Inquiry Search
Rec-ID | Code | Recommendation |
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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. |
REC002-4003 | 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. |
Rec-ID | Code | Recommendation |
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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. |
REC258-2540 | 6 - Insurance and legal liability | The Civil Aviation Safety Authority continues to provide appropriate indemnity to all industry personnel with delegations of authority. |
REC258-2551 | 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. |
REC258-2539 | 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. |
REC258-2550 | 6 - Insurance and legal liability | The Civil Aviation Safety Authority introduces grading of Non-Compliance Notices on a scale of seriousness. |
REC258-2559 | 15 - Inter-service cooperation | The Civil Aviation Safety Authority’s Director of Aviation Safety meet with industry sector leaders to jointly develop a plan for renewing a collaborative and effective Standards Consultative Committee. |
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. |
REC258-2549 | 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. |
REC258-2557 | 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. |
REC258-2556 | 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. |
REC258-2543 | 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. |
Rec-ID | Code | Recommendation |
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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. |
REC236-2806 | 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. |
REC236-2791 | 37 - Funding | The committee recommends that the government develop a process by which the ATSB can request access to supplementary funding via the minister. |
REC236-2805 | 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. |
REC236-2801 | 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. |
REC236-2795 | 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. |
REC236-2793 | 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. |
Rec-ID | Code | Recommendation |
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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. |
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. |
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. |
Rec-ID | Code | Recommendation |
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REC227-2847 | 15 - Inter-service cooperation | I recommend that Border Protection Command implement a surveillance strategy, possibly with the assistance of other Commonwealth authorities and organisations on the island such as the AFP, which heightens its coverage at times when the weather and sea conditions are rough. |
Rec-ID | Code | Recommendation |
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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 |
REC215-1874 | 15 - Inter-service cooperation | Fire services can improve outcomes by working with EPA as the regulator and licensing authority to achieve improved compliance with the required outcomes specified in the BPEM guidelines |
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 |
Rec-ID | Code | Recommendation |
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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. |
REC208-0527 | 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. |
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. |
Rec-ID | Code | Recommendation |
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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. |
REC204-1913 | 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. |
REC204-1910 | 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. |
REC204-1920 | 6 - Insurance and legal liability | The Attorney General gives urgent consideration to determining an ex gratia payment for: |
REC204-1916 | 25 - Inquiry, audit, lessons management and after action review | Local Emergency Management Committee (LEMC) processes should be reviewed to ensure that: |
Rec-ID | Code | Recommendation |
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REC198-2903 | 15 - Inter-service cooperation | The CFA works with MFB to ensure that the MFB control unit is available for responding to large fires and multi-agency incidents in fringe CFA areas |
Rec-ID | Code | Recommendation |
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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. |
Rec-ID | Code | Recommendation |
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REC166-3007 | 15 - Inter-service cooperation | That Tasmania Fire Service implement Recommendation 5 above; and that Aurora continue to co-operate with that Service. |
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. |
REC166-3009 | 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. |
Rec-ID | Code | Recommendation |
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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. |
REC158-3447 | 15 - Inter-service cooperation | That emergency services are required to work directly with port/channel managers and the nominated marine safety authority to ensure that a training and exercise regime is established to enable emergency services personnel to develop and maintain the skills and knowledge relevant to marine emergency management. |
REC158-3446 | 15 - Inter-service cooperation | That emergency services are required to work directly with port/channel managers and the nominated marine safety authority to identify and ensure availability of marine resources necessary for emergency services to meet their statutory obligations in responding to marine emergencies (this recommendation should be read in conjunction with recommendation 26 & 27). |
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. |
REC158-3445 | 15 - Inter-service cooperation | That emergency services are required to work directly with ports and the nominated marine safety authority when ports are preparing marine emergency response arrangements. |
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. |
REC158-3444 | 15 - Inter-service cooperation | That the Office of the Emergency Services Commissioner ensures that an emergency services multi-agency working group is established to develop a specialist marine emergency response capability for Victoria based on the multi-agency Urban Search and Rescue (USAR) model. The specialist personnel should be required to have: |
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 |
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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. |
REC149-3145 | 25 - Inquiry, audit, lessons management and after action review | NOPSA should consider an audit regime that targets Greenfields operations at commencement of operations. |
REC149-3133 | 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. |
Rec-ID | Code | Recommendation |
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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. |
REC121-3691 | 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. |
REC121-3726 | 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. |
REC121-3768 | 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. |
REC121-3678 | 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. |
REC121-3713 | 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. |
REC121-3765 | 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. |
REC121-3703 | 6 - Insurance and legal liability | Alcohol and drug testing should be mandatory for any train driver or guard involved in any accident or incident. |
REC121-3758 | 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. |
REC121-3694 | 25 - Inquiry, audit, lessons management and after action review | The ITSRR should conduct random audits of accredited rail organisations for compliance with communications protocols. |
REC121-3757 | 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. |
REC121-3693 | 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. |
Rec-ID | Code | Recommendation |
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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. |
REC061-3417 | 37 - Funding | The Committee recommends that an equitable funding system be implemented which relates premiums to: |
REC061-3252 | 37 - Funding | The Committee recommends that an equitable funding system be implemented which relates premiums to: |
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. |
REC061-3251 | 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. |
REC061-3414 | 37 - Funding | That the cost of a Bureau of Emergency Services Telecommunications centre be recovered through user charges. |
REC061-3249 | 37 - Funding | That the cost of a Bureau of Emergency Services Telecommunications centre be recovered through user charges. |
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: |
REC061-3423 | 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. |
REC061-3248 | 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: |
REC061-3258 | 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. |
REC061-3418 | 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. |