Inquiry Search
Rec-ID | Code | Recommendation |
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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. |
REC325-4324 | 32 - Doctrine, standards, and reform | The Inspector-General of Emergency Management recommends Queensland Fire and Emergency Services review the tasking protocols used to manage State Emergency Service (SES) tasks undertaken in the response phase of a disaster to enable more complete recording of details for all ‘jobs of opportunity’ (including the personal details of those assisted and/or rescued) to enable better coordination of tasks and reflect outcomes of activities by 1 November 2023. |
REC325-4325 | 32 - Doctrine, standards, and reform | The Inspector-General of Emergency Management recommends Queensland Fire and Emergency Services review and implement State Emergency Service (SES) protocol by 1 November 2023 outlining procedures to be undertaken to ensure persons uplifted from places of immediate danger or risk are transferred to a place of safety. |
REC325-4334 | 32 - Doctrine, standards, and reform | The Inspector-General of Emergency Management recommends Queensland Fire and Emergency Services develop and publish an operationally based quick reference guide that complements the training offered (as per Recommendation 5) by 1 November 2022. The guide will identify key and critical aspects of the Emergency Alert system in relation to the development, composition, request for and authorising of Emergency Alerts and will include a template and an example of ‘good’ messaging using concise, minimal language and Clear Explicit Translatable Language (CETL). |
Rec-ID | Code | Recommendation |
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REC324-4318 | 12 - EM agency and authority | Permanent SEOCON: That, to improve NSW’s ability to prepare and respond to floods and other disasters, Government establish a new Deputy Commissioner of NSW Police Force to take on permanently the SEOCON role. This role, in addition to current SEOCON functions, would be responsible for: |
REC324-4309 | 12 - EM agency and authority | SES and RFS back-office merger: That, to help protect life and property across NSW in storm and flood events, and to improve resourcing and NSW State Emergency Service (SES) frontline capability, Government implement, before the next storm season, a merger of the SES and NSW Rural Fire Services (RFS) back-office and corporate service functions, while maintaining their separate legislative identity, brand, uniform and volunteer membership. This ‘joined-up’ RFS/SES corporate support structure would be under the command of the RFS given its corporate and operational maturity and would be responsible for: |
REC324-4320 | 12 - EM agency and authority | Knowledge resources to support flood management: That, to provide more accurate and complete data for flood threat identification, warning and modelling systems, Government through the proposed new NSW Reconstruction Authority (NSWRA) work with the Australian Government to: |
REC324-4311 | 33 - Relief and recovery | Transition initiatives: That, to improve the community’s experience during immediate disaster recovery phase, Government through the SEOCON, NSWRA, DCS/Service NSW and other state agencies as required provide greater support (financial, health [including mental health], temporary accommodation, administrative and other support services) to affected communities by: |
REC324-4297 | 33 - Relief and recovery | Housing , especially social housing: That, to ease housing stress in flood prone areas and ensure new development is resilient and community-centred, Government pursue a multi-pronged, decadal strategy through: |
REC324-4315 | 36 - Volunteers | The Community First Responders Program: That, to better coordinate community efforts to save life and property during a disaster, Government create a ‘Community First Responders Program’, funding appropriate community equipment and training, particularly in high-risk catchments along the east coast of NSW. This training would be delivered by combat and/or other appropriate government agencies. This program could support and empower community led initiatives such as disaster response, evacuation centres and the provision of services such as psychological first aid. |
REC324-4298 | 37 - Funding | Housing and development funding options: That, to empower vulnerable people and communities to avoid significant impacts from flood as well as drive broader investment in adaptation, Government through NSWRA: |
REC324-4316 | 12 - EM agency and authority | Resilience NSW and recovery: That, in order to enhance NSW disaster preparedness, response and recovery, and meet the needs of the people of NSW prior to, during and after a disaster, and provide clarity on agency roles and responsibilities, Resilience NSW be reshaped to ‘Recovery NSW’. The new agency will be more streamlined and agile to drive recovery in the first 100 days post disaster. To achieve this, Resilience NSW’s functions should be reallocated as follows: |
REC324-4301 | 32 - Doctrine, standards, and reform | Floodplains as assets: That, to establish the capacity and maximise the economic, social and environmental potential and consequently unlock the value of NSW floodplains, Government adopt the following guiding principles for floodplain management: |
REC324-4317 | 32 - Doctrine, standards, and reform | Flood rescue capability: That, to help improve the protection of life across NSW in flood events: |
REC324-4302 | 32 - Doctrine, standards, and reform | Disaster adaptation plans for all towns: That, to establish realistic expectations of safe spaces to live and deliver much needed housing quickly, Government through NSWRA working with local government: |
Rec-ID | Code | Recommendation | |
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REC323-4279 | 37 - Funding |
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REC323-4270 | 37 - Funding | That the NSW Government consider entering into a service agreement with an organisation that has the resources and capacity to manage donations and activate quickly during natural disasters. |
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REC323-4281 | 37 - Funding | That the NSW Government allocate funding to the improvement of the Pitt Town Evacuation Route and other key possible evacuation routes in Sydney's northwest. |
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REC323-4280 | 37 - Funding | That the NSW Government work with local governments to identify alternative routes to vulnerable roads, and that the NSW and Australian Governments fund the construction of these important routes to improve evacuation and access options in times of disaster. |
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REC323-4271 | 33 - Relief and recovery | That Service NSW establish teams of assessors that can be on the ground to assess and approve grant applications. |
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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. |
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REC323-4272 | 37 - Funding | That the NSW Government ensure that flood affected individuals can continue to access financial assistance for as long as there is demonstrated need. |
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REC323-4261 | 37 - Funding | That the NSW Government advocate through the National Cabinet to widen eligibility under the Disaster Funding Recovery Arrangements to allow local councils to build back better. |
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REC323-4289 | 33 - Relief and recovery | That the NSW Government ensure that all emergency and recovery plans, including state plans, local emergency management plans and functional area plans, are reviewed and updated regularly and provide clarity on the role of non-government partners. |
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REC323-4273 | 33 - Relief and recovery | That the NSW Government overhaul the way in which it conducts its grants process as it frustrated applicants and further traumatised them by repeatedly re-interviewing them and making them prove that they were flooded. |
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REC323-4262 | 33 - Relief and recovery | That the NSW Government provide an increased level of targeted support to flood affected communities contending with widespread mould. |
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REC323-4291 | 12 - EM agency and authority | That the NSW Government consider abolishing Resilience NSW if it is unable to ensure: |
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REC323-4277 | 33 - Relief and recovery | That the NSW Government develop a more proactive, rapid response to manage animal welfare following natural disasters which includes improved collaboration and communication with local veterinarians and animal welfare organisations. |
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REC323-4269 | 33 - Relief and recovery | That the NSW Government address the mental health needs of local communities following the February-March 2022 floods by: • embedding within state emergency and recovery plans a strategy that provides surge capacity for mental health and social workers by: • prioritising funding for community groups that are currently providing social and mental health support to their local communities • ensuring all flood-impacted communities receive the mental health support they need to fully recover. |
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REC323-4292 | 12 - EM agency and authority | That the NSW Government consider a restructure of the NSW State Emergency Service with consideration to: realigning the focus of the organisation to harness local knowledge and networks; coordinating more closely with other rescue agencies to bolster its capacity to respond; and increasing salaried staff and resources, and driving volunteer recruitment. |
Rec-ID | Code | Recommendation |
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REC306-2423 | 37 - Funding | We recommend that, in the absence of stand-alone catchment management authorities, the Department of Infrastructure, Local Government and Planning as a matter of priority, establish what funding is reasonably required and complete all elements of the Brisbane River Catchment Flood Studies. |
Rec-ID | Code | Recommendation |
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REC002-4005 | 40 - Equipment and consumables | Where safety-lamps are used the lock should be of such a character as to prevent any workman opening it. If the "Protector" type of lamp be employed the necessity for a lock is the less necessary, as the unscrewing of this type of lamp extinguishes the light. |
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. |
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. |
REC002-4010 | 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. |
REC002-4003 | 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. |
REC002-4009 | 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. |
REC002-4001 | 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. |
REC002-4008 | 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 |
REC002-4007 | 40 - Equipment and consumables | A measure of safety may be found in the use of high explosives combined with wet tamping, or, still better, water cartridges, instead of powder under any of its modifications. Encouragement ought also to be given to the use of patent multiple wedges and applicances of a like nature, for supplanting the use of explosives. Under all circumstances and conditions some provision should be adopted for compelling workmen to thoroughly undercut, shear, or nick, and generally to work the coal as directed by the Manager. |
Rec-ID | Code | Recommendation |
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REC297-1260 | 32 - Doctrine, standards, and reform | That DPIPWE clarifies responsibility for river restoration and riparian management and, having done so, communicates this to councils, landowners and other owners of relevant infrastructure. |
REC297-1257 | 35 - Business and Industry in relation to industry | That in the event that Hydro Tasmania decides to start cloud seeding again, water managers, represented by DPIPWE, work with Hydro Tasmania to ensure appropriate, best practice application of the guidelines issued by the Agricultural and Resource Management Council of Australia and New Zealand. |
REC297-1269 | 35 - Business and Industry in relation to industry | That Government engages with non-government organisations that may provide services during emergency events to clarify the terms and conditions for support through a written arrangement (MOU or similar). |
REC297-1254 | 13 - Mapping and data quality | That Government: |
REC297-1265 | 13 - Mapping and data quality | That BoM and the Flood Warning Consultative Committee, in consultation with gauge owners, review flood gauges and develop a program to update data used to support hydrologic modelling. This should include reviewing gauge maintenance before and after floods. |
REC297-1253 | 13 - Mapping and data quality | That agencies undertaking flood studies adopt a standardised approach, based on Australia Handbook 7, maintain public ownership of underlying data sets to support future modelling, and ensure open access to these studies. |
REC297-1263 | 13 - Mapping and data quality | Subject to funding, that the Flood Warning Consultative Committee investigates the hydrological matters and advice received during this Review and detailed in this Report in Sections 4.1.9 and 4.1.11. |
REC297-1252 | 13 - Mapping and data quality | That SES uploads current flood studies and plans to the Common Operating Platform as a flood plan layer and that councils, subject to resolving licence restrictions, arrange to have appropriate access. |
REC297-1262 | 13 - Mapping and data quality | That the Flood Warning Consultative Committee considers the merits of delineating the Ouse River as a separate catchment from the Derwent River Basin. |
Rec-ID | Code | Recommendation |
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REC292-2364 | 32 - Doctrine, standards, and reform | I recommend that the Australia New Zealand Policing Advisory Agency and the Australia–New Zealand Counter-Terrorism Committee review the Australia–New Zealand Guidelines for Deployment of Police to High-Risk Situations and the Police Tactical Group Operations Manual to ensure that those documents give commanders guidance on how to assess imminent or immediate risk. |
REC292-2346 | 12 - EM agency and authority | I recommend that the New South Wales Police Force investigate the development of an integrated intelligence system that allows selected officers secure access to all information platforms and to record and share operational decisions. |
REC292-2352 | 16 - Training and behaviour | The New South Wales Police Force should consider drawing on international experience when reviewing its negotiator training |
REC292-2371 | 32 - Doctrine, standards, and reform | I recommend that the New South Wales Police Force develop a comprehensive policy and set of procedures in relation to family liaison capability for high-risk situations. Those policies and procedures should ensure that: The capability is scalable depending on the nature of the incident, An appropriately senior officer is responsible for overseeing the liaison process, He or she should have direct access to officers in the Police Forward Command Post for the purpose of conveying and receiving information in a timely manner, A dedicated family liaison officer (or officers) is assigned to the family of each victim and given responsibility for managing the needs of that family Officers are given guidance on communi-cating with families, including the appropriate frequency and content of briefings both during and after an incident, Officers are advised of the proper process for gathering and disseminating intelligence from family members. |
REC292-2357 | 12 - EM agency and authority | I recommend that the New South Wales Police Force review its policy of requiring negotiators to relinquish that role when they are promoted to commissioned officer rank |
REC292-2376 | 32 - Doctrine, standards, and reform | I recommend that the Commonwealth Attorney-General, in consultation with states and territories, review existing arrangements for information sharing between federal, state and territory agencies during terrorist events to determine whether those arrangements (and the guidance provided to officers in respect of them) adequately facilitate the efficient identification and transfer of pertinent information between agencies. |
REC292-2340 | 32 - Doctrine, standards, and reform | I recommend that the Director of Public Prosecutions develop a policy for overseeing lawyers' exercise of the discretion not to oppose bail that takes into account the seriousness of the offences involved; the experience of the prosecutor appearing; and the views of the police officer in charge of the investigation, insofar as those views are based on facts relevant to bail determinations. |
REC292-2363 | 32 - Doctrine, standards, and reform | I recommend that New South Wales Police Force policies be amended to require documentation of triggers for Emer-gency Actions. Consideration should be given to stipulating that “contingency triggers”—specific events that will require initiation of an EA or some other agreed response—should also be recorded. |
REC292-2345 | 12 - EM agency and authority | I recommend that the New South Wales Police Force establish procedures and the technical capability to ensure that phone calls from hostages in sieges or the victims of other ongoing high-risk situations are expeditiously transferred to officers involved in responding to the incident. |
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. |
REC292-2368 | 32 - Doctrine, standards, and reform | I recommend that the New South Wales Police Force develop a policy regarding the use of distraction devices and the training of officers in their use. |
REC292-2356 | 12 - EM agency and authority | I recommend that the New South Wales Police Force review the number, rank and function of the officers comprising the Negotiation Unit |
REC292-2375 | 32 - Doctrine, standards, and reform | I recommend that the ADF Review, in consultation with the police forces of the states and territories, examine the guidance available to ADF officers and state and territory police regarding: the role of ADF liaison officers; the availability of ADF assistance in the absence of a call-out; and the procedures to apply in relation to requests for, and the provision of, equipment or advice by the ADF. |
REC292-2338 | 32 - Doctrine, standards, and reform | I recommend that the Commissioner of Police issue guidelines to assist officers to determine when they should exercise their powers of arrest and take an accused into custody rather than proceeding by way of a court attendance notice. |
REC292-2362 | 32 - Doctrine, standards, and reform | I recommend that the New South Wales Police Force review its policies to ensure that the usual arrangements for placing a sniper coordinator in the Police Forward Command Post are departed from only for sound operational reasons that are recorded. |
REC292-2344 | 32 - Doctrine, standards, and reform | I recommend that the New South Wales Police Force review the division of tasks among the various officers responsible for responding to major high-risk situations to enable Police Forward Commanders to focus exclusively on their primary goals and that officers engaged in matters not directly related to the resolution of the incident be required to report to an officer other than the Police Forward Commander |
REC292-2350 | 32 - Doctrine, standards, and reform | I recommend that the Secretariat of the Australia–New Zealand Counter-Terrorism Committee prepare guidelines regarding the interpretation and scope of the restrictions contained Clause 92 of the National Counter Terrorism Plan 2012. The Secretariat should also update relevant Australia–New Zealand Counter-Terrorism Committee documents and the New South Wales Police Force should update State Protection Group documents to refer to the latest versions of the National Counter-Terrorism Plan |
REC292-2367 | 32 - Doctrine, standards, and reform | I recommend that the Australia New Zealand Policing Advisory Agency liaise with the Australia–New Zealand Counter-Terrorism Committee to determine whether policies requiring the consideration of more proactive intervention should be developed for responding to terrorist sieges. |
REC292-2355 | 12 - EM agency and authority | I recommend that the New South Wales Police Force review its procedures to ensure that handovers between negotiation teams are staggered so that a fully briefed officer is always available to receive a call from the stronghold. |
REC292-2374 | 32 - Doctrine, standards, and reform | I recommend that the ADF Review give consideration to amending the Australia–New Zealand Counter-Terrorism Committee protocols to ensure that they provide sufficient guidance as to the respective roles of the ADF and state police tactical groups. Such guidance should accord with the legislative framework in Part IIIAAA of the Defence Act 1903 (Cth). |
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. |
REC292-2361 | 32 - Doctrine, standards, and reform | I recommend that the Minister for Police consider whether the provisions of the Terrorism (Police Powers) Act2002 should be amended to ensure that police officers have sufficient legal protection to respond to terrorist incidents in a manner most likely to minimise the risk to members of the public. |
REC292-2343 | 32 - Doctrine, standards, and reform | I recommend that the New South Wales Police Force remedy the lack of detailed guidance on how State Protection Group officers should interact and communicate with the Police Forward Commander, and that such guidance be included in policy documents and reinforced with training. |
REC292-2349 | 12 - EM agency and authority | I recommend that the New South Wales Police Force review its personnel arrangements and structures for the monitoring of surveillance devices, including the number of officers allocated to a listening or viewing post for monitoring purposes, and the demarcation of roles, including primary monitor, scribe/log keeper, and disseminator. I also recommend that clear communication channels be established for reporting data captured during such surveillance, including via integrated electronic intelligence sharing platforms or applications. |
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. |
REC292-2354 | 12 - EM agency and authority | I recommend that the New South Wales Police Force consider expanding the panel of psychological advisers it retains and the range of disciplines it consults. |
REC292-2373 | 32 - Doctrine, standards, and reform | I recommend that the ADF Review confer with state and territory governments about the criteria governing applications for the ADF to be called out pursuant to the Defence Act 1903(Cth) with a view to determining: whether further guidance is required on the criteria to be used by states and territories in determining whether to apply for Commonwealth assistance; and if so, what criteria ought to be stipulated. |
REC292-2359 | 32 - Doctrine, standards, and reform | I recommend that the New South Wales Police Force develop policies that require the recording of negotiation strategies and tactics, demands made by a hostage taker, and any progress towards resolution (or lack thereof ) in a form readily accessible by commanders and negotiators. |
REC292-2342 | 13 - Mapping and data quality | The development of an integrated intelligence system that allows police officers secure access to all information platforms should also provide for the recording of all command decisions, the reasons for them, and the dissemination of those decisions. |
REC292-2365 | 32 - Doctrine, standards, and reform | I recommend that the Australia New Zealand Policing Advisory Agency and the Australia–New Zealand Counter-Terrorism Committee review the Australia New Zealand Guidelines for Deployment of Police to High Risk Situations and the Police Tactical Group Operations Manual to ensure that they adequately describe all aspects of the DA planning and approval pro-cess and present commanders with appropriate guidance on relevant considerations. |
REC292-2347 | 32 - Doctrine, standards, and reform | I recommend that the New South Wales Police Force consider developing a pro forma debriefing sheet containing standard questions relevant to all or most high risk situations, which can be supplemented by the negotiation coordinator and the tactical commander to maximise the likelihood of all available relevant information being obtained during hostage debriefings. Such measures would also aid contemporaneous documentation of information derived from debriefs and assist in relaying all relevant information to command. |
REC292-2353 | 32 - Doctrine, standards, and reform | I recommend that the New South Wales Police Force develop a comprehensive policy that describes the role and function of a psychological adviser engaged to assist in responses to high-risk situations and that all those involved be made familiar with that policy. |
REC292-2372 | 32 - Doctrine, standards, and reform | I recommend that the New South Wales Police Force review its policies, procedures and training to ensure the rapid identification of persons killed or injured in high-risk situations. Those policies should provide appropriate guidance on how and when death messages ought to be conveyed following such incidents. |
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. |
REC292-2382 | 32 - Doctrine, standards, and reform | I recommend that the Minister for Police undertake a review of the Law Enforcement Conduct Commission Act 2016 with a view to enabling the Law Enforcement Conduct Commission to facilitate urgent debriefs and confidential internal reviews of critical incidents focused on improving current practice. |
REC292-2341 | 32 - Doctrine, standards, and reform | I recommend that the New South Wales Police Force review the Management Operational Guidelines to resolve any inconsistency between them and relevant counter terrorism protocols. |
Rec-ID | Code | Recommendation |
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REC271-1526 | 13 - Mapping and data quality | In accordance with recommendations of the BMT WBM report, the Banana Shire Council, SunWater, and the Bureau of Meteorology, under the stewardship of the Department of Natural Resources and Mines, jointly identify the requirements for a suitable gauge network for the Callide Valley to allow meaningful and timely flood warnings. The review should identify key stakeholders, examine potential funding sources and include a cost benefit analysis. |
REC271-1532 | 32 - Doctrine, standards, and reform | The evacuation sub-plan component of the Local Disaster Managment Plan should be reviewed, including any identified triggers for activation. Ideally, the plan should be tested in a live, multi-agency exercise prior to next summer. |
REC271-1531 | 32 - Doctrine, standards, and reform | Banana Shire Council completes business continuity planning as a matter of priority, including documentation and testing of the plan. |
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 |
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REC258-2532 | 12 - EM agency and authority | The next Director of Aviation Safety has leadership and management experience and capabilities in cultural change of large organisations. Aviation or other safety industry experience is highly desirable. |
REC258-2558 | 12 - EM agency and authority | The Civil Aviation Safety Authority applies a project management approach to the completion of all Civil Aviation Safety Regulation Parts not yet in force, with drafting to be completed within one year and consultation completed one year later, with: |
REC258-2537 | 32 - Doctrine, standards, and reform | The Civil Aviation Safety Authority delegates responsibility for the day-to-day operational management of airspace to Airservices Australia, including the designation of air routes, short term designations of temporary Restricted Areas, and temporary changes to the classification of airspace for operational reasons. |
REC258-2545 | 12 - EM agency and authority | The Australian Transport Safety Bureau transfers its safety education function to the Civil Aviation Safety Authority. |
REC258-2531 | 32 - Doctrine, standards, and reform | The Civil Aviation Safety Authority’s Board exercises full governance control. The nonexecutive directors should possess a range of appropriate skills and backgrounds in aviation, safety, management, risk, regulation, governance and government. |
REC258-2555 | 32 - Doctrine, standards, and reform | The Civil Aviation Safety Authority changes the current two-tier regulatory framework (act and regulations) to a three-tier structure (act, regulations and standards), with: |
REC258-2536 | 32 - Doctrine, standards, and reform | The Australian Transport Safety Bureau and the Civil Aviation Safety Authority amend the wording of their existing Memorandum of Understanding to make it more definitive about interaction, coordination, and cooperation. |
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. |
REC258-2529 | 32 - Doctrine, standards, and reform | The Australian Transport Safety Bureau and the Civil Aviation Safety Authority utilise the provision in their bilateral Memorandum of Understanding to accredit CASA observers to ATSB investigations. |
REC258-2554 | 32 - Doctrine, standards, and reform | Recreational Aviation Administration Organisations, in coordination with the Civil Aviation Safety Authority, develop mechanisms to ensure all aircraft to be regulated under CASR Part 149 are registered. |
REC258-2535 | 32 - Doctrine, standards, and reform | Airservices Australia, in conjunction with the Department of Infrastructure and Regional Development and the Civil Aviation Safety Authority, reconsiders the policy on ‘Assessment of Priorities’ that stipulates that air traffic controllers sequence arriving aircraft based on category of operation, rather than on the accepted international practice of ‘first come, first served’. |
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: |
REC258-2527 | 32 - Doctrine, standards, and reform | The Department of Infrastructure and Regional Development plays a stronger policy role in the State Safety Program. |
REC258-2553 | 12 - EM agency and authority | The Civil Aviation Safety Authority establishes a safety oversight risk management hierarchy based on a categorisation of operations. Rule making and surveillance priorities should be proportionate to the safety risk. |
REC258-2534 | 16 - Training and behaviour | The Civil Aviation Safety Authority develops a staff exchange program with industry. |
REC258-2562 | 32 - Doctrine, standards, and reform | The Civil Aviation Safety Authority amends the current Terms of Reference of the Industry Complaints Commissioner so that: |
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. |
REC258-2547 | 12 - EM agency and authority | The Civil Aviation Safety Authority establishes small offices at specific industry centres to improve monitoring, service quality, communications and collaborative relationships. |
REC258-2533 | 32 - Doctrine, standards, and reform | The Civil Aviation Safety Authority: |
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. |
REC258-2538 | 32 - Doctrine, standards, and reform | The Department of Infrastructure and Regional Development and Department of Defence (and appropriate agencies) establish an agreed policy position on safety oversight of civil operations into joint user and military airports. |
REC258-2546 | 12 - EM agency and authority | The Civil Aviation Safety Authority changes its organisational structure to a client-oriented output model. |
Rec-ID | Code | Recommendation |
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REC250-0795 | 33 - Relief and recovery | Regional Development Victoria should implement the recommendations from the Department of Planning and Community Development's review of the Community Recovery Fund to improve the delivery of relief and recovery programs in the future. |
Rec-ID | Code | Recommendation |
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REC238-0806 | 33 - Relief and recovery | Review the adequacy of current arrangements for infrastructure reconstruction following a major flood event in the Hawkesbury-Nepean Valley. |
REC238-0805 | 33 - Relief and recovery | Develop a Hawkesbury-Nepean Flood Recovery Plan, which identifies strategies and arrangement for recovery from severe floods in the Hawkesbury-Nepean Valley. |
REC238-0803 | 32 - Doctrine, standards, and reform | Ensure effective flood gauging arrangements in the Hawkesbury-Nepean Valley |
REC238-0798 | 32 - Doctrine, standards, and reform | Optimise the configuration of a raised Warragamba Dam for flood mitigation of the full range of flood events and water supply, with due consideration of upstream impacts. |
REC238-0797 | 32 - Doctrine, standards, and reform | Determine the appropriateness and the steps required to allow the reduction of full supply level by up to five metres and/or the implementation of alternative gate operation at Warragamba Dam for the mitigation of minor to moderate flood events in the short-term. |
Rec-ID | Code | Recommendation |
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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. |
REC236-2786 | 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. |
REC236-2791 | 37 - Funding | The committee recommends that the government develop a process by which the ATSB can request access to supplementary funding via the minister. |
REC236-2802 | 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. |
REC236-2785 | 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. |
REC236-2790 | 12 - EM agency and authority | The committee recommends that an expert aviation safety panel be established to ensure quality control of ATSB investigation and reporting processes along the lines set out by the committee. |
REC236-2798 | 32 - Doctrine, standards, and reform | The committee recommends that, where relevant, the ATSB include thorough human factors analysis and discussion in future investigation reports. Where human factors are not considered relevant, the ATSB should include a statement explaining why. |
REC236-2784 | 32 - Doctrine, standards, and reform | The committee recommends that the minister, in issuing a new Statement of Expectations to the ATSB, valid from 1 July 2013, make it clear that safety in aviation operations involving passengers (fare paying or those with no control over the flight they are on, e.g. air ambulance) is to be accorded equal priority irrespective of flight classification. |
REC236-2789 | 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. |
REC236-2797 | 12 - EM agency and authority | The committee recommends that all meetings between the ATSB and CASA, whether formal or informal, where particulars of a given investigation are being discussed be appropriately minuted. |
REC236-2807 | 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. |
REC236-2788 | 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 |
REC236-2796 | 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: |
REC236-2804 | 32 - Doctrine, standards, and reform | The committee recommends that Airservices Australia discuss the safety case for providing a hazard alert service with Fijian and New Zealand ATC (and any other relevant jurisdictions) and encourage them to adopt this practice. |
REC236-2787 | 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. |
REC236-2794 | 32 - Doctrine, standards, and reform | The committee recommends that CASA, in consultation with an Emergency Medical Services industry representative group (eg. Royal Flying Doctor Service, air ambulance operators, rotary wing rescue providers) consider the merit, form and standards of a new category of operations for Emergency Medical Services. The minister should require CASA to approve the industry plan unless there is a clear safety case not to. Scope for industry to assist as part of an audit team should also be investigated where standardisation is an issue. This should be completed within 12 months and the outcome reported publicly. |
Rec-ID | Code | Recommendation |
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REC235-2809 | 32 - Doctrine, standards, and reform | The Australian National Audit Office recommends that the Department of Regional Australia, Local Government, Arts and Sport improve the arrangements for conducting value for money reviews of Victorian reconstruction projects by pursuing amendments to the operating protocol with Victoria to require that, at regular intervals, the Taskforce is provided with information on all reconstruction projects being delivered within the scope of the National Partnership Agreement. |
Rec-ID | Code | Recommendation |
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REC234-2812 | 37 - Funding | In order to further build on the value for money review work being undertaken by the National Disaster Recovery Taskforce (on behalf of the Australian Government Reconstruction Inspectorate), the Australian National Audit Office (ANAO) recommends that the Taskforce: |
REC234-2811 | 32 - Doctrine, standards, and reform | In order to maximise the envisaged benefits from the Inspectorate’s program of value for money reviews, the Australian National Audit Office (ANAO) recommends that the National Disaster Recovery Taskforce improve the application of the sampling approach to make it more representative of the |
Rec-ID | Code | Recommendation |
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REC227-2858 | 13 - Mapping and data quality | I recommend that the Commonwealth prioritise completion of a hydrographic survey of Christmas Island and ensure that such a survey is completed in the near future. |
REC227-2856 | 12 - EM agency and authority | I recommend that BPC establish an onshore presence as recommended by Lieutenant Commander Livingstone. |
REC227-2855 | 32 - Doctrine, standards, and reform | I recommend that arrangements be put in place which would remove the requirements for Masters of Volunteer Marine Rescue vessels to hold a commercial certificate of competency. Operators could then be qualified through the FESA Volunteer Marine Rescue Training pathway as skippers and crew. This would increase the number of available skippers in the event of a search and rescue incident and would make appropriate training easier to arrange. |
REC227-2854 | 12 - EM agency and authority | I recommend that the Christmas Island VMRS be given autonomy to maintain operational readiness for the VMRS rescue vessel(s) and an appropriate budget be provided to allow this to take place. |
Rec-ID | Code | Recommendation |
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REC217-1828 | 32 - Doctrine, standards, and reform | The revised Victoria Flood Management Strategy should clearly articulate the policy guidelines for the management of vegetation and debris in Victorian waterways, for the purposes of flood protection and mitigation, taking into account the localised potential flooding effects of in‐stream vegetation in townships. |
REC217-1838 | 32 - Doctrine, standards, and reform | That statements of obligations, issued under the Water Industry Act 1994 for water authorities, be amended to include a provision whereby managing authorities must: |
REC217-1820 | 32 - Doctrine, standards, and reform | The Department of Sustainability and Environment will develop guidelines for the management of levees in emergencies, during and after a flood event, which can be incorporated into local flood response plans. The department will also provide, as part of these guidelines, a set of criteria for assessing the ongoing viability of ad hoc levees post‐flood. The Emergency Management Act 1986 will be amended to support the implementation of these guidelines. A more effective means for councils to remove illegal levees will also be examined by the Department of Sustainability and Environment. |
REC217-1837 | 32 - Doctrine, standards, and reform | The state government give consideration to enacting legislation to provide protection from legal liability for public authorities conducting works on priority levees in good faith, acting reasonably and responsibly in the public interest, and in accordance with standards agreed to under approved schemes. Public authorities should not be excluded from liability if they have acted negligently. |
REC217-1814 | 37 - Funding | The funding model for works on levees and their ongoing maintenance be revised, to be primarily based on the beneficiary pays principle. The state government should give consideration to wholly funding, or contributing to, the initial upgrade of high priority levees to an agreed standard. The construction of any new public levees will be the subject of a cost‐benefit analysis to be undertaken by DSE and the public authority, and be supported by a floodplain management study. Levees deemed low priority will be wholly the responsibility of the beneficiaries. |
REC217-1834 | 32 - Doctrine, standards, and reform | The Department of Sustainability and Environment will develop clear policy for the coordinated management of rural drainage, clarifying the legal framework, and identifying authorities with responsibility for the management and ongoing maintenance of formal schemes, and their development: |
REC217-1830 | 32 - Doctrine, standards, and reform | The Department of Sustainability and Environment will develop a code of practice on the removal of vegetation around critical public assets, in consultation with councils, CMAs and asset managers. Regional Flood Strategies will support this code of practice as part of shared flood risk management planning. |
REC217-1845 | 37 - Funding | The state government should provide core, ongoing funding to the responsible authority for the FloodSafe community education program. Funding should be provided for education about prevention, response and recovery phases and include information on rates notices about the height of particular floods. |
REC217-1829 | 32 - Doctrine, standards, and reform | The Department of Sustainability and Environment should develop guidelines for streamlining the permitting system for works on waterways for incorporation in the revised Victoria Flood Management Strategy. An exemption process will be introduced, with particular application to identified reaches of rivers and streams that require ongoing vegetation management and maintenance: |
REC217-1842 | 37 - Funding | The state government review the current funding approach used for the operation, maintenance and upgrade of river gauges, with a view to improving the river gauge network. |
Rec-ID | Code | Recommendation |
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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. |
REC210-0712 | 32 - Doctrine, standards, and reform | The Queensland Government should legislate to clarify the purposes for which a transitional environmental program can be granted. In particular, if the government considers the transitional environmental program the appropriate regulatory mechanism to deal with the discharge of water from mines during flood, section 330 of the Environmental Protection Act 1994 should be clarified to make it clear that it extends to that use. |
REC210-0759 | 32 - Doctrine, standards, and reform | CS Energy should review its emergency action plan and business procedures to ensure they are wholly consistent and give appropriate consideration to flooding as a possible emergency event. |
REC210-0728 | 12 - EM agency and authority | Emergency Management Queensland, in consultation with councils, should develop a directive that makes clear the authority of an officer of that agency to command a major SES operation. This could be expected to occur when a deployment of additional SES members is made to a region because the response needed is beyond the capacity of its local units. The directive should make clear the powers of the officer and his or her reporting responsibilities to disaster managers in these circumstances. Emergency Management Queensland must also ensure that any officer who assumes such a role has adequate training and skills in the conduct of disaster operations. |
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. |
REC210-0733 | 32 - Doctrine, standards, and reform | Emergency Management Queensland should pursue the execution of the ‘Local Arrangements’ with councils where a Memorandum of Agreement is in place. The contents of the arrangements should be reviewed and updated regularly |
REC210-0683 | 13 - Mapping and data quality | All councils should, resources allowing, map the overland flow paths of their urban areas. |
REC210-0708 | 35 - Business and Industry in relation to industry | The Queensland Government should work collaboratively with the Commonwealth Government and mine operators to ensure co-ordinated and effective monitoring of salts, metals and other contaminants in marine environments that may be affected by mine discharges. |
REC210-0755 | 13 - Mapping and data quality | CS Energy should supplement physical monitoring of Splityard Creek Dam with visual monitoring by installing surveillance cameras or similar devices. |
REC210-0725 | 12 - EM agency and authority | The fire service should ensure that station officers are familiar with the procedure for contacting management when requesting the calling in of additional staff; and, in particular, that they have available to them the names and current telephone numbers of the officers to be contacted in the first instance, with alternative contact details in the event that those officers prove unavailable. |
REC210-0770 | 32 - Doctrine, standards, and reform | The Queensland Government should legislate to oblige each owner of a referable dam to have an emergency action plan approved by the appropriate Queensland Government agency. Such plans should be reviewed periodically |
REC210-0732 | 37 - Funding | Emergency Management Queensland should develop and implement a new formula for the distribution of its recurrent SES subsidy, which takes into account relevant factors including the size of a local SES contingent and the population, area and natural hazard risk profile of the local government area concerned. |
REC210-0665 | 13 - Mapping and data quality | Councils should make their flood and overland flow maps and models available to applicants for development approvals, and to consultants engaged by applicants. |
REC210-0750 | 32 - Doctrine, standards, and reform | The assessment of flood mitigation manuals should be completed by a person with appropriate expertise who has had no involvement in its development, at any stage, and who can be seen to be independent of all individuals who were so involved. |
REC210-0719 | 32 - Doctrine, standards, and reform | The Queensland Government should amend the Environmental Protection Act 1994 so as to permit an emergency direction to be given orally where it is not practicable to provide the direction in writing, with provision for its subsequent confirmation in writing |
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. |
REC210-0731 | 12 - EM agency and authority | Emergency Management Queensland should ensure its staff, SES members and disaster managers are familiar with the directives it develops in relation to these matters. |
REC210-0664 | 13 - Mapping and data quality | Councils should, resources allowing, maintain flood maps and overland flow path maps for use in development assessment. For urban areas these maps should be based on hydraulic modelling; the model should be designed to allow it to be easily updated as new information (such as information about further development) becomes available. |
REC210-0749 | 32 - Doctrine, standards, and reform | The Queensland Government should amend the Water Supply (Safety and Reliability) Act 2008 to designate the Minister as the person who must approve a flood mitigation manual. |
REC210-0717 | 32 - Doctrine, standards, and reform | The Queensland Government should consider amending the Environmental Protection Act 1994 to provide a definition of the term ‘emergency’ for the purposes of section 468 of that Act. |
REC210-0763 | 35 - Business and Industry in relation to industry | Seqwater should ensure that the Somerset Dam gallery is not susceptible to flooding during overtopping events. |
REC210-0730 | 12 - EM agency and authority | Emergency Management Queensland, in consultation with councils, should develop clear directives about: • the communication and reporting that should take place between the SES and disaster managers, including in relation to task allocation and completion, once disaster management groups have been activated • the communication and reporting that should take place between the SES and disaster managers, including in relation to task allocation and completion, once disaster management groups have been activated • the process for dealing with requests for assistance that exceed an SES unit’s capacity to respond them • the process for seeking extra support for an SES unit that has been overwhelmed by a disaster (whether by way of Emergency Management Queensland or the disaster management arrangements or both) • the role of SES liaison officers in communications with disaster managers about SES disaster operations • the role of incident controllers, and their teams, relative to those SES (or Emergency Management Queensland) personnel charged with the command of SES operations. |
REC210-0746 | 13 - Mapping and data quality | Seqwater should consider engaging a technical writer to develop completely new manuals after the operational strategies for Wivenhoe, Somerset and North Pine dams are set by the Queensland Government. |
REC210-0714 | 32 - Doctrine, standards, and reform | The Queensland Government should consider amending the Environmental Protection Act 1994 so that it allows for the relaxation of environmental authority conditions, by transitional environmental program or otherwise, as to discharge of water: • pre-emptively, in advance of rainfall or flooding events, or • for all mines in a catchment that is flooding. |
REC210-0760 | 32 - Doctrine, standards, and reform | CS Energy should amend its business procedure to remove any ambiguity as to the establishment of communications with Seqwater and to acknowledge the formal communications protocol regarding releases. |
REC210-0729 | 12 - EM agency and authority | Emergency Management Queensland should ensure its staff, SES members and disaster managers are familiar with the directive when it is developed. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC199-0425 | 35 - Business and Industry in relation to industry | the state require that dam owners and operators inform the control agency and the Bureau of Meteorology about the management and operation of dams and weirs consistent with the flood warning requirements of the relevant river systems, including providing telemetry at sites as necessary. This may require the state proactively liaising with other states to ensure equivalent obligations are placed on interstate dam operators where the dam may impact Victorian communities. |
REC199-0469 | 32 - Doctrine, standards, and reform | the state update the current fire specific guidelines and resources for evacuation planning to take an ‘all hazards’ approach |
REC199-0443 | 32 - Doctrine, standards, and reform | the state reconfigure the Victorian Emergency Management Council and the supportive committee arrangements to ensure a comprehensive, accountable, effective and integrated approach to the development of emergency management arrangements is in place for Victoria. The process should also include consideration of the Security and Emergencies Committee and Central Government Response Committee roles, functions, reporting arrangements and relationships with other state level emergency management groups. Settled arrangements must be clearly articulated to ensure stakeholder understanding. |
REC199-0478 | 33 - Relief and recovery | the state amend the current protocol governing National Registration and Inquiry System information collection and sharing to: • clarify the role of councils and Centrelink during and after emergencies • ensure the amended protocol is written in plain English and easily understood; and • coordinate, in conjunction with the state and federal privacy commissioners, the development of a new National Registration and Inquiry System information sharing protocol in line with the proposed National Registration and Inquiry System 6 and state or federal privacy legislation. |
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 |
REC199-0459 | 32 - Doctrine, standards, and reform | the state undertake a complete review of emergency management legislation. This should include agencyspecific emergency management legislation and should focus on service interoperability and securing an ‘all hazards, all agencies’ capability |
REC199-0488 | 33 - Relief and recovery | the Department of Human Services develop proactive strategies to provide information and assistance for people applying for emergency grants. |
REC199-0424 | 35 - Business and Industry in relation to industry | the state require dam owners and operators to review storage operating manuals to incorporate lessons from the 2010–11 floods and make this information publicly available. The manuals should include a clear policy on dam surcharging and pre-release. |
REC199-0467 | 32 - Doctrine, standards, and reform | the state review and align all policies and procedures for evacuation, such as the interim evacuation guidelines and the State Health Emergency Response Plan, to ensure consistency and to clarify roles and responsibilities. |
REC199-0442 | 32 - Doctrine, standards, and reform | the state appoint a state emergency controller who is ultimately accountable for all major emergencies. |
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. |
REC199-0408 | 13 - Mapping and data quality | the state, in consultation with Bureau of Meteorology and Melbourne Water, take the necessary action to ensure that all flood warnings issued are linked to the geographical location of the gauge the data was derived from. |
REC199-0457 | 32 - Doctrine, standards, and reform | the state: • revise the Emergency Management Team Practice Note to include a template to ensure an appropriate and consistent approach to Emergency Management Team operations • provide the revised Emergency Management Team Practice Note to all stakeholders to enable familiarisation; and • ensure that there is regular exercising of Emergency Management Teams with an `all hazards’ focus. |
REC199-0487 | 32 - Doctrine, standards, and reform | the state develop and incorporate into emergency management planning regimes plans based on geographic risk, such as sub-regional plans |
REC199-0422 | 36 - Volunteers | the state establish a process for volunteer community member accreditation to allow volunteers to provide flood information to the control agency during a flood event. This process should establish a base competency standard and provide appropriate emergency management and Australasian Inter-service Incident Management System training to accredited community volunteers. |
REC199-0464 | 32 - Doctrine, standards, and reform | the state develop and implement a strategy that maximises the flexibility and united capacity of the Country Fire Authority and Victoria State Emergency Service to respond to emergencies. |
REC199-0429 | 13 - Mapping and data quality | the state take into account any outcomes from the Commonwealth Government’s flood mapping reviews in the continual development of the Victorian flood database and to incorporate into the database flood data currently held by Melbourne Water. |
REC199-0474 | 33 - Relief and recovery | the state, in respect of the Rapid Impact Assessment process: • resolve which agency/ies has policy and operational responsibility for this process • define the purpose of Rapid Impact Assessment; and • review the process, in light of the 2010–11 floods, to examine options to improve the efficiency of the collection of information. |
REC199-0456 | 32 - Doctrine, standards, and reform | the state: • ensure an ‘all hazards, all agencies’ approach to Incident Action Plan compilation is developed and implemented to enable the timely issue of functional Incident Action Plans. All agency incident action planning processes should be standardised to the fullest extent possible, including consideration of a library of pro-forma Incident Action Plans; and • develop and implement mechanisms to test and ensure that agencies possess satisfactory incident action planning capability and capacity for ‘all hazards’ at all levels of operations. |
REC199-0484 | 32 - Doctrine, standards, and reform | the state: • assess current risk and risk mitigation strategies for essential services, with a focus on ensuring that risks are appropriately identified at all levels of emergency planning; and • ensure that the responsible authority or owner/ operator of essential services put in place appropriate strategies to mitigate any risk to service continuity |
REC199-0420 | 13 - Mapping and data quality | the state establish standards for flood mapping to ensure they are kept contemporary and meet the purposes of landuse risk planning and emergency response. In doing so, maps should extend where appropriate to include Probable Maximum Flood, over a range of Annual Exceedence Probability levels and be explicitly linked to a stream gauge. |
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. |
REC199-0491 | 33 - Relief and recovery | the state: • ensure that the concerns raised by Victorians regarding the Natural Disaster Relief and Recovery Arrangements are provided to the national review, including the issues of: – betterment (what it means and how it is applied); and – the 51 per cent income rule for eligibility of businesses for grants. • establish a single point of information (such as the single web portal referred to in recommendation 33) on all emergency related financial assistance available to individuals, businesses and local government. The means of accessing this information should be widely circulated in the community. |
REC199-0427 | 35 - Business and Industry in relation to industry | the state require dam owners and operators provide regular situational reports to the relevant control agency where dam issues may impact incident management. |
REC199-0473 | 33 - Relief and recovery | the state make available to the public a clear guide of who is responsible for: • clean-up and recovery of various types of infrastructure that straddle the public/private boundary; and • the policies agencies will follow in determining whether to repair infrastructure under their control. |
REC199-0454 | 32 - Doctrine, standards, and reform | the State Emergency Response Coordinator further develop the Strategic Emergency Management Assurance Team process by involving subject matter experts from relevant emergency management control agencies who are the subject of Strategic Emergency Management Assurance Team focus. |
REC199-0480 | 33 - Relief and recovery | the state clarify the transition to recovery arrangements including the processes for approving and funding of essential works after transition to recovery has been formalised. |
REC199-0417 | 13 - Mapping and data quality | the state ensure that regional and local flood plans incorporate all available flood mapping and intelligence, including assessments of levees and flood consequence information. |
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. |
REC199-0490 | 33 - Relief and recovery | the state finalise the 2008 review of Victoria’s municipal assistance. This should include addressing: • the provision of upfront funding for local councils for repair of community assets • packages for early relief and recovery to be included in both the Natural Disaster Funding Arrangements and the Natural Disaster Relief and Recovery Arrangements, including outreach packages; and • the process of reimbursement of local councils after floods. |
REC199-0426 | 35 - Business and Industry in relation to industry | the state require that dam owners and operators inform people situated downstream of water storages if the owners/operators become aware of an immediate threat arising from the dam to the safety of those people. The owner/operators should provide this information as soon as the owner/operators become aware of the threat. |
REC199-0472 | 33 - Relief and recovery | the state review the legislation and policies that set out clean-up and recovery responsibilities for infrastructure such as crossovers, culverts, drains, bridges and waterways, including consideration of: • whether the entities who are given obligations or powers to undertake clean-up works have the capacity to do so; and • the appropriateness of having different legal regimes for what is essentially the same piece of infrastructure. If the review reveals that the current responsibility matrix is inadequate, the state develop an action plan to address the identified shortcomings. |
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. |
REC199-0479 | 33 - Relief and recovery | the state review the way early outreach occurs and implement changes that will ensure that there is a consistency of approach regardless of which agency undertakes the service. |
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. |
REC199-0461 | 32 - Doctrine, standards, and reform | the state ensure: • water rescue/swift water rescue definitions, roles and responsibilities are clarified and communicated to all stakeholders to ensure common understanding • appropriate training, equipment and support is provided to those required to perform water rescue/swift water rescue. Common training programs, standards and accreditation should be utilised wherever possible to increase potential for joined up operations and maximised capability • that based upon the experiences of these flood events, an appropriate level of water rescue capacity and capability is established and maintained • flood plans (all levels) and flood emergency response planning incorporate consideration of pre-positioning of appropriate water rescue capability in the event that such services should be required; and • that revised water rescue roles, responsibilities and arrangements are clearly defined in the Emergency Management Manual Victoria and such definitions are replicated in all individual agency planning and operational documents |
REC199-0489 | 33 - Relief and recovery | the state implement arrangements to improve the support provided to local government on disaster financing before, during and after emergency events. |
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). |
REC189-2914 | 32 - Doctrine, standards, and reform | The review team recommend that: |
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: |
REC189-2909 | 32 - Doctrine, standards, and reform | Equipping the regulator with a wider range of compliance tools under the legislation should continue to be a policy priority. The aim should be to enhance the regulator’s capacity to secure compliance in an appropriately graduated way. The opportunity should be taken to ensure that the regulator and inspectors can, in appropriate cases, bring proceedings that do not require referral to the Commonwealth Director of Public Prosecutions, such as actions for civil penalties or injunctions. |
Rec-ID | Code | Recommendation |
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REC188-2916 | 33 - Relief and recovery | The committee recommends that the Department of Regional Australia and DIAC liaise with the Christmas Island community to explore options for a permanent memorial to be erected on the island, at a site of the residents' choosing, for the victims of the tragedy. |
REC188-2915 | 33 - Relief and recovery | The committee recommends that Department of Immigration and Citizenship (DIAC) and its relevant contractors continue to monitor the wellbeing of the survivors and that counselling and support services should be provided for as long as is necessary. |
REC188-2917 | 33 - Relief and recovery | The committee recommends that relevant Commonwealth agencies continue to monitor the wellbeing of their personnel and that counselling and support services should be provided for as long as necessary. |
Rec-ID | Code | Recommendation |
---|---|---|
REC169-2996 | 32 - Doctrine, standards, and reform | The Department of Premier and Cabinet should provide clear guidance on terms such as ‘audit’, ‘auditor’ and ‘adequacy of the exercise’ to assist departments, Victoria Police and industry to implement requirements more reliably. |
REC169-2988 | 32 - Doctrine, standards, and reform | The Department of Premier and Cabinet should establish clear oversight and coordination of the arrangements for both Part 6 of the Terrorism (Community Protection) Act 2003 and the CIP framework by an appropriate body, such as the Government Security and Continuity Network Coordination Group with expanded responsibilities. |
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 |
REC164-0072 | 32 - Doctrine, standards, and reform | SERCon consider that the proposed State Recovery Committee review the recommended considerations arising from |
REC164-0071 | 32 - Doctrine, standards, and reform | SERCon consider the establishment of a body, such as a State Recovery Committee, with responsibility for the |
REC164-0077 | 32 - Doctrine, standards, and reform | SERCon consider the continued development of a State Recovery Sub-Plan (including complementary local and district |
REC164-0076 | 32 - Doctrine, standards, and reform | SERCon consider meeting with the State Emergency Management Committee, Directors General and agency heads to |
Rec-ID | Code | Recommendation |
---|---|---|
REC158-3438 | 32 - Doctrine, standards, and reform | That the port/channel managers coordinate marine emergency management planning in the port and are required to ensure that individual port stakeholder marine emergency management arrangements plans are integrated with the whole of port marine emergency management arrangements. |
REC158-3443 | 12 - EM agency and authority | That emergency services increase their capability/capacity to respond to marine emergencies by undertaking the necessary training, increasing their awareness of port and ship operations and ensuring knowledge of the roles/responsibilities of the relevant authorities and stakeholders. |
REC158-3426 | 32 - Doctrine, standards, and reform | That the nominated marine safety authority, in consultation with the Emergency Services Commissioner, senior emergency services personnel and relevant port stakeholders, is responsible for establishing appropriate performance standards, risk management guidelines and good practice guidelines for marine emergency management. |
REC158-3437 | 32 - Doctrine, standards, and reform | That port/channel managers coordinate marine emergency planning for the port and are required to ensure that marine emergency arrangements are integrated with whole of port emergency management plans. |
REC158-3442 | 12 - EM agency and authority | That emergency services continue to take the lead role in marine emergencies and operate under their respective legislation, the Emergency Management Act and the State’s emergency management arrangements. |
REC158-3425 | 32 - Doctrine, standards, and reform | Consequential or complementary amendments to the Emergency Management Act are required to ensure that: |
REC158-3453 | 32 - Doctrine, standards, and reform | That, where applicable, consideration is given to legislative amendment that will enable the findings of this report to be applied to areas inside State waters but outside commercial port waters. |
REC158-3436 | 32 - Doctrine, standards, and reform | That Harbour Masters are the designated principle marine specialists within the port and work directly with emergency services to provide advice and the interface with the marine legislative powers, to manage a marine emergency. |
REC158-3441 | 32 - Doctrine, standards, and reform | That, where practical, risk assessments, emergency planning, training and exercising are integrated to minimise duplication of effort. |
REC158-3424 | 32 - Doctrine, standards, and reform | That legislation is prepared by the Department of Transport to ensure marine emergency management arrangements are clarified and provide: |
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. |
REC158-3435 | 32 - Doctrine, standards, and reform | That Harbour Masters have the appropriate powers, authority, accountability, skills, responsibility and indemnity to provide a coordinated response of marine resources in support of emergency services, except where the nominated marine safety authority is the control agency for a marine pollution or marine casualty emergency. |
REC158-3440 | 32 - Doctrine, standards, and reform | That the Water Division Emergency Response Plan is amended, by the Water Division emergency response coordinator, to provide a framework to coordinate a marine response that crosses declared port water boundaries and requires resource coordination and prioritisation. |
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. |
REC158-3434 | 32 - Doctrine, standards, and reform | That the accountability relationship between Harbour Masters and the Director of Marine Safety is strengthened in the relevant legislation. |
REC158-3439 | 32 - Doctrine, standards, and reform | That the port marine emergency management arrangements are integrated with the Victorian Water Division Emergency Response Plan. |
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. |
REC158-3427 | 32 - Doctrine, standards, and reform | That the standards and guidelines determined by the nominated marine safety authority require port/channel managers to conduct a marine emergency risk assessment using AS/NZ 4360:2004 Risk Management and, in addition, must require port/channel managers to: |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC149-3129 | 32 - Doctrine, standards, and reform | The consequences of the disapplication of the Navigation Act 1912 should be analysed, the actual consequences identified and unintended consequences addressed. |
REC149-3134 | 32 - Doctrine, standards, and reform | Improved and agreed guidelines for Safety Case application and assessment, including suggested structure and content, would alleviate many current problems related to Safety Case processes. |
REC149-3141 | 32 - Doctrine, standards, and reform | NOPSA should complete the next revision of Safety Case guidelines in consultation and agreement with stakeholders and continue its program to achieve consistency with a firmer hand from the CEO and management. |
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. |
REC149-3133 | 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. |
REC149-3140 | 32 - Doctrine, standards, and reform | The industry should provide advice to NOPSA on where the regulations do not provide sufficient clarity and consider developing broad policy/process guidelines in consultation with the regulator to provide clarity and consistency. Regulators should not take personal views or preferences. |
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. |
REC149-3137 | 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. |
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. |
REC149-3131 | 35 - Business and Industry in relation to industry | The exploration/production operator making all major decisions related to petroleum activities (i.e. selection of rig, well design and selection of service companies) should be made responsible for demonstrating to the regulator that drilling operations can be conducted safely. Where the drilling contractor owns the rig and conducts the day-to-day management of safety on the rig, this duty can be described in a rig specific Safety Case that is owned by the drilling contractor. This rig specific Safety Case does not have to be submitted for every well/well operation. |
REC149-3136 | 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. |
REC149-3146 | 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. |
REC149-3130 | 32 - Doctrine, standards, and reform | The regulations pertaining to vessels of opportunity or their interpretation should be changed to facilitate a risk based approach to regulation. This approach will be consistent with the approach taken in other jurisdictions. |
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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC137-3530 | 16 - Training and behaviour | I recommend that Civil Aviation Safety Authority (CASA) expedite the introduction of mandatory crew resource management training. |
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. |
REC137-3531 | 32 - Doctrine, standards, and reform | I recommend that CASA consider creating firm guidelines that require consideration of workload, lines of authority, potential conflicts of interest and any other factors that impact upon the ability of “key personnel” to discharge their responsibilities within an aviation organisation when its officers are approving appointments to those positions. |
Rec-ID | Code | Recommendation |
---|---|---|
REC125-3893 | 35 - Business and Industry in relation to industry | That Melbourne Water ensures that stakeholders (and especially local councils) are fully consulted before and during the development of drainage strategies and plans. These plans should consider councils’ drainage systems. |
REC125-3892 | 35 - Business and Industry in relation to industry | That Melbourne Water ensures stakeholder expectations are fully considered when setting flood risk reduction targets. |
REC125-3900 | 12 - EM agency and authority | That agencies integrate condition information into their asset management decision-making practices and use it as the basis for validating asset valuations and depreciation calculations. |
REC125-3895 | 32 - Doctrine, standards, and reform | That all agencies develop drainage asset management plans, consistent with best practice, and that these incorporate: |
Rec-ID | Code | Recommendation |
---|---|---|
REC121-3679 | 32 - Doctrine, standards, and reform | The rail safety regulator should set standards for the design, manufacture, testing and commissioning of rolling stock to ensure that the rolling stock is fit for its purpose. |
REC121-3705 | 32 - Doctrine, standards, and reform | The ITSRR should develop standards for periodic medical examinations which include the following: |
REC121-3730 | 32 - Doctrine, standards, and reform | Legislation should be enacted and any necessary arrangements made, to enable the ATSB to review any reports of any investigation by a rail organisation or the OTSI into any serious incident or accident in New South Wales. |
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. |
REC121-3770 | 32 - Doctrine, standards, and reform | A safety management system regulation should be promulgated, specifying the requirements of safety management systems in all accredited organisations, using Annexure I to this report as a guide |
REC121-3655 | 32 - Doctrine, standards, and reform | Procedures should be put in place by RailCorp to ensure that electrical power supply to the area of an accident can be immediately isolated, if necessary, in the event of a rail accident, so as to reduce any risk of exposure of emergency response personnel to injury or harm. |
REC121-3686 | 32 - Doctrine, standards, and reform | The standard in relation to the collection and use of data from data loggers should provide that such information must be accessed in the circumstances of any accident or incident and can be accessed to monitor driver performance generally. |
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. |
REC121-3735 | 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. |
REC121-3754 | 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. |
REC121-3662 | 32 - Doctrine, standards, and reform | The rail displan should provide for the site controller to have complete control of the site, with other agencies co-ordinating with and supporting him or her, until the rescue phase of the emergency response has been completed. |
REC121-3696 | 32 - Doctrine, standards, and reform | Defects reporting, recording and rectification should be integrated with the RailCorp regimes for train maintenance. |
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. |
REC121-3740 | 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. |
REC121-3761 | 32 - Doctrine, standards, and reform | Legislative changes should be enacted to ensure the complete independence of ITSRR from the Minister for Transport Services. |
REC121-3671 | 32 - Doctrine, standards, and reform | The RailCorp emergency response plan should include a requirement for the debriefing of all senior rail and emergency response personnel involved in any rail accident, so as to determine the way or ways in which emergency response arrangements for rail accidents can be continually improved, and thereafter implement such improvements. |
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. |
REC121-3702 | 29 - Operational Health and Safety | Random alcohol testing should be continued. |
REC121-3728 | 32 - Doctrine, standards, and reform | Any barriers to communication between OTSI and ITSRR should be removed, so as to ensure that any findings made by OTSI in relation to any investigation it conducts are reported immediately to ITSRR. |
REC121-3747 | 29 - Operational Health and Safety | All trains should have windows available through which passengers can escape. |
REC121-3769 | 32 - Doctrine, standards, and reform | The ITSRR should continue to participate in the development of a national system for rail safety regulation, provided that any ultimate agreement between the States and Territories and the Australian Government does not produce a safety outcome for New South Wales that is less than would be achieved by the implementation of all the recommendations contained in this report. |
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. |
REC121-3685 | 32 - Doctrine, standards, and reform | The ITSRR should impose a standard in relation to the collection and use of data from data loggers. |
REC121-3709 | 29 - Operational Health and Safety | RailCorp should provide access to electronic versions of safety documentation for all operational staff at their workplace. |
REC121-3734 | 29 - Operational Health and Safety | RailCorp should integrate its management of occupational health and safety into its overall safety management. |
REC121-3752 | 12 - EM agency and authority | RailCorp should establish clear safety accountability statements and reporting lines for all management positions. |
REC121-3661 | 32 - Doctrine, standards, and reform | The rail displan should include provision for the appointment of a rail emergency management co-ordinator at the RMC, and an on-site rail commander with the sole function of assisting and supporting the emergency services during the rescue phase of the emergency response. |
REC121-3692 | 32 - Doctrine, standards, and reform | Communications protocols and procedures should be standardised and mandated by regulations making them a condition of accreditation. |
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. |
REC121-3739 | 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. |
REC121-3760 | 32 - Doctrine, standards, and reform | The Advisory Board established under the Transport Legislation Amendment (Safety and Reliability) Act 2003 must be abolished. |
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. |
REC121-3701 | 32 - Doctrine, standards, and reform | Train inspections should be carried out at the time of stabling RailCorp trains, as well as a part of train preparation prior to entering service. |
REC121-3727 | 32 - Doctrine, standards, and reform | The relevant legislation should be amended to provide expressly that OTSI and the Chief Investigator have the power to initiate a rail accident or incident investigation. |
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. |
REC121-3766 | 12 - EM agency and authority | Staffing arrangements for ITSRR should be reviewed by it to ensure that adequate staff are employed in field positions, actively monitoring the safety of rail operations and compliance with conditions of accreditation. |
REC121-3650 | 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. |
REC121-3677 | 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. |
REC121-3682 | 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. |
REC121-3708 | 12 - EM agency and authority | RailCorp should employ a Chief Safety Information Officer to manage the collection, collation, and dissemination of safety information within RailCorp. |
REC121-3733 | 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. |
REC121-3751 | 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. |
REC121-3773 | 32 - Doctrine, standards, and reform | The ITSRR should ensure that RailCorp establishes a safety management system containing the 29 elements identified in the SMSEP report, and ensure the ongoing monitoring and improvement of the safety management system established. |
REC121-3660 | 32 - Doctrine, standards, and reform | The rail displan should include the use by all emergency response personnel of a uniform incident command system, involving procedures for such matters as the establishment of inner and outer perimeters, control of access to the site, orderly evacuation of injured passengers and the establishment of a staging area remote from the accident site, in a unified command structure with the site controller co-ordinating the various emergency services through representatives of each service. |
REC121-3690 | 32 - Doctrine, standards, and reform | All communications protocols must be strictly enforced by all accredited rail organisations. |
REC121-3716 | 16 - Training and behaviour | Train driver and guard training should encourage teamwork and discourage authority gradients. |
REC121-3738 | 29 - Operational Health and Safety | All passenger trains must be fitted with an internal passenger emergency door release. |
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: |
REC121-3669 | 16 - Training and behaviour | All operational rail staff should be trained by RailCorp in the action check list relevant to each. |
REC121-3700 | 12 - EM agency and authority | The RailCorp defects unit should be combined with the passenger fleet maintenance division of RailCorp. |
REC121-3725 | 13 - Mapping and data quality | The data and information management system should be compatible with any data and information management system established by the ATSB for the designated interstate rail network, provided that the establishment of a compatible system does not reduce the amount or quality of the information obtained by ITSRR below the optimum levels which it needs to conduct trend analysis, and otherwise properly manage the safety of rail operations in New South Wales. |
REC121-3744 | 16 - Training and behaviour | All RailCorp operational personnel should be trained in the location and operation of external emergency door release mechanisms. |
REC121-3764 | 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. |
REC121-3675 | 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. |
REC121-3681 | 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. |
REC121-3707 | 29 - Operational Health and Safety | The safety document management system should provide for the distribution of electronic versions of safety documentation to relevant staff. |
REC121-3732 | 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. |
REC121-3750 | 32 - Doctrine, standards, and reform | ITSRR should initiate and/or participate in the development of a national standard for crashworthiness of all passenger trains. |
REC121-3772 | 32 - Doctrine, standards, and reform | RailCorp should establish a safety management system containing the 29 elements identified in the SMSEP report which is in volume 2 of this report. |
REC121-3659 | 32 - Doctrine, standards, and reform | A railway disaster plan, or rail displan, should be developed by RailCorp and the emergency services to ensure co-ordinated inter-agency response to rail accidents and incidents on the RailCorp network. |
REC121-3689 | 12 - EM agency and authority | All RMC communications related staff should be selected upon the basis of the ability to convey information clearly, accurately and concisely and to follow strict communications protocols. |
REC121-3715 | 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. |
REC121-3737 | 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. |
REC121-3756 | 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. |
REC121-3668 | 32 - Doctrine, standards, and reform | The RailCorp emergency response plan should include action checklists of the steps that each employee is required to take, and the order for specific employees to follow in case of emergency. |
REC121-3699 | 32 - Doctrine, standards, and reform | All reported train defects should be certified by a person in a supervisory position in RailCorp as having been rectified. |
REC121-3724 | 13 - Mapping and data quality | The ITSRR should establish a data and information management system, containing all data and information that it requires, to continually monitor the safety of the New South Wales rail system. |
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”. |
REC121-3763 | 32 - Doctrine, standards, and reform | The ITSRR should publish guidelines to be followed by accredited organisations. |
REC121-3674 | 32 - Doctrine, standards, and reform | Uniform verbal descriptions identifying that power has been isolated should be developed by RailCorp and utilised by all railway personnel, electrical service providers and all emergency response personnel. |
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. |
REC121-3706 | 29 - Operational Health and Safety | RailCorp should establish a comprehensive safety document management system. |
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: |
REC121-3749 | 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”. |
REC121-3771 | 32 - Doctrine, standards, and reform | RailCorp should establish an integrated safety management system which includes the following: |
REC121-3658 | 12 - EM agency and authority | All emergency services stations should be provided with access keys to, and maps showing, all gates providing access to RailCorp tracks within their geographic area of responsibility. |
REC121-3688 | 32 - Doctrine, standards, and reform | Communications procedures must be standardised throughout the rail network, so that all railway employees describe the same subject matter in an identical way. |
REC121-3714 | 16 - Training and behaviour | RailCorp should use its simulators in an interactive manner. |
REC121-3736 | 32 - Doctrine, standards, and reform | The RailCorp passenger containment policy must be abandoned. |
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. |
REC121-3667 | 32 - Doctrine, standards, and reform | RailCorp should develop and implement an emergency response plan for management of all rail accidents. Such a plan should be subsumed by the rail displan in the case of serious accidents or incidents. |
REC121-3698 | 32 - Doctrine, standards, and reform | No RailCorp train should enter into revenue service or remain in service if, in the opinion of the driver in charge of that train, any defect in it creates a risk of injury. |
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. |
REC121-3741 | 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. |
REC121-3762 | 32 - Doctrine, standards, and reform | The Chief Executive of ITSRR should have sole accountability and responsibility for the regulation of rail safety in New South Wales. |
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. |
Rec-ID | Code | Recommendation |
---|---|---|
REC117-3640 | 37 - Funding | The ANAO recommends that the Attorney-General’s Department better monitor and account for the expenditure of individual exercise costs under the National Capability Development Exercise Programme, through: |
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. |
REC008-3991 | 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. |
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. |
REC008-3988 | 40 - Equipment and consumables | The Commission recommends that buckets of sand or other apparatus for extinguishing fire be kept in any chamber where high powered electricity is used. |
Rec-ID | Code | Recommendation |
---|---|---|
REC004-3997 | 40 - Equipment and consumables | That suitable metal receptacles be fitted under the spittoons of all smoking compartments of country trains, to receive pipe ashes, lighted tobacco, cigars, cigarettes, matches, or other inflammable matter used by smokers. |
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. |
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. |