Inquiry Search
Rec-ID | Code | Recommendation |
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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. |
REC258-2559 | 15 - Inter-service cooperation | The Civil Aviation Safety Authority’s Director of Aviation Safety meet with industry sector leaders to jointly develop a plan for renewing a collaborative and effective Standards Consultative Committee. |
Rec-ID | Code | Recommendation |
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REC217-1816 | 21 - Role of Commonwealth Government | That the Department of Sustainability and Environment continue to invest in the auditing of Victoria’s levee systems, both public and private, so that the Victoria Flood Database contains reliable and up to date data, including information on levees’ location, height, condition and ongoing viability for flood protection. |
Rec-ID | Code | Recommendation |
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REC208-0525 | 7 - Inter-agency communication | That the Office of Environment and Heritage amend its operating procedures for the Environment Line to ensure that there are clear obligations to pass on information relevant to other agencies, to those agencies in a timely manner. |
Rec-ID | Code | Recommendation |
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REC199-0412 | 21 - Role of Commonwealth Government | the Bureau of Meteorology adjust its flood prediction models to incorporate water storage conditions (to enable it to issue more timely and useful flood predictions for communities based downstream of water storages). |
REC199-0446 | 7 - Inter-agency communication | the state commit to securing effective multi-agency interoperable communications as a high level priority and that all future communications projects and upgrades incorporate compliance provisions mandating interoperability requirements. |
REC199-0470 | 21 - Role of Commonwealth Government | the commonwealth consider including (as part of its review of standards for aged care services) requirements for: • robust ‘all hazards’ evacuation plans that include current after-hour contact details of people who are able to make authoritative decisions during an emergency; and • rehearsal of those plans. |
REC199-0411 | 21 - Role of Commonwealth Government | the Bureau of Meteorology undertake a review of its radar coverage in the context of flash and riverine flood warnings for Victoria, with a particular focus on known gap areas such as the Horsham/Nhill region. |
REC199-0423 | 21 - Role of Commonwealth Government | the Bureau of Meteorology expand its volunteer amateur weather watch groups to enhance its weather and flood information gathering procedures. |
REC199-0458 | 7 - Inter-agency communication | the state ensure: • a common, functional and accessible system be introduced to enable effective Municipal Emergency Coordination Centre and Incident Control Centre communications • a regime of regular Municipal Emergency Coordination Centre exercising is introduced with oversight by an appropriate independent body. Such exercising should include testing of systems utilised for Incident Control Centre and Municipal Emergency Coordination Centre communications • those required to perform Emergency Management Liaison Officer roles have undertaken appropriate training; and • resource requesting arrangements are clarified and documented so that control and coordination functions do not overlap. |
REC199-0409 | 21 - Role of Commonwealth Government | the Bureau of Meteorology should present water levels in both local datum and Australian Height Datum (gauge zero) for all its published information and warnings |
REC199-0419 | 21 - Role of Commonwealth Government | the Bureau of Meteorology provide Incident Control Centres with real-time access to flood data held by the Bureau of Meteorology. This will require Bureau of Meteorology staff making themselves available to respond to enquiries from Incident Control Centres during a flood event. |
REC199-0451 | 15 - Inter-service cooperation | the state ensure, as a matter of priority, that the State Control Centre is able to function as a fit for purpose, multi-agency emergency management centre. Necessary works to achieve this outcome should have an overarching focus on the implementation of common agency systems and processes to the fullest extent possible. |
REC199-0405 | 21 - Role of Commonwealth Government | the state and the Bureau of Meteorology liaise to ensure the existence of appropriate quality control processes for gauges and contingency measures in the event that gauges are damaged during flood events. |
REC199-0418 | 7 - Inter-agency communication | the state develop an efficient process to ensure that, during flood events, temporary construction of flood mitigation works, such as levees, is controlled so as not to unacceptably impact on flood intelligence. |
REC199-0449 | 7 - Inter-agency communication | the state ensure that interoperable information management practices are developed and implemented by emergency management agencies. Common systems should be utilised to the fullest extent possible. |
REC199-0404 | 21 - Role of Commonwealth Government | the state engage with the Bureau of Meteorology to establish a joint initiative to review existing flash flood warning systems in Victoria and identify where additional systems are needed, with a particular focus on urban centres with a history of flash flooding. This review should seek to achieve outcomes similar to those implemented in NSW. Subject to those outcomes being implemented, the state should determine which agency is responsible for flash flood warnings. |
REC199-0413 | 14 - Incident Mgt Teams | the state clarify the role of intelligence cell staff (for example, hydrologists and/or Catchment Management Authority) who are utilised in Incident Control Centres during flood events |
REC199-0447 | 7 - Inter-agency communication | the state ensure that common and interoperable resource management systems are developed and implemented by emergency management agencies. Common systems should be utilised to the fullest extent possible. |
REC199-0403 | 21 - Role of Commonwealth Government | the state and commonwealth undertake a review into the appropriate institutional arrangements for the forecasting and predictions function currently undertaken by Melbourne Water for the Port Phillip and Westernport region. |
REC199-0477 | 21 - Role of Commonwealth Government | the state review the potential for National Registration and Inquiry System 6 to provide a single point of information collection to both register individuals and plan the delivery of recovery services. If the review determines National Registration and Inquiry System 6 is unable to fulfil this function, the state should work with the commonwealth and other states to implement the necessary changes to National Registration and Inquiry System 6. If National Registration and Inquiry System 6 is unable to be developed as a single information collection system: the state should develop and implement a single point of information collection system, including how information obtained from outreach activities can be incorporated into this system and how such information may be linked into the Rapid Impact Assessment process. |
Rec-ID | Code | Recommendation |
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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: |
REC189-2910 | 21 - Role of Commonwealth Government | NOPSA should: |
REC189-2908 | 21 - Role of Commonwealth Government | To ensure that NOPSEMA is in a strong position to perform its functions effectively: |
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). |
REC189-2913 | 21 - Role of Commonwealth Government | In developing and improving its policies and practices for stakeholder engagement, NOPSA should ensure that: |
REC189-2906 | 21 - Role of Commonwealth Government | In order to improve the effectiveness of National Offshore Petroleum Safety and Environmental Management Authority (NOPSEMA), with similar benefits for State or Territory regulators, attention should be given to the following actions. |
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. |
REC149-3143 | 21 - Role of Commonwealth Government | The role of the advisory Board, namely to give advice to Ministers and NOPSA when asked, should be made clear to Board members and all stakeholders. The Board and NOPSA should consider the need for a clear description of who does what based on the legislated responsibilities of the NOPSA CEO. |
REC149-3135 | 29 - Operational Health and Safety | The initial acceptance of a new facility Safety Case should be in conjunction with inspection of a facility upon commencement of operations. |
REC149-3128 | 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. |
REC149-3147 | 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. |
Rec-ID | Code | Recommendation |
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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. |
REC121-3739 | 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. |
REC121-3706 | 29 - Operational Health and Safety | RailCorp should establish a comprehensive safety document management system. |
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. |
REC121-3732 | 29 - Operational Health and Safety | If ITSRR accepts such a plan as an appropriate response to the existing weak safety culture, ITSRR should approve it and monitor the effectiveness of the plan. |
REC121-3764 | 29 - Operational Health and Safety | The ITSRR should not grant accreditation to any rail organisation unless it has an integrated safety management system in accordance with any safety management system regulation and the guidelines published from time to time by ITSRR. |
REC121-3657 | 10 - Infrastructure | All signal telephones must be maintained by RailCorp in proper working order. |
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. |
REC121-3738 | 29 - Operational Health and Safety | All passenger trains must be fitted with an internal passenger emergency door release. |
REC121-3702 | 29 - Operational Health and Safety | Random alcohol testing should be continued. |
REC121-3747 | 29 - Operational Health and Safety | All trains should have windows available through which passengers can escape. |
REC121-3731 | 29 - Operational Health and Safety | RailCorp should develop a plan to be submitted to ITSRR to address the deficiencies in the safety culture of RailCorp, including: |
REC121-3759 | 29 - Operational Health and Safety | A Safety Reform Program Director (hereafter referred to as SRPD), reporting directly to the Chief Executive of RailCorp, should be retained to manage, as head of a Safety Reform Program Office, any safety reform program being undertaken by RailCorp. The SRPD should work with the Chief Executive and senior management to ensure the implementation of an integrated safety management system and the cultural change required. The SRPD must have qualifications suitable for recognition by the Australian Institute of Project Management as a master program director. He or she should report to and be under the control of the Chief Executive, to ensure that the accountability of the Chief Executive is not reduced. The SRPD should co-ordinate and integrate any existing rail safety reform programs and, in consultation with and with the authority of the Chief Executive he or she should: |
REC121-3653 | 10 - Infrastructure | The RMC should be equipped by RailCorp with a transcriber system, or mimic board, or such other system as is necessary to enable identification of the precise location at any time of any train on the RailCorp network. |
REC121-3676 | 14 - Incident Mgt Teams | A direct line of communication should be established between the RMC and Emergency Services Operations Control Centre by a “tie line” or otherwise, so as to ensure that in the case of a serious rail accident there is an open line of communication between the officer in charge of the management of the incident at the RMC and the various emergency response services. |
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. |
REC121-3695 | 10 - Infrastructure | There should be interoperability of communications equipment between all trains operating on the New South Wales rail network. |
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”. |
REC121-3711 | 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. |
REC121-3755 | 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. |
REC121-3652 | 14 - Incident Mgt Teams | A designated staff member at the RMC should act as the rail emergency management co-ordinator. He or she should be the sole point of contact at the RMC with other rail personnel involved in the rail accident and emergency services personnel during the rescue phase of the emergency response. |
REC121-3666 | 14 - Incident Mgt Teams | The rail commander should have complete authority to direct and control any rail employees attending the site of a rail accident, in accordance with directions given or arrangements put in place by the site controller, until the rescue phase of the emergency response to the rail accident has been completed. |
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. |
REC121-3687 | 10 - Infrastructure | There must be compatibility of communications systems throughout the rail network. It is essential that all train drivers, train controllers, signallers, train guards and supervisors of trackside work gangs in New South Wales be able to communicate using the same technology. |
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. |
REC121-3709 | 29 - Operational Health and Safety | RailCorp should provide access to electronic versions of safety documentation for all operational staff at their workplace. |
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. |
REC121-3651 | 10 - Infrastructure | A dedicated telephone line should be established by RailCorp between the RMC and any Emergency Services Control Centre for use during any emergency. |
REC121-3734 | 29 - Operational Health and Safety | RailCorp should integrate its management of occupational health and safety into its overall safety management. |
REC121-3665 | 14 - Incident Mgt Teams | The role of the rail commander should be to provide support and assistance to the site controller and emergency services personnel until the rescue phase of the emergency response to any rail accident is completed. |
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. |
REC121-3740 | 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. |
REC121-3707 | 29 - Operational Health and Safety | The safety document management system should provide for the distribution of electronic versions of safety documentation to relevant staff. |
REC121-3749 | 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”. |
REC121-3733 | 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. |
REC121-3663 | 14 - Incident Mgt Teams | The incident command system should clearly identify the roles of the rail commander, site controller, police commander and commanders of the other emergency services, and the way in which each is to work together during the recovery phase of any rail accident. |