Inquiry Search
Rec-ID | Code | Recommendation |
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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. |
REC236-2785 | 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. |
REC236-2806 | 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. |
REC236-2793 | 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. |
REC236-2784 | 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. |
REC236-2805 | 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. |
REC236-2792 | 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. |
REC236-2797 | 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. |
REC236-2804 | 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. |
REC236-2790 | 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. |
REC236-2796 | 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: |
REC236-2803 | 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. |
REC236-2789 | 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. |
REC236-2795 | 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. |
REC236-2802 | 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. |
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. |
REC236-2807 | 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. |
REC236-2794 | 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. |
Rec-ID | Code | Recommendation |
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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. |
REC208-0530 | 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. |
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’. |
Rec-ID | Code | Recommendation |
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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. |
REC204-1921 | 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. |
REC204-1908 | 39 - Disaster Risk Management | As part of the current revision of its contract template for sponsorship agreements, Tourism WA should ensure that: |
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. |
REC204-1907 | 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. |
REC204-1918 | 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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REC061-3407 | 12 - EM agency and authority | The Committee recommends that the Metropolitan Fire Brigades Board continue to exist. |
REC061-3419 | 12 - EM agency and authority | The Committee recommends that: |
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. |
REC061-3258 | 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. |
REC061-3412 | 32 - Doctrine, standards, and reform | The Committee recommends that the Ministry for Police and Emergency Services seek common national fire standards. |
REC061-3244 | 32 - Doctrine, standards, and reform | The Committee recommends that, following the development of standards of fire cover, related standards be established for: |
REC061-3256 | 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. |
REC061-3411 | 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. |
REC061-3423 | 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. |
REC061-3243 | 12 - EM agency and authority | The Committee recommends that one standard model of fire cover be developed for Victoria as a matter of urgency. |
REC061-3255 | 12 - EM agency and authority | The Committee recommends that the Metropolitan Fire Brigades Board remain a statutory authority. |
REC061-3410 | 32 - Doctrine, standards, and reform | The Committee recommends that, following the development of standards of fire cover, related standards be established for: |
REC061-3421 | 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. |
REC061-3254 | 12 - EM agency and authority | The Committee recommends that: |
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. |
REC061-3420 | 12 - EM agency and authority | The Committee recommends that the Metropolitan Fire Brigades Board remain a statutory authority. |
REC061-3247 | 32 - Doctrine, standards, and reform | The Committee recommends that the Ministry for Police and Emergency Services seek common national fire standards. |