Inquiry Search
Rec-ID | Code | Recommendation |
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REC002-4010 | 35 - Business and Industry in relation to industry | The Commission do not approve of removing any responsibility from the management by increasing the power or number of the Inspectors. The visits of these officials should, so far as possible, be visits of surprise. |
REC002-4008 | 35 - Business and Industry in relation to industry | Where dust exists in quantity, and under conditions favourable for ignition, it should be periodically and sufficiently dampened by water |
REC002-4004 | 35 - Business and Industry in relation to industry | Where safety-lamps are used, and the obligation is laid upon the men to cleanse the same, all examinations, tests, and repairs to these should be done by the owners. |
REC002-4003 | 35 - Business and Industry in relation to industry | Where gas exists, and no provisions are made for its constant removal, no shots should be fired, and, where permitted in a gassy mine, shots should be fired only by a man specially appointed, and at such hours when the miners are not within the mine. All shots should be tamped by stone well damped, and only copper or wooden tools should be employed. As far as possible the use of explosives should be discouraged, and skilful mining encouraged. Danger-boards should be placed further from the faces whence gas issues (say), where practicable, 50 yards. |
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. |
Rec-ID | Code | Recommendation |
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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. |
REC292-2360 | 2 - Emergency powers | I recommend that the Commissioner of Police consider seeking an agreement with news media outlets whereby the New South Wales Police Force will establish a way for such outlets to rapidly and confidentially determine whether publishing specific material could compromise the response to an ongoing high-risk incident and the media in turn will agree not to publish such material without first alerting a nominated senior police officer of their intention to do so. |
REC292-2346 | 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. |
REC292-2357 | 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 |
REC292-2345 | 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. |
REC292-2356 | 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 |
REC292-2355 | 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. |
REC292-2380 | 24 - Govt responsibility | I recommend that the New South Wales Police Force, in conjunction with NSW Health, establish a Fixated Threat Assessment Centre to identify and gather information about fixated persons, assess the risks they pose, and attempt to mitigate such risks through early intervention. |
REC292-2354 | 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. |
REC292-2379 | 24 - Govt responsibility | I recommend that the Premier of New South Wales consider whether the Privacy and Personal Information Protection Act 1998 and the Health Records and Information Privacy Act 2002 should be amended to ensure that there is appropriate access to health related information available to ASIO (consistent with recommendation 12 of the report of the Martin Place Siege Joint Commonwealth—New South Wales review) |
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. |
REC258-2553 | 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. |
REC258-2530 | 24 - Govt responsibility | The Australian Government appoints an additional Australian Transport Safety Bureau Commissioner with aviation operational and safety management experience. |
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. |
REC258-2526 | 24 - Govt responsibility | The Australian Government develops the State Safety Program into a strategic plan for Australia’s aviation safety system, under the leadership of the Aviation Policy Group, and uses it as the foundation for rationalising and improving coordination mechanisms. |
REC258-2546 | 12 - EM agency and authority | The Civil Aviation Safety Authority changes its organisational structure to a client-oriented output model. |
REC258-2545 | 12 - EM agency and authority | The Australian Transport Safety Bureau transfers its safety education function to the Civil Aviation Safety Authority. |
REC258-2561 | 24 - Govt responsibility | The Australian Government amends regulations so that background checks and the requirement to hold an Aviation Security Identification Card are only required for unescorted access to Security Restricted Areas, not for general airside access. This approach would align with international practice. |
REC258-2539 | 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. |
REC258-2558 | 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: |
Rec-ID | Code | Recommendation |
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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. |
REC236-2790 | 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. |
REC236-2783 | 2 - Emergency powers | The committee recommends that the Australian Transport Safety Bureau retrieve VH-NGA flight data recorders without further delay. |
Rec-ID | Code | Recommendation |
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REC227-2849 | 20 - Role of police | I recommend that the AFP takes steps to ensure that there are on Christmas Island at all times appropriately trained AFP officers who have completed the National Police Search and Rescue Manager’s Course and that upskilling should be ongoing to establish a cadre of trained search and rescue personnel. |
REC227-2856 | 12 - EM agency and authority | I recommend that BPC establish an onshore presence as recommended by Lieutenant Commander Livingstone. |
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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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. |
REC208-0525 | 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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REC177-3338 | 12 - EM agency and authority | Licensees and rig operators should be astute in ensuring that corporate systems and culture encourage rather than discourage raising of well control issues. For instance, do performance bonuses or rewards actually encourage or discourage reporting of issues? Is there a system in place to enable anonymous reporting of well control concerns? What whistleblower protections are in place? |
REC177-3289 | 39 - Disaster Risk Management | 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. |
REC177-3337 | 12 - EM agency and authority | Supervision/oversight of well control operations (within licensees, rig operators and by regulators) must occur without assuming adherence to good oilfield practice. The opposite assumption should prevail: namely adherence to good oilfield practice may well be compromised by the pursuit of time and cost savings. |
REC177-3286 | 39 - Disaster Risk Management | 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. |
REC177-3336 | 12 - EM agency and authority | Achievement and maintenance of well control should be written into the job responsibilities of key personnel, at every level up to and including CEOs. That is, a functional line of accountability for well control must exist up to, and including, CEOs. |
REC177-3285 | 39 - Disaster Risk Management | Pre‐drilling assessments should include a risk assessment of the worst‐case blowout scenario. |
REC177-3336 | 12 - EM agency and authority | Achievement and maintenance of well control should be written into the job responsibilities of key personnel, at every level up to and including CEOs. That is, a functional line of accountability for well control must exist up to, and including, CEOs. |
REC177-3356 | 39 - Disaster Risk Management | 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. |
REC177-3330 | 39 - Disaster Risk Management | 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. |
REC177-3345 | 2 - Emergency powers | 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. |
REC177-3291 | 39 - Disaster Risk Management | 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. |
Rec-ID | Code | Recommendation |
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REC169-2993 | 24 - Govt responsibility | The Department of Premier and Cabinet should clarify the requirements in relation to establishing Security and Continuity Networks in designated sectors, so that there is a shared understanding of those requirements. |
REC169-2992 | 24 - Govt responsibility | The Department of Premier and Cabinet should identify risks arising from the joined-up nature of the approach to protecting essential services and critical infrastructure, and to assist departments and agencies to develop associated risk management arrangements at the whole-of-government level. |
REC169-2991 | 24 - Govt responsibility | The Department of Premier and Cabinet should provide definitive guidance on identifying essential services for declaration to better inform relevant departments in discharging their responsibilities under Part 6 of the Act. |
REC169-2990 | 24 - Govt responsibility | The Department of Premier and Cabinet should clarify the roles and responsibilities of departments and agencies under Part 6 of the Act and CIP framework to reduce confusion and gaps. |
REC169-2995 | 24 - Govt responsibility | The Department of Premier and Cabinet, in consultation with Victoria Police, should develop clear guidance to distinguish between declared essential services and critical infrastructure to assist departments, Victoria Police and industry in implementing Part 6 of the Act and the CIP framework more effectively. |
REC169-2994 | 24 - Govt responsibility | Representatives of lead departments should obtain necessary security clearances so appropriate officers can access information relevant to their sectors. |
Rec-ID | Code | Recommendation |
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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. |
REC158-3442 | 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. |
REC158-3433 | 24 - Govt responsibility | That Harbour Masters are employed by a government body and remain geographically located at the port. |
REC158-3454 | 24 - Govt responsibility | That the Department of Transport ensures that key stakeholders are engaged during the implementation of the approved Review recommendations. |
REC158-3448 | 24 - Govt responsibility | That the Director of Marine Safety works with the Australian Maritime Safety Authority to ensure that State and port emergency arrangements interface appropriately with the National Maritime Emergency Response Arrangements. |
Rec-ID | Code | Recommendation |
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REC149-3133 | 35 - Business and Industry in relation to industry | Because some issues related to emergency response are beyond any single operator and usually occur outside the title area, there is a need for the representatives of the offshore industry to work together with other governments, interested and involved parties to develop the strategies to be utilised and the emergency planning model that will satisfy the requirements of all parties. |
REC149-3132 | 35 - Business and Industry in relation to industry | Coverage of the regime should be increased to cover the complete hydrocarbons production system from wells through to custody transfer point or reasonable physical/technical system boundary. If NOPSA is also to be responsible for Carbon Capture and Storage it needs to be resourced to ensure that this does not detract from NOPSA's current responsibilities. |
REC149-3131 | 35 - Business and Industry in relation to industry | The exploration/production operator making all major decisions related to petroleum activities (i.e. selection of rig, well design and selection of service companies) should be made responsible for demonstrating to the regulator that drilling operations can be conducted safely. Where the drilling contractor owns the rig and conducts the day-to-day management of safety on the rig, this duty can be described in a rig specific Safety Case that is owned by the drilling contractor. This rig specific Safety Case does not have to be submitted for every well/well operation. |
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. |
REC149-3139 | 39 - Disaster Risk Management | 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. |
Rec-ID | Code | Recommendation |
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REC121-3683 | 39 - Disaster Risk Management | RailCorp should undertake risk assessments of each of its activities as follows: |
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. |
REC121-3766 | 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. |
REC121-3678 | 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. |
REC121-3700 | 39 - Disaster Risk Management | Maintenance plans on all trains should be revised annually. |
REC121-3752 | 12 - EM agency and authority | RailCorp should establish clear safety accountability statements and reporting lines for all management positions. |
REC121-3664 | 20 - Role of police | The location of the command post for site control at the scene of any rail accident should be identified by NSW Police by a distinctive flashing light. |
REC121-3700 | 12 - EM agency and authority | The RailCorp defects unit should be combined with the passenger fleet maintenance division of RailCorp. |
REC121-3721 | 24 - Govt responsibility | The ITSRR should ensure that OTSI, as a division of ITSRR, co-operates and assists the ATSB in the conduct of any independent investigation by the ATSB of any rail accident or incident in New South Wales. |
REC121-3658 | 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. |
REC121-3689 | 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. |
REC121-3720 | 24 - Govt responsibility | The New South Wales Government should make the necessary arrangements with the Australian Government, including any necessary legislation, for the Australian Transport Safety Bureau (ATSB) to have the power to investigate all rail accidents occurring on the New South Wales rail network the investigation of which may advance the knowledge of the causes of rail accidents in Australia. |
REC121-3684 | 39 - Disaster Risk Management | 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. |
REC121-3710 | 39 - Disaster Risk Management | The ITSRR should have permanent access to the RailCorp intranet. |
REC121-3767 | 24 - Govt responsibility | All accredited rail organisations should be required to re-apply every three years to ITSRR for accreditation. |