Complete sets of daily-report books should be provided, and kept in the mine or office, to be overlooked by the Inspector during his periodical visits.

The committee recommends that the Australian Transport Safety Bureau retrieve VH-NGA flight data recorders without further delay.

The committee recommends that in relation to mandatory and confidential reporting, the default position should be that no identifying details should be provided or disclosed. However, if there is a clear risk to safety then the ATSB, CASA and industry representatives should develop a process that contains appropriate checks and balances.

The committee recommends that where a safety action has not been completed before a report being issued that a recommendation should be made. If it has been completed the report should include details of the action, who was involved and how it was resolved.

The committee recommends that the ATSB prepare and release publicly a list of all its identified safety issues and the actions which are being taken or have been taken to address them. The ATSB should indicate its progress in monitoring the actions every 6 months and report every 12 months to Parliament.

NOPSA’s prohibition powers should be extended such that a prohibition notice can be issued where a NOPSA Occupational Health and Safety Inspector believes, on reasonable grounds, that an activity is occurring or may occur at a facility involving an immediate threat to the health or safety of a person.

Licensees should be subject to an express obligation to inform regulators of problems which arise in the course of installing barriers, even if they consider that well integrity is not thereby compromised. The information should be provided by way of special report, rather than included in a standard reporting document (such as a DDR). The information provided should include risk assessment details.

The use/type of barriers (including any change requests relating thereto) must be the subject of consultation between licensees and rig operators prior to installation. A proper risk assessment should be carried out, agreed upon, and documented in writing before installation. Joint written certification as to the appropriateness of the use of particular barriers should take place before installation. Senior onshore representatives of stakeholder entities should be involved in that certification process.

Problems which arise in the course of installing barriers must be the subject of consultation between licensees, rig operators, and contractors (if used). A proper risk assessment should then be carried out and remedial steps (including further testing/verification) should be agreed upon, and documented in writing before the performance of remedial work whenever practicable. Joint written certification as to resolution of the problem should take place before resumption of drilling operations. Senior onshore representatives of stakeholder entities should be involved in that certification process.

Pre‐drilling assessments should include a risk assessment of the worst‐case blowout scenario.

The regulator should pre‐assess and review in a generic sense, and in conjunction with the offshore petroleum industry, available options for well control in the event of a blowout. Being ‘match fit’ in this sense will enable a quicker and more effective response in terms of safety assessment, and will ensure that expectations of both operator and regulator are more readily aligned.

DEWHA should participate in training programs and exercises relevant to an oil spill in the marine environment.

Decision‐making about well control issues should be professionalised. Industry participants must recognise that decision‐makers owe independent duties to the public, not just their employer or principal, in relation to well control. Risk management in the context of well control needs to be understood as an ethical/professional duty. Self‐regulation contemplates self‐regulation by the industry, not just by individual licensees and operators.

The successful installation of every barrier should be the subject of written verification within and between licensees and rig operators; and should be the subject of explicit reporting to the relevant regulator(s).

Removal of a barrier must be the subject of consultation between licensees and rig operators prior to removal. A proper risk assessment should be carried out and agreed upon, and documented in writing before removal. Joint written certification as to the appropriateness of removal should take place before removal. Senior onshore representatives of stakeholder entities should be involved in that certification process.

That the nominated marine safety authority is required to ensure that incident notification and data recording requirements for Victorian commercial ports are consistent and adhered to.

That the nominated marine safety authority, in consultation with the Emergency Services Commissioner and senior emergency services personnel, is responsible for monitoring the implementation and auditing against appropriate performance standards, risk management guidelines and good practice guidelines.

The current KPI measures used by the Regulator and industry need to be reassessed and the performance indicators need to be related to the risk profiles of the industry. The industry needs to develop the indicators, which need to be agreed and measured by the industry in discussion with other stakeholders. The KPI's selected should be published in comparison with the worldwide offshore industry and with other industries. NOPSA should continue discussions with Australian Safety and Compensation Council (ASCC) with a view to adopting their goals. 

The industry should develop in conjunction with the Regulator a process for addressing the need to maintain the risk profile of a facility moving into extended life operation at the same risk profile as when it was within design life.

The ATSB should deliver any report of any such rail accident which it investigates to the Board of any rail organisation involved in the accident, ITSRR and the Minister for Transport Services.

Maintenance plans on all trains should be revised annually.

The Minister for Transport Services should retain, independently of ITSRR, safety auditors to provide a report to the Minister confirming or qualifying the contents of each such ITSRR quarterly report.

RailCorp and ITSRR should co-operate with national programs for the collection, collation, trend analysis and dissemination of safety critical information.

The ITSRR should conduct its own risk assessment in relation to the risk of any such high consequence, low probability accident and, if necessary, direct RailCorp to conduct a further risk assessment to reduce the level of residual risk to a level ITSRR regards as acceptable.

The Minister for Transport Services must table in Parliament, each such quarterly report by ITSRR.

All train drivers’ defects reports should be entered by RailCorp into a computerised record and tracked to finalisation.

RailCorp should undertake risk assessments of each of its activities as follows:
(a) identify the features of the system, subsystem or activities that are to be risk assessed and managed, to determine what makes the system work in terms of equipment, infrastructure and human factors;
(b) identify all hazards that may exist within the particular system, subsystem or activity, whether it is a driver safety system, passenger safety system, engineering design system, train maintenance system or involves human factors or performance;
(c) identify what controls are in place to eliminate or minimise the risks associated with any identified hazard;
(d) test the validity of the controls to ensure that the risk is eliminated or reduced to an acceptable level and, if not, institute additional or further control measures;
(e) specify, in safety documentation, the level of any residual risk;
(f) in the case of low probability, high consequence risks retain the services of an independent verifier of the risk assessments and controls to certify that all risks of such potentially catastrophic accidents have either been eliminated, or controlled to the extent identified by the independent expert;
(g) the Board of RailCorp certify that it regards any residual risk of a high consequence, low probability accident as acceptable, notwithstanding the severity of the consequences, by reason of the cost of further measures to control the risk; and
(h) provide to ITSRR records of the processes of hazard identification, risk assessment, risk control, independent verification and certification, and any Board certification relating to any high consequence, low probability accident.

The ITSRR must provide a quarterly report to the Minister for Transport Services on the progress made by RailCorp in implementing these recommendations, including:
(a) a statement as to whether or not the recommendation has been implemented and, if so, is working effectively; and
(b) if the recommendation has not been implemented, the me

All reports of the Chief Investigator of OTSI should be delivered, upon completion and without being reviewed, to ITSRR and the Minister for Transport Services.

All ATSB accident investigation reports should be made public.

The ITSRR should have permanent access to the RailCorp intranet.