Inquiry Search
Rec-ID | Code | Recommendation |
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REC002-4004 | 35 - Business and Industry in relation to industry | Where safety-lamps are used, and the obligation is laid upon the men to cleanse the same, all examinations, tests, and repairs to these should be done by the owners. |
REC002-4003 | 35 - Business and Industry in relation to industry | Where gas exists, and no provisions are made for its constant removal, no shots should be fired, and, where permitted in a gassy mine, shots should be fired only by a man specially appointed, and at such hours when the miners are not within the mine. All shots should be tamped by stone well damped, and only copper or wooden tools should be employed. As far as possible the use of explosives should be discouraged, and skilful mining encouraged. Danger-boards should be placed further from the faces whence gas issues (say), where practicable, 50 yards. |
REC002-4001 | 35 - Business and Industry in relation to industry | The Commission consider that in all mines where gas exists the course of the air should be directed to sweep along the working-faces; in mines worked by Pillar and Stall, bratticing must be resorted to to carry the gas from the face as it issues, and so prevent any accumulation of explosive gases or of gases inimical to life. In cases where gas exists it would be better that no bords should be broken off the back or return heading or supplied with air fouled by dangerous gases. The panel system of working by confining and localising districts, or some modification thereof, might be pursued with advantage. |
REC002-4010 | 35 - Business and Industry in relation to industry | The Commission do not approve of removing any responsibility from the management by increasing the power or number of the Inspectors. The visits of these officials should, so far as possible, be visits of surprise. |
REC002-4008 | 35 - Business and Industry in relation to industry | Where dust exists in quantity, and under conditions favourable for ignition, it should be periodically and sufficiently dampened by water |
Rec-ID | Code | Recommendation |
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REC258-2545 | 12 - EM agency and authority | The Australian Transport Safety Bureau transfers its safety education function to the Civil Aviation Safety Authority. |
REC258-2557 | 6 - Insurance and legal liability | The Civil Aviation Safety Authority reassesses the penalties in the Civil Aviation Safety Regulations. |
REC258-2544 | 6 - Insurance and legal liability | The Australian Transport Safety Bureau transfers information from Mandatory Occurrence Reports to the Civil Aviation Safety Authority, without redaction or de-identification. |
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. |
REC258-2543 | 6 - Insurance and legal liability | The Civil Aviation Safety Authority reintroduces a ‘use of discretion’ procedure that gives operators or individuals the opportunity to discuss and, if necessary, remedy a perceived breach prior to CASA taking any formal action. This procedure is to be followed in all cases, except where CASA identifies a Serious and Imminent Risk to Air Safety. |
REC258-2550 | 6 - Insurance and legal liability | The Civil Aviation Safety Authority introduces grading of Non-Compliance Notices on a scale of seriousness. |
REC258-2540 | 6 - Insurance and legal liability | The Civil Aviation Safety Authority continues to provide appropriate indemnity to all industry personnel with delegations of authority. |
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. |
REC258-2539 | 35 - Business and Industry in relation to industry | The Civil Aviation Safety Authority changes its regulatory philosophy and, together with industry, builds an effective collaborative relationship on a foundation of mutual understanding and respect. |
REC258-2546 | 12 - EM agency and authority | The Civil Aviation Safety Authority changes its organisational structure to a client-oriented output model. |
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: |
REC258-2532 | 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. |
Rec-ID | Code | Recommendation |
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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. |
REC236-2790 | 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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC233-1597 | 35 - Business and Industry in relation to industry | Community service providers consider updating their business continuity plans to take into account the possibility of a major telecommunications outage involving both fixed and mobile voice and data services. |
REC233-1595 | 35 - Business and Industry in relation to industry | Department of Broadband, Communications and the Digital Economy to work with the Trusted Information Sharing Network’s Communications Sector Group to develop general telecommunications continuity advice for businesses and individuals to assist in developing continuity plans. |
REC233-1601 | 35 - Business and Industry in relation to industry | Community service providers consider in their business continuity planning how they could assist with facilitating access to telecommunications services for the public during mass outages. |
REC233-1594 | 35 - Business and Industry in relation to industry | When businesses review their business continuity plans they should take into account the prospect of a major telecommunications outage that affects both mobile and fixed voice and data services. |
REC233-1600 | 35 - Business and Industry in relation to industry | Community service providers consider, in consultation with relevant government authorities, reviewing their current privacy practices concerning personal information about vulnerable persons to ensure they are able to appropriately share information during major disruptive incidents. |
REC233-1593 | 35 - Business and Industry in relation to industry | Telstra and other service providers to consider improving processes to assist customers with setting up temporary call diversions during future outages. |
REC233-1599 | 35 - Business and Industry in relation to industry | Providers of personal alert devices consider telecommunications outages in their service continuity plans and provide clear advice to their customers regarding their options during a telecommunications service outage. |
REC233-1591 | 35 - Business and Industry in relation to industry | While noting the importance of voice communications, telecommunications providers should consider as part of their mass outage business continuity planning, options for the provision of interim mobile broadband services for the community e.g. local wireless broadband access hubs (i.e. Wi-Fi). |
REC233-1598 | 35 - Business and Industry in relation to industry | Community service providers consider developing information and advice regarding telecommunications outages for clients managed remotely using telecommunication services, including personal alert devices. |
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. |
REC227-2854 | 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 |
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REC215-1876 | 39 - Disaster Risk Management | Fire services can improve outcomes by initiating discussions with landfill operators about fire management planning and emphasising the critical importance of water supplies and early intervention |
REC215-1875 | 1 - Land-use and building regs | Fire services can improve outcomes by seeking input to decisions about siting, design and fire water systems as part of the planning and licensing processes |
REC215-1870 | 12 - EM agency and authority | Fire services can improve outcomes by using a pre-planned response to provide appropriate resources |
REC215-1881 | 35 - Business and Industry in relation to industry | Landfill operators must be encouraged to achieve greater compliance with the required outcomes relating to fire that are set out in the BPEM guidelines, particularly with regard to water supplies |
REC215-1877 | 39 - Disaster Risk Management | Regulators can help to achieve improved outcomes by considering the issues identified by this review |
Rec-ID | Code | Recommendation |
---|---|---|
REC208-0527 | 35 - Business and Industry in relation to industry | That the Office of Environment and Heritage require Orica to engage and fund appropriate independent experts to oversee any modifications to the plant in the next major maintenance overhaul of the plant in 2016 and in any upgrades to the plant prior to that date. |
Rec-ID | Code | Recommendation |
---|---|---|
REC204-1910 | 6 - Insurance and legal liability | As part of its review of its contract management processes, Tourism WA (with the Board of Tourism WA taking a lead role) should amend its contract template for event sponsorship to ensure that: |
REC204-1909 | 35 - Business and Industry in relation to industry | Eventscorp should ensure that organisers of events its sponsors are directed to all appropriate authorities and stakeholders to ensure the responsible, safe and efficient planning and conduct of the event. |
REC204-1908 | 39 - Disaster Risk Management | As part of the current revision of its contract template for sponsorship agreements, Tourism WA should ensure that: |
REC204-1920 | 6 - Insurance and legal liability | The Attorney General gives urgent consideration to determining an ex gratia payment for: |
REC204-1919 | 1 - Land-use and building regs | Tourism WA must give specific regard as to whether land use approvals need to be sought, particularly from Department of Regional Development and Lands, when conducting due diligence for event sponsorship proposals that require sign off by both departments. |
REC204-1918 | 1 - Land-use and building regs | Department of Regional Development and Lands and Department of Environment and Conservation should consider how their respective land use approval processes can incorporate the input of Local Emergency Management Committees (LEMCs) as part of risk assessments for high risk events and adventure sport activities. |
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: |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC197-1736 | 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. |
REC197-1746 | 12 - EM agency and authority | The CFA revisit with the UFU the arrangements relating to the employment of part‐time and casual employees. |
REC197-1769 | 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. |
REC197-1744 | 12 - EM agency and authority | The CFA revisit with the UFU the arrangements relating to lateral entry and secondment. |
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. |
REC197-1743 | 12 - EM agency and authority | The CFA revisit with the UFU the arrangement relating to the recruitment of volunteer firefighters as an employee. |
REC197-1760 | 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. |
REC197-1773 | 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. |
REC197-1738 | 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. |
REC197-1759 | 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. |
REC197-1772 | 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. |
REC197-1737 | 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. |
REC197-1758 | 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. |
Rec-ID | Code | Recommendation |
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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 |
---|---|---|
REC177-3289 | 39 - Disaster Risk Management | The use/type of barriers (including any change requests relating thereto) must be the subject of consultation between licensees and rig operators prior to installation. A proper risk assessment should be carried out, agreed upon, and documented in writing before installation. Joint written certification as to the appropriateness of the use of particular barriers should take place before installation. Senior onshore representatives of stakeholder entities should be involved in that certification process. |
REC177-3336 | 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. |
REC177-3369 | 6 - Insurance and legal liability | The obligation of companies involved in an incident to meet the full costs of monitoring and remediation should be made a condition of approval of proposals under the EPBC Act and OPGGS Act. Suitable arrangements (insurance or otherwise) need to be in place to ensure that companies have this capacity. |
REC177-3286 | 39 - Disaster Risk Management | Problems which arise in the course of installing barriers must be the subject of consultation between licensees, rig operators, and contractors (if used). A proper risk assessment should then be carried out and remedial steps (including further testing/verification) should be agreed upon, and documented in writing before the performance of remedial work whenever practicable. Joint written certification as to resolution of the problem should take place before resumption of drilling operations. Senior onshore representatives of stakeholder entities should be involved in that certification process. |
REC177-3336 | 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. |
REC177-3365 | 6 - Insurance and legal liability | The National Plan should specify that the cost of responding to an oil spill, or other damage to the offshore marine environment, will be totally met by the owner/operator. This would be consistent with the Inquiry’s recommendation for legislative changes to the regulatory framework concerning owner/operators meeting the cost of monitoring and remediation of environmental damage. |
REC177-3285 | 39 - Disaster Risk Management | Pre‐drilling assessments should include a risk assessment of the worst‐case blowout scenario. |
REC177-3330 | 39 - Disaster Risk Management | Decision‐making about well control issues should be professionalised. Industry participants must recognise that decision‐makers owe independent duties to the public, not just their employer or principal, in relation to well control. Risk management in the context of well control needs to be understood as an ethical/professional duty. Self‐regulation contemplates self‐regulation by the industry, not just by individual licensees and operators. |
REC177-3356 | 39 - Disaster Risk Management | The regulator should pre‐assess and review in a generic sense, and in conjunction with the offshore petroleum industry, available options for well control in the event of a blowout. Being ‘match fit’ in this sense will enable a quicker and more effective response in terms of safety assessment, and will ensure that expectations of both operator and regulator are more readily aligned. |
REC177-3310 | 6 - Insurance and legal liability | Consideration should be given to ways to ensure that contractors who are involved in barrier installation (such as cementing companies) have a direct interest in the performance of works to a proper standard. In particular, consideration should be given to (i) preventing contractors from avoiding the economic consequences of negligent installation of barriers; and/or (ii) imposing specific legislative standards of workmanship on contractors with respect to well control (similar to those which presently apply to licensees). |
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? |
REC177-3291 | 39 - Disaster Risk Management | Removal of a barrier must be the subject of consultation between licensees and rig operators prior to removal. A proper risk assessment should be carried out and agreed upon, and documented in writing before removal. Joint written certification as to the appropriateness of removal should take place before removal. Senior onshore representatives of stakeholder entities should be involved in that certification process. |
REC177-3337 | 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. |
Rec-ID | Code | Recommendation |
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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: |
REC166-2999 | 35 - Business and Industry in relation to industry | That Aurora ensure that regular audits are conducted of all electrical systems of all commercial buildings to confirm that they comply with modern standards. |
REC166-3008 | 1 - Land-use and building regs | That any building fitted with heat-activated closing devices or fire and smoke doors be assessed to establish if it constitutes a fire hazard under section 165 of the Building Act 2000 and that, where appropriate, such doors be replaced with smoke activated doors. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC158-3442 | 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. |
Rec-ID | Code | Recommendation |
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REC149-3133 | 35 - Business and Industry in relation to industry | Because some issues related to emergency response are beyond any single operator and usually occur outside the title area, there is a need for the representatives of the offshore industry to work together with other governments, interested and involved parties to develop the strategies to be utilised and the emergency planning model that will satisfy the requirements of all parties. |
REC149-3132 | 35 - Business and Industry in relation to industry | Coverage of the regime should be increased to cover the complete hydrocarbons production system from wells through to custody transfer point or reasonable physical/technical system boundary. If NOPSA is also to be responsible for Carbon Capture and Storage it needs to be resourced to ensure that this does not detract from NOPSA's current responsibilities. |
REC149-3131 | 35 - Business and Industry in relation to industry | The exploration/production operator making all major decisions related to petroleum activities (i.e. selection of rig, well design and selection of service companies) should be made responsible for demonstrating to the regulator that drilling operations can be conducted safely. Where the drilling contractor owns the rig and conducts the day-to-day management of safety on the rig, this duty can be described in a rig specific Safety Case that is owned by the drilling contractor. This rig specific Safety Case does not have to be submitted for every well/well operation. |
REC149-3146 | 35 - Business and Industry in relation to industry | NOPSA should consider establishing a small forum for consultation consisting of representatives of relevant stakeholders. The representatives should have standing, with authority to participate in decision making and take on commitment on behalf of their stakeholder group. |
REC149-3139 | 39 - Disaster Risk Management | The industry should develop in conjunction with the Regulator a process for addressing the need to maintain the risk profile of a facility moving into extended life operation at the same risk profile as when it was within design life. |
Rec-ID | Code | Recommendation |
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REC121-3700 | 12 - EM agency and authority | The RailCorp defects unit should be combined with the passenger fleet maintenance division of RailCorp. |
REC121-3651 | 10 - Infrastructure | A dedicated telephone line should be established by RailCorp between the RMC and any Emergency Services Control Centre for use during any emergency. |
REC121-3752 | 12 - EM agency and authority | RailCorp should establish clear safety accountability statements and reporting lines for all management positions. |
REC121-3678 | 35 - Business and Industry in relation to industry | All railway owners and operators should have a quality assurance program for the design and construction of rolling stock and regular review of construction to ensure that the rolling stock satisfies the original functional performance specifications. |
REC121-3695 | 10 - Infrastructure | There should be interoperability of communications equipment between all trains operating on the New South Wales rail network. |
REC121-3710 | 39 - Disaster Risk Management | The ITSRR should have permanent access to the RailCorp intranet. |
REC121-3673 | 41 - Emergency Management exercises | Regular field training exercises should be conducted by RailCorp with the emergency services to ensure that the incident command system and rail displan are able to be fully implemented as quickly as possible and are reviewed and improved. |
REC121-3689 | 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. |
REC121-3658 | 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. |
REC121-3687 | 10 - Infrastructure | There must be compatibility of communications systems throughout the rail network. It is essential that all train drivers, train controllers, signallers, train guards and supervisors of trackside work gangs in New South Wales be able to communicate using the same technology. |
REC121-3703 | 6 - Insurance and legal liability | Alcohol and drug testing should be mandatory for any train driver or guard involved in any accident or incident. |
REC121-3657 | 10 - Infrastructure | All signal telephones must be maintained by RailCorp in proper working order. |
REC121-3684 | 39 - Disaster Risk Management | The ITSRR should conduct its own risk assessment in relation to the risk of any such high consequence, low probability accident and, if necessary, direct RailCorp to conduct a further risk assessment to reduce the level of residual risk to a level ITSRR regards as acceptable. |
REC121-3700 | 39 - Disaster Risk Management | Maintenance plans on all trains should be revised annually. |
REC121-3653 | 10 - Infrastructure | The RMC should be equipped by RailCorp with a transcriber system, or mimic board, or such other system as is necessary to enable identification of the precise location at any time of any train on the RailCorp network. |
REC121-3766 | 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. |
REC121-3683 | 39 - Disaster Risk Management | RailCorp should undertake risk assessments of each of its activities as follows: |
Rec-ID | Code | Recommendation |
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REC061-3254 | 12 - EM agency and authority | The Committee recommends that: |
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. |
REC061-3245 | 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. |
REC061-3409 | 12 - EM agency and authority | The Committee recommends that one standard model of fire cover be developed for Victoria as a matter of urgency. |
REC061-3243 | 12 - EM agency and authority | The Committee recommends that one standard model of fire cover be developed for Victoria as a matter of urgency. |
REC061-3407 | 12 - EM agency and authority | The Committee recommends that the Metropolitan Fire Brigades Board continue to exist. |
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. |
REC061-3241 | 12 - EM agency and authority | The Committee recommends that the Metropolitan Fire Brigades Board continue to exist. |
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. |
REC061-3420 | 12 - EM agency and authority | The Committee recommends that the Metropolitan Fire Brigades Board remain a statutory authority. |
REC061-3255 | 12 - EM agency and authority | The Committee recommends that the Metropolitan Fire Brigades Board remain a statutory authority. |
REC061-3419 | 12 - EM agency and authority | The Committee recommends that: |
Rec-ID | Code | Recommendation |
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REC004-3999 | 10 - Infrastructure | That, in view of the fact that along many of the lines, between the road-bed and the fences, there are numbers of dry inflammable stumps, which, when they catch fire, are very difficult to extinguish, and that the surface of the ground surrounding these stumps is usually chipped by the permanent-way men every summer, thus causing considerable expense without removing the risk of fire, the Railway Department should remove this source of danger, by grabbing them out and burning them as early as may be found practicable. |