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. |
REC258-2541 | 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: |
REC258-2556 | 25 - Inquiry, audit, lessons management and after action review | The Civil Aviation Safety Authority structures all regulations not yet made with the three-tier approach, and subsequently reviews all other Civil Aviation Safety Regulation Parts (in consultation with industry) to determine if they should be remade using the three-tier structure. |
REC258-2534 | 16 - Training and behaviour | The Civil Aviation Safety Authority develops a staff exchange program with industry. |
REC258-2552 | 25 - Inquiry, audit, lessons management and after action review | The Civil Aviation Safety Authority implements a system of using third-party commercial audits as a supplementary tool to its surveillance system. |
REC258-2528 | 25 - Inquiry, audit, lessons management and after action review | The Australian Transport Safety Bureau investigates as many fatal accidents in the sport and recreational aviation sector as its resources will allow. |
REC258-2551 | 25 - Inquiry, audit, lessons management and after action review | The Civil Aviation Safety Authority assures consistency of audits across all regions, and delivers audit reports within an agreed timeframe. |
REC258-2549 | 25 - Inquiry, audit, lessons management and after action review | The Civil Aviation Safety Authority provides full disclosure of audit findings at audit exit briefings in accordance with international best practice. |
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. |
Rec-ID | Code | Recommendation |
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REC236-2793 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that CASA processes in relation to matters highlighted by this investigation be reviewed. This could involve an evaluation benchmarked against a credible peer (such as FAA or CAA) of regulation and audits with respect to: non-RPT passenger carrying operations; approach to audits; and training and standardisation of FOI across regional offices. |
REC236-2792 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that the investigation be re-opened by the ATSB with a focus on organisational, oversight and broader systemic issues. |
REC236-2806 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that the relevant agencies investigate appropriate methods to ensure that information about the incidence of, and variable weather conditions at, Norfolk Island is available to assist flight crews and operators managing risk that may result from unforseen weather events. |
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. |
REC236-2805 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that the relevant agencies review whether any equipment or other changes can be made to improve the weather forecasting at Norfolk Island. The review would include whether the Unicom operator should be an approved meteorological observer. |
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 |
REC236-2801 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that the ATSB review its process to track the implementation of recommendations or safety actions to ensure it is an effective closed loop system. This should be made public, and provided to the Senate Regional and Rural Affairs and Transport Committee prior to each Budget Estimates. |
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. |
REC236-2795 | 25 - Inquiry, audit, lessons management and after action review | The committee recommends that a short inquiry be conducted by the Senate Standing Committee on Rural and Regional Affairs and Transport into the current status of aviation regulatory reform to assess the direction, progress and resources expended to date to ensure greater visibility of the processes. |
Rec-ID | Code | Recommendation |
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REC189-2907 | 29 - Operational Health and Safety | a) For the purposes of designing and implementing its regulatory activities, National Offshore Petroleum Safety Authority (NOPSA) should continue to identify priority hazards and risks and their underlying causes, in consultation with the NOPSA Advisory Board and stakeholders (see Theme 9, Stakeholder engagement). |
REC189-2912 | 29 - Operational Health and Safety | The review team recommend that the safety case system be strengthened by including provisions for a design notification scheme along the lines of that under the British Offshore Safety Case Regulations. |
REC189-2911 | 29 - Operational Health and Safety | The review team recommend that: |
Rec-ID | Code | Recommendation |
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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. |
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. |
Rec-ID | Code | Recommendation |
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REC177-3303 | 29 - Operational Health and Safety | Tracking and analysis of cementing problems/failures should occur to assess industry trends, principal causes, remedial techniques and so on. |
REC177-3344 | 25 - Inquiry, audit, lessons management and after action review | There should be a review to determine whether it is appropriate to introduce a rigorous civil penalty regime and/or substantially increase some or all of the penalties that can be imposed for breaches of legislative requirements relating to well integrity and safety. |
REC177-3282 | 29 - Operational Health and Safety | If a risk assessment or compliance review is triggered by the happening of a predetermined event, specific consideration should be given to whether a ‘hold point’ should be introduced such that work must cease until the problem is resolved (and the subject of appropriate certification). |
REC177-3299 | 29 - Operational Health and Safety | Regulatory approval to rely on only one barrier should not be given unless (i) a proper risk assessment is carried out; (ii) exceptional circumstances exist; and (iii) risks involved are reduced to ‘as low as reasonably practicable’. The default position must be that well integrity must be assured. |
REC177-3333 | 16 - Training and behaviour | Licensees and rig operators (and third party contractors involved in well control operations) should specifically assess, and document, the nature and extent of knowledge/skills of relevant personnel in relation to well control (including familiarity of personnel with agency‐specific requirements and procedures). Training needs and opportunities should be identified. This process should take place on engagement and at appropriate intervals. |
REC177-3281 | 29 - Operational Health and Safety | Wellbore gas bubbling should be regarded as a trigger for independent review of well integrity. Industry and regulators should identify and document other triggers. |
REC144-3387 | 25 - Inquiry, audit, lessons management and after action review | In order that the ACT public can be reassured about the project management and financial planning in relation to the Fairbairn site as a proposed centralised accommodation facility for emergency services, the Auditor-General undertake a review of the project from a financial probity and project management perspective. |
REC177-3295 | 29 - Operational Health and Safety | Wells drilled into hydrocarbon zones should be treated as live wells, with the potential to blowout unless a documented risk assessment establishes otherwise. |
REC177-3332 | 16 - Training and behaviour | A specific focus on well control training should be mandatory for key personnel involved in well control operations (including both on‐rig personnel and onshore personnel in supervisory capacities). |
REC177-3279 | 29 - Operational Health and Safety | Well construction and management plans, and drilling programs, should include provision for testing and verifying the integrity of all barriers as soon as practicable after installation. |
REC177-3378 | 25 - Inquiry, audit, lessons management and after action review | In view of the numerous well integrity problems in all of the Montara Oilfield wells, the Minister should commission a detailed audit of all the other offshore wells operated by PTTEPAA to determine whether they too may suffer from well integrity problems. |
REC177-3294 | 29 - Operational Health and Safety | Perceived time and cost savings relating to any matters impacting upon well control should be subjected to rigorous safety assessment. |
REC177-3331 | 16 - Training and behaviour | Existing well control training programs should be reviewed by the industry, regulators and training providers, with a focus on well control accidents that have occurred (in Australia and overseas). |
REC177-3278 | 29 - Operational Health and Safety | Well construction and management plans should include provision(s) for reviewing the integrity of barriers at safety‐critical times or milestones, such as (i) prior to suspension involving departure of the rig from the platform; (ii) prior to re‐entry of a well after suspension; (iii) prior to removal of any barrier. |
REC177-3374 | 25 - Inquiry, audit, lessons management and after action review | The Minister should, as the JA for the offshore area of the Territory of Ashmore and Cartier Islands, undertake a review of PTTEPAA’s permit and licence to operate at the Montara Oilfield. |
REC177-3293 | 29 - Operational Health and Safety | If a dispute arises between a licensee and a rig operator in relation to a well control issue, and is not resolved between them, the matter must be raised with the relevant regulator before discretionary operations proceed. |
REC177-3321 | 29 - Operational Health and Safety | Careful consideration must be given to equipment compatibility as part of well construction design. |
REC177-3364 | 37 - Funding | The funding arrangements that support the National Plan should be reviewed to ensure that the costs associated with both preparedness and response capability are equitably shared between the shipping and offshore petroleum industries. |
REC177-3288 | 29 - Operational Health and Safety | As soon as a risk of barrier failure arises, no other activities should take place in the well other than those directed to removal of the risk. |
Rec-ID | Code | Recommendation |
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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. |
REC149-3145 | 25 - Inquiry, audit, lessons management and after action review | NOPSA should consider an audit regime that targets Greenfields operations at commencement of operations. |
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. |
REC149-3137 | 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. |
REC149-3136 | 16 - Training and behaviour | There is a need for industry in consultation with NOPSA to establish a priority programme of accredited education modules in the Safety Case regime targeting stakeholders in the regime at their respective levels to improve the understanding of the Safety Case and correspondent responsibilities. |
REC149-3135 | 29 - Operational Health and Safety | The initial acceptance of a new facility Safety Case should be in conjunction with inspection of a facility upon commencement of operations. |
REC149-3147 | 29 - Operational Health and Safety | As all stakeholders have responsibility for safe outcomes, decisions regarding target subjects for safety promotion need to have the support of all stakeholders including NOPSA and the workforce. Industry, which ultimately has the responsibility for managing risk as well as funding the promotion, should take a leadership role in implementation. |