Inquiry Search
Rec-ID | Code | Recommendation |
---|---|---|
REC325-4322 | 24 - Govt responsibility | The Inspector-General of Emergency Management recommends the Dam Safety Regulator review the Emergency Action Plan for Referable Dam Guideline with particular regard to the distinction between the process required by a flood event as compared to a dam failure event by 1 November 2023. The Emergency Action Plan for Referable Dam Guideline review will be informed by a discussion, facilitated by the Dam Safety Regulator, between dam owner Seqwater, the Brisbane City Council Flood Information Centre, the Brisbane Local Disaster Management Group and the Brisbane District Disaster Management Group. The purpose of the facilitation is to achieve inter-agency understanding of warning and notification responsibilities. The reviewed Emergency Action Plan for Referable Dam Guideline should be published, promoted and shared via a stakeholder engagement exercise with Queensland’s referable dam owners, disaster management stakeholders including local disaster management groups and district disaster management group. |
REC325-4335 | 16 - Training and behaviour | The Inspector-General of Emergency Management recommends Queensland Fire and Emergency Services update and deliver training on the workflow reviewed (as per Recommendation 3) of the current Emergency Alert system to all persons responsible at a local, district and state level by 1 November 2022. Training should address system constraints and system complexities in addition to the process of requesting, composing (including Clear Explicit Translatable Language [CETL]), authorising and issuing Emergency Alerts. |
Rec-ID | Code | Recommendation |
---|---|---|
REC323-4282 | 16 - Training and behaviour | That the NSW Government invest in the required personnel, training and vessels to ensure that all agencies involved in flood rescue can be mobilised to their fullest potential. |
REC319-4199 | 24 - Govt responsibility | Relief and recovery capability: The Inspector-General for Emergency Management recommends that Emergency Management Victoria and the entity referred to in Recommendation 13, or otherwise responsible government department – in collaboration with the relevant relief and recovery organisations: |
Rec-ID | Code | Recommendation |
---|---|---|
REC306-2425 | 24 - Govt responsibility | We recommend that the Department of Natural Resources and Mines and the four councils work together to effectively and economically regulate levee banks. |
REC306-2422 | 24 - Govt responsibility | We recommend that, in the absence of stand-alone catchment management authorities, the Department of Infrastructure, Local Government and Planning fulfil its obligation under the State Disaster Management Plan to drive the enhancement of flood resilience in the four catchments by: |
Rec-ID | Code | Recommendation |
---|---|---|
REC002-4013 | 19 - Offences | Infringement of the regulations by either party should be followed by a summary form of justice, instituted before two Magistrates. |
REC002-4009 | 16 - Training and behaviour | In gassy mines the Manager should be specially competent, and one possessing a thorough knowledge of the principles and practice of mining, the properties of gases, and systems of ventilation; and, above all, he must be prudent and cautious, yet resolute, possessing sound judgement. He must have absolute and supreme control over the whole operations, and of the men within the mine, to maintain rigid discipline, and be perfectly free and untrammelled by any outside influences. The competency of a manager should be certified by an examination before a specially-appointed Board. The Commission consider that better results may be obtained if such examinations be oral, and probably assume a more practical form than those hitherto conducted in Great Britain for the same object. |
REC002-4002 | 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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC297-1268 | 24 - Govt responsibility | That DPAC becomes the Management Authority for recovery in Tasmania. |
REC297-1255 | 24 - Govt responsibility | That Government establishes a central flood policy unit responsible for coordinating flood policy across all government agencies, including Government Businesses, and ensures that such a unit has a whole-of-government and community focus. |
REC297-1270 | 24 - Govt responsibility | That, in the event of a major emergency such as the June floods, a government department (DPAC or State Growth) be appointed to coordinate infrastructure repair, to the extent that funding allows, for the whole state. Individual entities will still have the right and responsibility to repair and maintain their own assets, but some central oversight and coordination is, in our view, likely to be beneficial. |
Rec-ID | Code | Recommendation |
---|---|---|
REC292-2337 | 16 - Training and behaviour | I recommend that the Director of Public Prosecutions initiate reviews of the training in file management given to lawyers employed by the Office of the Director of Public Prosecutions to ensure important original documents are not discarded and that the files accurately reflect relevant events. |
REC292-2360 | 2 - Emergency powers | I recommend that the Commissioner of Police consider seeking an agreement with news media outlets whereby the New South Wales Police Force will establish a way for such outlets to rapidly and confidentially determine whether publishing specific material could compromise the response to an ongoing high-risk incident and the media in turn will agree not to publish such material without first alerting a nominated senior police officer of their intention to do so. |
REC292-2358 | 16 - Training and behaviour | I recommend that the New South Wales Police Force develop a cadre of counterterrorist negotiators and provide them with appropriate training to equip them to respond to a terrorist siege. |
REC292-2352 | 16 - Training and behaviour | The New South Wales Police Force should consider drawing on international experience when reviewing its negotiator training |
REC292-2380 | 24 - Govt responsibility | I recommend that the New South Wales Police Force, in conjunction with NSW Health, establish a Fixated Threat Assessment Centre to identify and gather information about fixated persons, assess the risks they pose, and attempt to mitigate such risks through early intervention. |
REC292-2351 | 16 - Training and behaviour | The sections above dealing with negotiators’ attempts to engage with Monis, their responses to his demands, and their assessment of progress demonstrate deficiencies in current practice. To respond to those deficiencies, I recommend that the New South Wales Police Force conduct a general review of the training afforded to negotiators and the means by which they are assessed and accredited. Specifically, the review should consider the training provided regarding: measuring progress in negotiations; recording of information, including the systems by which that occurs; the use of third-party intermediaries; additional approaches to securing direct contact with a person of interest; and handovers. |
REC292-2379 | 24 - Govt responsibility | I recommend that the Premier of New South Wales consider whether the Privacy and Personal Information Protection Act 1998 and the Health Records and Information Privacy Act 2002 should be amended to ensure that there is appropriate access to health related information available to ASIO (consistent with recommendation 12 of the report of the Martin Place Siege Joint Commonwealth—New South Wales review) |
REC292-2339 | 19 - Offences | I recommend that the Law, Crime and Community Safety Council develop a mechanism to ensure that all information on criminal history (including bail) that is relevant to the investigation and prosecution of criminal offences is readily accessible to police and prosecutors across all Australian jurisdictions. |
REC292-2366 | 16 - Training and behaviour | I recommend that the New South Wales Police Force review the training provided to officers in relation to DA planning and approval. |
Rec-ID | Code | Recommendation |
---|---|---|
REC271-1530 | 16 - Training and behaviour | Local Disaster Coordination Centre capability and capacity should be reviewed to ensure adequate staffing arrangements are in place to fill key positions, and that operational protocols are known and practiced across all functions to provide redundancy. Assistance for review and necessary training should be sought from key Local Disaster Management Group member agencies. |
Rec-ID | Code | Recommendation |
---|---|---|
REC258-2560 | 29 - Operational Health and Safety | The Civil Aviation Safety Authority devolve to Designated Aviation Medical Examiners the ability to renew aviation medical certificates (for Classes 1, 2, and 3) where the applicant meets the required standard at the time of the medical examination. |
REC258-2542 | 16 - Training and behaviour | The Civil Aviation Safety Authority publishes and demonstrates the philosophy of ‘just culture’ whereby individuals involved in a reportable event are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training. However, actions of gross negligence, wilful violations and destructive acts should not be tolerated. |
REC258-2541 | 16 - Training and behaviour | The Civil Aviation Safety Authority finalises its Capability Framework and overhauls its training program to ensure identified areas of need are addressed, including: |
REC258-2534 | 16 - Training and behaviour | The Civil Aviation Safety Authority develops a staff exchange program with industry. |
REC258-2530 | 24 - Govt responsibility | The Australian Government appoints an additional Australian Transport Safety Bureau Commissioner with aviation operational and safety management experience. |
REC258-2561 | 24 - Govt responsibility | The Australian Government amends regulations so that background checks and the requirement to hold an Aviation Security Identification Card are only required for unescorted access to Security Restricted Areas, not for general airside access. This approach would align with international practice. |
REC258-2526 | 24 - Govt responsibility | The Australian Government develops the State Safety Program into a strategic plan for Australia’s aviation safety system, under the leadership of the Aviation Policy Group, and uses it as the foundation for rationalising and improving coordination mechanisms. |
Rec-ID | Code | Recommendation |
---|---|---|
REC250-0794 | 24 - Govt responsibility | Rural Finance Corporation (Department of Treasury and Finance) and Regional Development Victoria should coordinate any future disaster relief and recovery programs for businesses. |
REC250-0793 | 24 - Govt responsibility | The Department of Premier and Cabinet should develop clear guidelines for departments in designing community disaster relief and recovery programs. |
Rec-ID | Code | Recommendation |
---|---|---|
REC238-0799 | 18 - Access to fire ground | Develop and implement a program of cost-effective road improvement works that can enhance flood evacuation capacity in the short-medium term. |
Rec-ID | Code | Recommendation |
---|---|---|
REC236-2788 | 16 - Training and behaviour | The committee recommends that, as far as available resources allow, ATSB investigators be given access to training provided by the agency's international counterparts. Where this does not occur, resultant gaps in |
REC236-2787 | 16 - Training and behaviour | The committee recommends that the training offered by the ATSB across all investigator skills sets be benchmarked against other agencies by an independent body by, for example, inviting the NTSB or commissioning an industry body to conduct such a benchmarking exercise. |
REC236-2783 | 2 - Emergency powers | The committee recommends that the Australian Transport Safety Bureau retrieve VH-NGA flight data recorders without further delay. |
Rec-ID | Code | Recommendation |
---|---|---|
REC217-1824 | 24 - Govt responsibility | The Victorian Government to implement the recommendations of the Victorian Floods Review in relation to the development and implementation of appropriate flood mitigation and protection strategies for essential services. |
REC217-1846 | 24 - Govt responsibility | The state government should implement the recommendations of the Victorian Floods Review in relation to the creation of resilience committees and resilience plans, with responsible authorities. |
REC217-1823 | 24 - Govt responsibility | The Victorian Government should work with the New South Wales Government and the Murray Darling Basin Authority to establish an appropriate floodplain management committee and to develop a floodplain management strategy for the Murray River. The strategy will define priority regions for the development of floodplain management plans, address ways of improving the management of all levees on the Murray River, and seek agreement in relation to improved approvals processes, levee heights and maintenance regimes. |
REC217-1843 | 24 - Govt responsibility | The state government implement the Victorian Floods Review recommendation 10 in relation to the datums used to describe river and stream heights. |
REC217-1822 | 24 - Govt responsibility | The state government will work with Grampians Wimmera Mallee Water and stakeholders to determine ongoing ownership and associated responsibilities for redundant channel infrastructure in the Wimmera and the Mallee. |
REC217-1839 | 24 - Govt responsibility | The state government accept recommendations 25 to 28, inclusive, of the Victorian Floods Review. |
REC217-1835 | 24 - Govt responsibility | Within the jurisdiction of Melbourne Water, it shares with local councils the responsibility to manage local drainage systems as outlined under the Water Act 1989 and the Local Government Act 1989 respectively: |
REC217-1827 | 24 - Govt responsibility | The role of flood risk management planning rests with CMAs and Melbourne Water (under the Water Act 1989), and is a shared responsibility with local government. Shared responsibilities for flood risk management planning and implementation will be consistently reflected in government policy. |
Rec-ID | Code | Recommendation |
---|---|---|
REC210-0720 | 24 - Govt responsibility | The Queensland Government should determine which of its agencies should take responsibility for the management of all existing and new abandoned mine sites in Queensland. |
REC210-0775 | 16 - Training and behaviour | The Department of Environment and Resource Management should conduct periodic dam safety information and education sessions with emergency management personnel including those from Emergency Management Queensland, local and district disaster management groups and local councils. Priority should be given to sessions if the Bureau of Meteorology forecasts a wet season with a greater than 50 per cent chance of above median rainfall. |
REC210-0748 | 24 - Govt responsibility | The Queensland Government should consider whether North Pine Dam should be operated as a flood mitigation dam when it considers possible operating strategies and full supply levels as part of the longer term review of the Manual of Operational Procedures for Flood Mitigation at North Pine Dam. |
REC210-0710 | 24 - Govt responsibility | The Department of Environment and Resource Management should assist mine operators in their applications for amended environmental authorities to ensure, as far as possible, that each environmental authority contains a tailored version of Table 4 of the model conditions. The Department of Environment and Resource Management should provide to mining companies its monitoring data and its suggested values for Table 4 on the basis of an assessment of the catchment which takes into account the cumulative effect of different operators’ releases. |
REC210-0761 | 2 - Emergency powers | The Queensland Government should consider whether to empower Seqwater, through the flood operations centre, to direct CS Energy to stop or delay releases from Splityard Creek Dam where a flood event is declared under the Manual of Operational Procedures for Flood Mitigation at Wivenhoe Dam and Somerset Dam. |
REC210-0718 | 24 - Govt responsibility | The Queensland Government should make public the procedural guide used by Department of Environment and Resource Management officers to decide whether to grant an emergency direction. |
REC210-0774 | 24 - Govt responsibility | The Department of Environment and Resource Management and Emergency Management Queensland should ensure that each has copies of current emergency action plans for all dams in Queensland. |
REC210-0745 | 24 - Govt responsibility | The Queensland Government should ensure that all flood mitigation manuals include the requirement that those operating the dam during flood events hold current registrations as professional engineers. |
REC210-0681 | 19 - Offences | Councils and distributor-retailers should agree to protocols for the exchange of information about suspected illegal connections, the steps being taken to investigate them or the basis for concluding that no investigation is required, and the results of any investigations or enforcement actions. |
REC210-0707 | 24 - Govt responsibility | The Department of Environment and Resource Management should conduct risk assessments in time for site inspections, and the implementation of solutions to problems identified at inspections, to take place before 1 November of each year. |
REC210-0754 | 2 - Emergency powers | As part of the longer term review of the Manual of Operational Procedures for Flood Mitigation at Wivenhoe Dam and Somerset Dam the Queensland Government should consider whether the dam operators should be able to extend the drawdown of the lake beyond seven days in order to reduce downstream bank slumping |
REC210-0716 | 24 - Govt responsibility | The Queensland Government should make public the procedural guide used by Department of Environment and Resource Management officers to decide whether to grant a transitional environmental program. |
REC210-0771 | 24 - Govt responsibility | The Queensland Government should, in consultation with the Department of Environment and Resource Management and Emergency Management Queensland, determine which agency is appropriate to review and approve emergency action plans for referable dams. |
REC210-0742 | 24 - Govt responsibility | The Queensland Government should ensure that, when it considers options for the operational strategies to |
REC210-0620 | 24 - Govt responsibility | The Queensland Government should determine whether existing guidelines are sufficient for councils to understand best practice in the performance of flood studies and the production of flood maps. If a lack of current guidelines is identified, the government should create and circulate guidance material for councils. |
REC210-0706 | 24 - Govt responsibility | The Department of Environment and Resource Management should prepare a list of relevant considerations to be taken into account in performing a risk assessment to decide which sites to inspect. Bureau of Meteorology forecasts should be one consideration. |
REC210-0753 | 24 - Govt responsibility | The Department of Environment and Resource Management should prepare formal work procedures for the review of flood event reports created under emergency action plans and flood mitigation manuals. These should include procedures for: • making enquiries with the owners of referable dams that have catchments that have been subject to heavy rainfall (or where there is other reason to believe the emergency action plan has been triggered) as to whether the emergency action plans have been triggered • reminding owners of referable dams that have had emergency action plans triggered of their obligation to submit a flood event report • upon receipt of a flood event report, reviewing it, identifying any dam safety or other issues or areas where insufficient detail has been provided, raising those matters with the dam owner or other affected party and identifying appropriate remedial steps 28 Queensland Floods Commission of Inquiry | Final Report Complete list of Final Report recommendations • raising any issues identified in the report that are beyond the expertise of the Department of Environment and Resource Management, or are likely to be of particular interest to another body, with the appropriate body • keeping a record of the process and results of the review of the flood event report • fixing an appropriate timeline for the completion of each of the above steps: the time required may depend on specific circumstances, but must allow for any potential safety issues to be identified and remedied efficiently. |
REC210-0715 | 24 - Govt responsibility | The Queensland Government should prepare a procedural guide for officers deciding whether to grant a relaxation of environmental authority conditions, by transitional environmental program or otherwise, with guidance as to: • the meaning of each criterion • examples of the types of things that may be relevant to each criterion • the priority, if any, to be afforded to different criteria. |
REC210-0766 | 16 - Training and behaviour | Wide Bay Water should, in addition to its usual wet season preparations and maintenance, undertake the following activities in advance of each wet season: Queensland Floods Commission of Inquiry | Final Report 29 Complete list of Final Report recommendations • conduct training for personnel on dam operation, including contingency plans for the situation in which one or more of the gates is inoperable • hold meetings of key personnel of Wide Bay Water involved in the operation of the dam during floods, which: – in addition to any other matters, inform staff about the current status of the gates, dam operation strategies and contingency plans for the situation in which one or more of the gates is inoperable – are recorded in minutes which document the information provided and are made available to all operational staff. |
REC210-0734 | 16 - Training and behaviour | Emergency Management Queensland should simplify the process by which SES members gain recognition for prior qualifications so that unnecessary duplication of training can be avoided. |
REC210-0619 | 24 - Govt responsibility | In the event that the review does not adequately account for Queensland conditions, the Queensland Government should produce a document that provides appropriate guidelines for floodplain management in the Queensland context. |
REC210-0752 | 24 - Govt responsibility | Prior to approving a flood mitigation manual, the Queensland Government should be satisfied that its terms are expressed in a manner that allows a determination of compliance with it to be made by reference to objective standards. |
REC210-0713 | 24 - Govt responsibility | The Queensland Government should refine the criteria which must be considered in assessment of applications for relaxation of environmental authority conditions, by transitional environmental program or otherwise, in response to flood. |
REC210-0765 | 24 - Govt responsibility | As part of the longer term review of the Manual of Operational Procedures for Flood Mitigation at Wivenhoe Dam and Somerset Dam, the Queensland Government should consider the impact of possible upgrades of bridges downstream of Wivenhoe Dam on different operating strategies for the dam. |
REC210-0727 | 2 - Emergency powers | The Disaster Management Act 2003 should be amended to give the chief executive of the department administering the Act (or his or her delegate) the authority to appoint an officer of Emergency Management Queensland to direct SES operations in extraordinary circumstances |
REC210-0618 | 24 - Govt responsibility | The Queensland Government should endeavour to ensure that Queensland conditions are appropriately considered in the National Flood Risk Advisory Group’s review of best practice principles. |
REC210-0751 | 24 - Govt responsibility | The Queensland Government should continue to assess and review the adequacy of work procedures DS 5.1 and 5.3, having regard to the need for flood mitigation manuals to reflect the will of the executive. |
REC210-0711 | 24 - Govt responsibility | Unless the Department of Environment and Resource Management has decided not to permit discharges, it should assist each mine operator in its application for an environmental authority to ensure, as far as possible, that each authority includes provisions for discharges during times of heavy rainfall and flood. |
REC210-0764 | 24 - Govt responsibility | The Department of Transport and Main Roads, in conjunction with Brisbane City Council and Somerset Regional Council, should investigate options for the upgrade of Brisbane River crossings between Wivenhoe Dam and Colleges Crossing and undertake a cost-benefit analysis of these to determine the outcome which best serves the public interest. |
Rec-ID | Code | Recommendation |
---|---|---|
REC199-0481 | 24 - Govt responsibility | the state (consistent with recommendation 46) develop a model for determining the capability and capacity of departments and agencies with roles and responsibilities in large scale or protracted emergencies. The issues of capability and capacity should be addressed at all levels of emergency management planning. |
REC199-0406 | 24 - Govt responsibility | the state expand the Regional Water Monitoring Partnerships model to include all flood warning gauges. |
REC199-0455 | 24 - Govt responsibility | the state conduct an ‘all hazards’ needs analysis to determine requirements for level 3 Incident Control Centres with a focus on ‘all hazards’ and multi-agency capability. Following this analysis, the state take steps to ensure the availability of sufficient and functional level 3 Incident Control Centres across the state with an ‘all hazards’ and multi-agency capability |
REC199-0475 | 16 - Training and behaviour | the Department of Planning and Community Development review the volunteer register and examine additional options to support councils in volunteer management, including the development of tools and staffing support. |
REC199-0400 | 24 - Govt responsibility | The state take the necessary measures to clarify roles, responsibilities and cost-sharing arrangements for flood warning systems, including tasking state and regional bodies to be responsible for the flood warning system. This will require engaging with the commonwealth to amend the 2001 arrangements, updating the 1998 floodplain management strategy accordingly and continuing to support commonwealth initiatives designed to improve flood mapping standards and associated issues. |
REC199-0448 | 16 - Training and behaviour | the state ensure that sector wide familiarity and understanding of the various systems for incident management is developed and maintained. Primarily, this should be achieved through multi-agency emergency management training and exercising involving usage of the various agency incident management systems. |
REC199-0466 | 24 - Govt responsibility | the Departments of Health and Human Services finalise the definition of ‘vulnerable person’ and the list of facility types where vulnerable people are located and ensure that the definition and associated policy(ies) are applicable across ‘all hazards’. |
REC199-0444 | 2 - Emergency powers | the state, as a matter of urgency, develop a multi-agency Incident Control Team capability to be readily available for statewide deployment to establish incident control or to relieve functioning control structures. |
REC199-0465 | 24 - Govt responsibility | the state undertake major reform of Victoria’s emergency management arrangements to bring about an effective ‘all hazards, all agencies’ approach, incorporating: • clarity of command and control in all emergencies • common operating platforms, including communications and information technology • interoperability between all agencies • regular joint training and exercising by all agencies • the development and implementation of performance standards for each emergency management agency • the development and maintenance of effective planning arrangements at all levels of emergency management • a meaningful monitoring and audit regime for designated standards and planning requirements; and • an effective accountability mechanism to support the maintenance of legislative and other agency obligations. |
REC199-0415 | 16 - Training and behaviour | the state ensure that all personnel who are likely to become involved in incident management teams for floods receive basic flood awareness training prior to such involvement. |
REC199-0463 | 16 - Training and behaviour | the state: • ensure an appropriate regime of regular emergency management training and exercising is introduced. This must be ‘all hazards’ and multi-agency focused and include all relevant stakeholders • designate an accountable officer to hold ongoing responsibility for conducting such exercises; and • designate the Emergency Services Commissioner as holding ongoing responsibility for auditing and reviewing this training and exercising. |
REC199-0414 | 16 - Training and behaviour | the state ensure that all personnel who, because of their particular flood expertise, are likely to be potential participants in an Incident Control Centre are familiar with the requirements of the Australasian Inter-service Incident Management System structure |
REC199-0462 | 16 - Training and behaviour | the state introduce a joint emergency management leadership training program that will deliver critical core competencies for all levels of management of major emergencies. Future appointments to senior operational emergency management positions should require successful accreditation at the appropriate level. |
Rec-ID | Code | Recommendation |
---|---|---|
REC189-2907 | 29 - Operational Health and Safety | a) For the purposes of designing and implementing its regulatory activities, National Offshore Petroleum Safety Authority (NOPSA) should continue to identify priority hazards and risks and their underlying causes, in consultation with the NOPSA Advisory Board and stakeholders (see Theme 9, Stakeholder engagement). |
REC189-2912 | 29 - Operational Health and Safety | The review team recommend that the safety case system be strengthened by including provisions for a design notification scheme along the lines of that under the British Offshore Safety Case Regulations. |
REC189-2911 | 29 - Operational Health and Safety | The review team recommend that: |
Rec-ID | Code | Recommendation |
---|---|---|
REC169-2992 | 24 - Govt responsibility | The Department of Premier and Cabinet should identify risks arising from the joined-up nature of the approach to protecting essential services and critical infrastructure, and to assist departments and agencies to develop associated risk management arrangements at the whole-of-government level. |
REC169-2991 | 24 - Govt responsibility | The Department of Premier and Cabinet should provide definitive guidance on identifying essential services for declaration to better inform relevant departments in discharging their responsibilities under Part 6 of the Act. |
REC169-2990 | 24 - Govt responsibility | The Department of Premier and Cabinet should clarify the roles and responsibilities of departments and agencies under Part 6 of the Act and CIP framework to reduce confusion and gaps. |
REC169-2995 | 24 - Govt responsibility | The Department of Premier and Cabinet, in consultation with Victoria Police, should develop clear guidance to distinguish between declared essential services and critical infrastructure to assist departments, Victoria Police and industry in implementing Part 6 of the Act and the CIP framework more effectively. |
REC169-2994 | 24 - Govt responsibility | Representatives of lead departments should obtain necessary security clearances so appropriate officers can access information relevant to their sectors. |
REC169-2993 | 24 - Govt responsibility | The Department of Premier and Cabinet should clarify the requirements in relation to establishing Security and Continuity Networks in designated sectors, so that there is a shared understanding of those requirements. |
Rec-ID | Code | Recommendation |
---|---|---|
REC164-0075 | 16 - Training and behaviour | SERCon consider development of an education program for other government and non-government agencies (with |
Rec-ID | Code | Recommendation |
---|---|---|
REC158-3454 | 24 - Govt responsibility | That the Department of Transport ensures that key stakeholders are engaged during the implementation of the approved Review recommendations. |
REC158-3448 | 24 - Govt responsibility | That the Director of Marine Safety works with the Australian Maritime Safety Authority to ensure that State and port emergency arrangements interface appropriately with the National Maritime Emergency Response Arrangements. |
REC158-3433 | 24 - Govt responsibility | That Harbour Masters are employed by a government body and remain geographically located at the port. |
Rec-ID | Code | Recommendation |
---|---|---|
REC149-3136 | 16 - Training and behaviour | There is a need for industry in consultation with NOPSA to establish a priority programme of accredited education modules in the Safety Case regime targeting stakeholders in the regime at their respective levels to improve the understanding of the Safety Case and correspondent responsibilities. |
REC149-3135 | 29 - Operational Health and Safety | The initial acceptance of a new facility Safety Case should be in conjunction with inspection of a facility upon commencement of operations. |
REC149-3147 | 29 - Operational Health and Safety | As all stakeholders have responsibility for safe outcomes, decisions regarding target subjects for safety promotion need to have the support of all stakeholders including NOPSA and the workforce. Industry, which ultimately has the responsibility for managing risk as well as funding the promotion, should take a leadership role in implementation. |
REC149-3128 | 29 - Operational Health and Safety | National Offshore Petroleum Safety Authority (NOPSA) should develop guidelines in consultation with stakeholders to provide clarity and consistency to the process which ultimately will result in better safety outcomes. |
REC149-3144 | 29 - Operational Health and Safety | The Safety Case proponent should be allowed some flexibility to involve appropriate experience matched with the proposed workforce competencies to enable the Safety Case to be developed with value adding processes. Subsequent to the hiring of the workforce Final Government Response Offshore Petroleum Safety Regulation Inquiry and 2008 Review of NOPSA Operational Activities and preferably before the commencement of operations a review of the Safety Case should take place with the new workforce to ensure they understand the accepted Safety Case, its risks and Safety Management Plan. |
REC149-3142 | 19 - Offences | NOPSA should use encouragement as the primary tool of enforcing compliance provided willingness to improve is exhibited by the players. |
REC149-3137 | 16 - Training and behaviour | As professional competency is one of the key pillars of any Safety Case, commitment to training for current and future needs remains a fundamental requirement for achieving best practice outcomes in safety. Industry should be encouraged to build on its training commitment now being made to achieve a competent and fully accredited workforce over the next five years. |
Rec-ID | Code | Recommendation |
---|---|---|
REC137-3532 | 16 - Training and behaviour | I recommend that CASA reconsider the introduction of measures to ensure the efficiency of training and checking organisations for air transport operations. I recommend that this include the way in which particular training needs of an air operator’s flight crew are to be identified (including recurrent training and CRM training) and how those needs are to be met by approved or certified training and checking organisations. |
REC137-3530 | 16 - Training and behaviour | I recommend that Civil Aviation Safety Authority (CASA) expedite the introduction of mandatory crew resource management training. |
Rec-ID | Code | Recommendation |
---|---|---|
REC121-3747 | 29 - Operational Health and Safety | All trains should have windows available through which passengers can escape. |
REC121-3675 | 16 - Training and behaviour | All rail employees should be trained by their employer to commence any emergency communication with the words “Emergency, emergency, emergency”, thereafter to identify themselves, the train, its location, what has occurred, the approximate passenger load and whether death or injuries have occurred. |
REC121-3720 | 24 - Govt responsibility | The New South Wales Government should make the necessary arrangements with the Australian Government, including any necessary legislation, for the Australian Transport Safety Bureau (ATSB) to have the power to investigate all rail accidents occurring on the New South Wales rail network the investigation of which may advance the knowledge of the causes of rail accidents in Australia. |
REC121-3755 | 29 - Operational Health and Safety | The RailCorp Board should require a full review of the safety competence of RailCorp managers to ensure that each has the ability to bring about those safety reforms recommended in this report which are applicable to his or her position. |
REC121-3702 | 29 - Operational Health and Safety | Random alcohol testing should be continued. |
REC121-3734 | 29 - Operational Health and Safety | RailCorp should integrate its management of occupational health and safety into its overall safety management. |
REC121-3714 | 16 - Training and behaviour | RailCorp should use its simulators in an interactive manner. |
REC121-3740 | 29 - Operational Health and Safety | The internal passenger emergency door release should be fitted with a facility which prevents it from operating unless the train is stationary. |
REC121-3746 | 16 - Training and behaviour | All emergency services personnel should be trained in the location and operation of emergency door release mechanisms on all rail cars. |
REC121-3672 | 16 - Training and behaviour | All emergency response personnel should be specifically trained in the features of railways which are relevant to their work, such as the location and means of operation of all emergency door releases on trains, the location and use of signal telephones, the methods by which electrical power can be isolated and the means by which they can readily identify and obtain information from the on-site rail commander. |
REC121-3719 | 16 - Training and behaviour | The position of team leader should be created by RailCorp to be responsible for a group of approximately 30 train drivers, with responsibility to ensure that each train driver’s training needs are being met and that any safety concerns of train drivers are being properly addressed. The team leaders are to have direct access to the Chief Executive of RailCorp if any safety concerns they have are not addressed. |
REC121-3754 | 29 - Operational Health and Safety | The RailCorp Board should ensure that RailCorp has an adequate and integrated safety management system, including adequate systems for risk assessment, clearly defined safety responsibilities and accountabilities for persons holding management positions, and specific performance criteria against which evaluations can be made of safety performance and accountability for safety performance of all managers. |
REC121-3682 | 29 - Operational Health and Safety | All new rolling stock should be designed to be compatible with at least level 2 automatic train protection discussed in chapter 7 of this report. |
REC121-3733 | 29 - Operational Health and Safety | RailCorp’s approach to occupational health and safety should be proactive and involve the systematic analysis of all current hazards, risks and controls and an assessment of their adequacy to reduce the risk of injury to, or death of, employees to an acceptable level. |
REC121-3767 | 24 - Govt responsibility | All accredited rail organisations should be required to re-apply every three years to ITSRR for accreditation. |
REC121-3711 | 29 - Operational Health and Safety | The ITSRR should establish an electronic document control system to enable effective and reliable information to be gathered for monitoring the safety of the New South Wales rail system. |
REC121-3739 | 29 - Operational Health and Safety | All passenger trains operating in New South Wales must be fitted with external emergency door releases which do not require any special key or other equipment to operate. |
REC121-3670 | 16 - Training and behaviour | The RailCorp emergency response plan should be provided to all emergency response agencies. The officers of each emergency service should be trained in any rail specific features of the plan, so as to better ensure inter-agency co-ordination in the circumstances of an emergency. |
REC121-3718 | 16 - Training and behaviour | Training should be based upon a needs analysis, to determine what skills a particular person will require to carry out the tasks of any position safely and efficiently, and instruction and practice, to acquire and demonstrate those skills. |
REC121-3744 | 16 - Training and behaviour | All RailCorp operational personnel should be trained in the location and operation of external emergency door release mechanisms. |
REC121-3751 | 16 - Training and behaviour | RailCorp should make it a condition of employment that all level 2 managers have or obtain a formal qualification in system safety management. |
REC121-3681 | 29 - Operational Health and Safety | RailCorp should progressively implement, within a reasonable time, level 2 automatic train protection with the features identified in chapter 8 of this report. |
REC121-3732 | 29 - Operational Health and Safety | If ITSRR accepts such a plan as an appropriate response to the existing weak safety culture, ITSRR should approve it and monitor the effectiveness of the plan. |
REC121-3764 | 29 - Operational Health and Safety | The ITSRR should not grant accreditation to any rail organisation unless it has an integrated safety management system in accordance with any safety management system regulation and the guidelines published from time to time by ITSRR. |
REC121-3709 | 29 - Operational Health and Safety | RailCorp should provide access to electronic versions of safety documentation for all operational staff at their workplace. |
REC121-3738 | 29 - Operational Health and Safety | All passenger trains must be fitted with an internal passenger emergency door release. |
REC121-3669 | 16 - Training and behaviour | All operational rail staff should be trained by RailCorp in the action check list relevant to each. |
REC121-3717 | 16 - Training and behaviour | RailCorp must establish a task analysis for particular categories of employees, to identify the specific skills and responsibility of those employees or groups of employees, and thereafter undertake a training needs analysis, to develop the skills required in particular areas. |
REC121-3743 | 29 - Operational Health and Safety | All passenger trains operating in New South Wales must have the external emergency door release clearly marked with the words “Emergency Door Release”. |
REC121-3749 | 29 - Operational Health and Safety | All new rolling stock must be designed with an area of the roof through which emergency services personnel can access a rail car without encountering wiring or other equipment. That access point must be clearly marked with words such as “emergency services cut here”. |
REC121-3680 | 29 - Operational Health and Safety | All trains must be fitted with a minimum of two independent engineering defences to minimise the risk of derailment or collision in the event of train driver incapacitation. |
REC121-3731 | 29 - Operational Health and Safety | RailCorp should develop a plan to be submitted to ITSRR to address the deficiencies in the safety culture of RailCorp, including: |
REC121-3759 | 29 - Operational Health and Safety | A Safety Reform Program Director (hereafter referred to as SRPD), reporting directly to the Chief Executive of RailCorp, should be retained to manage, as head of a Safety Reform Program Office, any safety reform program being undertaken by RailCorp. The SRPD should work with the Chief Executive and senior management to ensure the implementation of an integrated safety management system and the cultural change required. The SRPD must have qualifications suitable for recognition by the Australian Institute of Project Management as a master program director. He or she should report to and be under the control of the Chief Executive, to ensure that the accountability of the Chief Executive is not reduced. The SRPD should co-ordinate and integrate any existing rail safety reform programs and, in consultation with and with the authority of the Chief Executive he or she should: |
REC121-3707 | 29 - Operational Health and Safety | The safety document management system should provide for the distribution of electronic versions of safety documentation to relevant staff. |
REC121-3737 | 29 - Operational Health and Safety | There must be a minimum of two independent methods of self-initiated emergency escape for passengers from all trains at all times. |
REC121-3654 | 16 - Training and behaviour | All train guards should be trained by RailCorp in the use of the Metronet radio and instructed to use it in any emergency. |
REC121-3716 | 16 - Training and behaviour | Train driver and guard training should encourage teamwork and discourage authority gradients. |
REC121-3742 | 19 - Offences | The risk of abuse of internal passenger emergency door releases should be further reduced by introducing significant penalties for any improper use of such an emergency facility. It should be a criminal offence for anyone to use or tamper improperly with an emergency escape facility in a train. |
REC121-3748 | 29 - Operational Health and Safety | All new rail cars must have appropriate signage and lighting identifying escape routes in the case of emergency. |
REC121-3677 | 16 - Training and behaviour | A training centre for emergency services personnel should be established by RailCorp. The emergency services personnel should be required to undertake training at such a centre, which should be equipped with features replicating railway infrastructure and rolling stock. |
REC121-3721 | 24 - Govt responsibility | The ITSRR should ensure that OTSI, as a division of ITSRR, co-operates and assists the ATSB in the conduct of any independent investigation by the ATSB of any rail accident or incident in New South Wales. |
REC121-3756 | 16 - Training and behaviour | RailCorp should ensure that where the safety competency of any manager is deficient such manager is required to undertake professional development courses to raise his or her safety competency level to an adequate standard. |
REC121-3706 | 29 - Operational Health and Safety | RailCorp should establish a comprehensive safety document management system. |
REC121-3735 | 29 - Operational Health and Safety | Risk assessments of occupational health and safety issues by RailCorp should include an analysis of broader public safety risks and not be confined to narrow occupational health and safety issues. |
REC121-3650 | 16 - Training and behaviour | Staff at the Rail Management Centre (RMC) should receive training from RailCorp to enable them to quickly and accurately assess that an emergency has occurred and to provide precise and reliable information to emergency response personnel about the location of the emergency, the available access to the site and the resources necessary. |
REC121-3715 | 16 - Training and behaviour | RailCorp should use its simulators to train drivers and guards in methods of dealing with degraded operations on the rail network. |
REC121-3741 | 29 - Operational Health and Safety | The operation of the train doors should have an override facility whereby the train driver or the guard can override an internal passenger emergency door release system if the door release is interfered with when there is no emergency. There should be an alarm, together with an intercom, in the train guard’s compartment so that, if a passenger attempts to initiate an emergency door release, there is an appropriate delay during which time an alarm sounds in the train guard’s compartment and the guard can then, after first attempting to speak via the intercom to the person concerned, if necessary, override the door release, and make an appropriate announcement over the intercom system in the train. |
Rec-ID | Code | Recommendation |
---|---|---|
REC008-3984 | 16 - Training and behaviour | The Commission recommends that the live parts of resistances should be fixed so that no unprotected combustible material is within 6ins of the frames or cases containing them or within 24ins measured vertically above. |
REC008-3990 | 16 - Training and behaviour | The Commission recommends that more than one means of exit should be provided in every mine from every level of it to the surface; and that the miners should be kept informed where they are situated. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |