitted with a minimum of two independent engineering defences to minimise the risk of derailment or collision in the event of train driver incapacitation. |
REC121-3700 | 12 - EM agency and authority | The RailCorp defects unit should be combined with the passenger fleet maintenance division of RailCorp. |
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. |
REC121-3746 | 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. |
REC121-3762 | 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. |
REC121-3662 | 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. |
REC121-3688 | 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. |
REC121-3707 | 29 - Operational Health and Safety | The safety document management system should provide for the distribution of electronic versions of safety documentation to relevant staff. |
REC121-3733 | 29 - Operational Health and Safety | RailCorp’s approach to occupational health and safety should be proactive and involve the systematic analysis of all current hazards, risks and controls and an assessment of their adequacy to reduce the risk of injury to, or death of, employees to an acceptable level. |
REC121-3751 | 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. |
REC121-3768 | 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. |
REC121-3671 | 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. |
REC121-3693 | 25 - Inquiry, audit, lessons management and after action review | ITSRR should ensure that, as a condition of accreditation, each of these recommendations is carried into effect and should audit against them to enforce compliance. |
REC121-3713 | 25 - Inquiry, audit, lessons management and after action review | Recommendations one to seven of the final report of the Special Commission of Inquiry into the Glenbrook Rail Accident should be fully implemented, save that the random auditing referred to in recommendations five and seven should be carried out by ITSRR. |
REC121-3718 | 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. |
REC121-3738 | 29 - Operational Health and Safety | All passenger trains must be fitted with an internal passenger emergency door release. |
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. |
REC121-3773 | 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. |
REC121-3654 | 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. |
REC121-3679 | 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. |
REC121-3699 | 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. |
REC121-3727 | 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. |
REC121-3744 | 16 - Training and behaviour | All RailCorp operational personnel should be trained in the location and operation of external emergency door release mechanisms. |
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. |
REC121-3661 | 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. |
REC121-3686 | 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. |
REC121-3706 | 29 - Operational Health and Safety | RailCorp should establish a comprehensive safety document management system. |
Rec-ID | Code | Recommendation |
---|---|---|
REC117-3641 | 38 - Agency/Department Reporting | The ANAO recommends that, to ensure the outcomes of evaluations are effectively used to enhance the national counter-terrorism arrangements, the Attorney-General’s Department and the Department of the Prime Minister and Cabinet take appropriate measures to ensure: |
REC117-3640 | 37 - Funding | The ANAO recommends that the Attorney-General’s Department better monitor and account for the expenditure of individual exercise costs under the National Capability Development Exercise Programme, through: |
REC117-3633 | 38 - Agency/Department Reporting | The ANAO recommends that, to provide better information to contribute to strategic assessments, decisions and reporting, the Attorney-General’s Department, with input and guidance from the Department of the Prime Minister and Cabinet: |
Rec-ID | Code | Recommendation |
---|---|---|
REC061-3253 | 37 - Funding | The Committee recommends that any change to the funding system reflect in a reduction of the total price charged to consumers through premiums by the insurance industry. |
REC061-3411 | 12 - EM agency and authority | The Committee recommends that collocation shall occur unless it can be demonstrated to the satisfaction of the Minister that it is inappropriate. |
REC061-3418 | 37 - Funding | The Committee recommends that any change to the funding system reflect in a reduction of the total price charged to consumers through premiums by the insurance industry. |
REC061-3245 | 12 - EM agency and authority | The Committee recommends that collocation shall occur unless it can be demonstrated to the satisfaction of the Minister that it is inappropriate. |
REC061-3252 | 37 - Funding | The Committee recommends that an equitable funding system be implemented which relates premiums to: |
REC061-3258 | 25 - Inquiry, audit, lessons management and after action review | The Committee recommends that the Metropolitan Fire Brigades Board be reviewed five years from the tabling of this report in Parliament. |
REC061-3417 | 37 - Funding | The Committee recommends that an equitable funding system be implemented which relates premiums to: |
REC061-3244 | 32 - Doctrine, standards, and reform | The Committee recommends that, following the development of standards of fire cover, related standards be established for: |
REC061-3423 | 25 - Inquiry, audit, lessons management and after action review | The Committee recommends that the Metropolitan Fire Brigades Board be reviewed five years from the tabling of this report in Parliament. |
REC061-3410 | 32 - Doctrine, standards, and reform | The Committee recommends that, following the development of standards of fire cover, related standards be established for: |
REC061-3251 | 37 - Funding | The Committee recommends that the Government act urgently to make the existing system of funding the fire services fair and equitable to all Victorians. |
REC061-3256 | 12 - EM agency and authority | The Committee recommends that a new Board be appointed, consisting of nine members nominated by the Minister for Police and Emergency Services and including the Chief Executive Officer who shall not be Chairman. |
REC061-3416 | 37 - Funding | The Committee recommends that the Government act urgently to make the existing system of funding the fire services fair and equitable to all Victorians. |
REC061-3243 | 12 - EM agency and authority | The Committee recommends that one standard model of fire cover be developed for Victoria as a matter of urgency. |
REC061-3421 | 12 - EM agency and authority | The Committee recommends that a new Board be appointed, consisting of nine members nominated by the Minister for Police and Emergency Services and including the Chief Executive Officer who shall not be Chairman. |
REC061-3409 | 12 - EM agency and authority | The Committee recommends that one standard model of fire cover be developed for Victoria as a matter of urgency. |
REC061-3249 | 37 - Funding | That the cost of a Bureau of Emergency Services Telecommunications centre be recovered through user charges. |
REC061-3255 | 12 - EM agency and authority | The Committee recommends that the Metropolitan Fire Brigades Board remain a statutory authority. |
REC061-3414 | 37 - Funding | That the cost of a Bureau of Emergency Services Telecommunications centre be recovered through user charges. |
REC061-3241 | 12 - EM agency and authority | The Committee recommends that the Metropolitan Fire Brigades Board continue to exist. |
REC061-3420 | 12 - EM agency and authority | The Committee recommends that the Metropolitan Fire Brigades Board remain a statutory authority. |
REC061-3407 | 12 - EM agency and authority | The Committee recommends that the Metropolitan Fire Brigades Board continue to exist. |
REC061-3247 | 32 - Doctrine, standards, and reform | The Committee recommends that the Ministry for Police and Emergency Services seek common national fire standards. |
REC061-3254 | 12 - EM agency and authority | The Committee recommends that: |
REC061-3412 | 32 - Doctrine, standards, and reform | The Committee recommends that the Ministry for Police and Emergency Services seek common national fire standards. |
REC061-3419 | 12 - EM agency and authority | The Committee recommends that: |
REC061-3246 | 38 - Agency/Department Reporting | The Committee recommends that performance monitoring standards be established, reviewed and maintained through a common reporting system by the Minister for Police and Emergency Services. |
Rec-ID | Code | Recommendation |
---|---|---|
REC008-3984 | 16 - Training and behaviour | The Commission recommends that the live parts of resistances should be fixed so that no unprotected combustible material is within 6ins of the frames or cases containing them or within 24ins measured vertically above. |
REC008-3991 | 32 - Doctrine, standards, and reform | The Commission recommends that the provisios of section 185 of the "Mining Act 1905" relating to exits from coal mines be extended to metalliferous mines employing more than 20 men in any one shift. |
REC008-3990 | 16 - Training and behaviour | The Commission recommends that more than one means of exit should be provided in every mine from every level of it to the surface; and that the miners should be kept informed where they are situated. |
REC008-3988 | 40 - Equipment and consumables | The Commission recommends that buckets of sand or other apparatus for extinguishing fire be kept in any chamber where high powered electricity is used. |
Rec-ID | Code | Recommendation |
---|---|---|
REC004-3997 | 40 - Equipment and consumables | That suitable metal receptacles be fitted under the spittoons of all smoking compartments of country trains, to receive pipe ashes, lighted tobacco, cigars, cigarettes, matches, or other inflammable matter used by smokers. |
REC004-3995 | 32 - Doctrine, standards, and reform | That the standard double arrester, fitted to the locomotives during the summer months, be subjected to more careful daily inspection before and after each journey during such months, in addition to the present periodical examination by the locomotive foreman and boiler inspector; and that any omission of this duty on the part of the running staff be severely punished. |
REC004-3993 | 32 - Doctrine, standards, and reform | That in any case where there is primá facie evidence of a fire, creating damage to the extent of $100 or upwards in value, having been caused by the escape of particles of lighted matter from a locomotive engine, or by the action of railway employes in burning off grass or other inflammable material along any line of railway, a Special Board of Inquiry shall investigate and report on the subject, such Board to consist of a Police Magistrate as Chairman, with a railway officer and a competent person chosen from outside the State service as members. |
REC004-4000 | 32 - Doctrine, standards, and reform | That section 22 of the Police Offences Act 1890 be amended, to enable the burning of grass and debris along the railway lines in the summer season to be carried out at an earlier hour than two o'clock in the afternoon, when, in the judgement of the railway inspectors, it is safe and necessary to do so. |