Inquiry Search
Rec-ID | Code | Recommendation |
---|---|---|
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 |
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. |
REC002-4013 | 19 - Offences | Infringement of the regulations by either party should be followed by a summary form of justice, instituted before two Magistrates. |
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. |
REC002-4012 | 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. |
REC002-4002 | 19 - Offences | Where safety-lamps are necessary - gas being present for (say) one month after being found in dangerous quantity - they should be securely locked by a man duly appointed, and tampering with them must be punishable by a simple and inexpensive process of law. |
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. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC236-2798 | 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. |
REC236-2803 | 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. |
REC236-2808 | 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. |
REC236-2796 | 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: |
REC236-2802 | 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. |
REC236-2795 | 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. |
REC236-2801 | 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. |
REC236-2794 | 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. |
REC236-2800 | 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. |
REC236-2784 | 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. |
REC236-2793 | 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. |
REC236-2799 | 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. |
REC236-2783 | 2 - Emergency powers | The committee recommends that the Australian Transport Safety Bureau retrieve VH-NGA flight data recorders without further delay. |
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. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC208-0524 | 8 - Communications and warnings | That the Premier issue clear and unambiguous guidelines to all Government Ministers specifying the timing of notifications to the public of any matters that may affect public health or safety. |
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. |
REC208-0527 | 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 |
---|---|---|
REC204-1907 | 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. |
REC204-1913 | 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. |
REC204-1920 | 6 - Insurance and legal liability | The Attorney General gives urgent consideration to determining an ex gratia payment for: |
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. |
REC204-1917 | 32 - Doctrine, standards, and reform | The review of the Health Act 1911 (WA) should include the following amendments: |
REC204-1911 | 24 - Govt responsibility | As part of the review of its due diligence processes, Tourism WA should ensure that: |
REC204-1916 | 25 - Inquiry, audit, lessons management and after action review | Local Emergency Management Committee (LEMC) processes should be reviewed to ensure that: |
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: |
REC204-1915 | 24 - Govt responsibility | The Department of Regional Development and Lands should ensure that event organisers and government agencies responsible for sponsoring and approving events have a greater level of awareness about the requirements of section 91 licences under the Land Administration Act 1977 (WA). |
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. |
REC204-1914 | 15 - Inter-service cooperation | FESA, WA Police and St John Ambulance establish a uniform protocol for handling multiple agency emergency responses that does not involve callers having to make multiple calls to 000. |
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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC061-3248 | 15 - Inter-service cooperation | The Committee recommends to the Minister for Police and Emergency Services that a joint communications and dispatch facility be established under the Minister's control to implement the following minimum services to the Victoria Police and the emergency services: |
REC061-3410 | 32 - Doctrine, standards, and reform | The Committee recommends that, following the development of standards of fire cover, related standards be established for: |
REC061-3423 | 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. |
REC061-3247 | 32 - Doctrine, standards, and reform | The Committee recommends that the Ministry for Police and Emergency Services seek common national fire standards. |
REC061-3408 | 24 - Govt responsibility | It is inappropriate for an emergency services provider to develop its own standards, core objectives and functions. The Committee recommends that these be the responsibility of the Minister for Police and Emergency Services. |
REC061-3422 | 9 - Community education | The Committee recommends that the FireVision concept used by the Metropolitan Fire Brigades Board be extended through the Directorate of School Education's Interactive Television Program to all emergency services and in particular to rural fire and emergency services. |
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. |
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. |
REC061-3415 | 24 - Govt responsibility | The Committee recommends that the Bureau of Emergency Services Telecommunications Centre extend its services as a commercial venture to smaller government agencies who could not develop such a dedicated system. |
REC061-3244 | 32 - Doctrine, standards, and reform | The Committee recommends that, following the development of standards of fire cover, related standards be established for: |
REC061-3257 | 9 - Community education | The Committee recommends that the FireVision concept used by the Metropolitan Fire Brigades Board be extended through the Directorate of School Education's Interactive Television Program to all emergency services and in particular to rural fire and emergency services. |
REC061-3413 | 15 - Inter-service cooperation | The Committee recommends to the Minister for Police and Emergency Services that a joint communications and dispatch facility be established under the Minister's control to implement the following minimum services to the Victoria Police and the emergency services: |
REC061-3242 | 24 - Govt responsibility | It is inappropriate for an emergency services provider to develop its own standards, core objectives and functions. The Committee recommends that these be the responsibility of the Minister for Police and Emergency Services. |
REC061-3250 | 24 - Govt responsibility | The Committee recommends that the Bureau of Emergency Services Telecommunications Centre extend its services as a commercial venture to smaller government agencies who could not develop such a dedicated system. |
REC061-3412 | 32 - Doctrine, standards, and reform | The Committee recommends that the Ministry for Police and Emergency Services seek common national fire standards. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC004-3998 | 19 - Offences | That a by-law be made forbidding, under a heavy penalty, any persons travelling in such trains to throw lighted tobacco, cigars, cigarettes, pipe ashes, matches, or other inflammable matter on the railway line or right-of-way, or in any part of a railway carriage except the receptacles duly provided for the purpose. |
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. |