Inquiry Search
Rec-ID | Code | Recommendation |
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REC309-2469 | 12 - EM agency and authority | Entities with disaster management responsibilities need to integrate the eight priorities identified within the Emergency Management Sector Adaptation Plan for Climate Change into their disaster management planning cycle. |
REC309-2467 | 9 - Community education | Further work be undertaken to develop effective public flood risk messaging and community education materials that are easy to understand and tested with the community to ensure flood risk is understood. |
REC309-2474 | 16 - Training and behaviour | The provision of system-wide tools, education, guidance and testing for requests for assistance is strengthened to enhance understanding and outcomes. |
REC309-2471 | 17 - Assets and technology | As part of the annual Emergency Action Plan review for the Ross River Dam, consideration should be given to the potential impacts of operating the gate outside automatic mode and whether this event has provided any new information and learnings which can be incorporated into the Emergency Action Plan. This should occur prior to the 2019/20 wet season. |
Rec-ID | Code | Recommendation |
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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. |
REC002-4010 | 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. |
REC002-4001 | 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. |
REC002-4009 | 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. |
REC002-4008 | 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 |
REC002-4006 | 17 - Assets and technology | The Commisison would not insist upon a barometer being provided at each mine. Experience has proved that this is a tardy index to atmospheric conditions. Serious changes in the atmospheric pressure occur and are felt before they are indicated by a barometer. |
Rec-ID | Code | Recommendation |
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REC295-1299 | 17 - Assets and technology | That systems for Automatic Vehicle Location and personnel tracking be implemented within the emergency services sector. |
REC295-1320 | 17 - Assets and technology | Review existing electronic information systems used by emergency services organisations and other government agencies, and: a) establish a single incident information system across the Emergency Services Sector (MFS, CFS and SES), and b) identify opportunities to consolidate incident information systems of other agencies |
REC295-1329 | 8 - Communications and warnings | Review and update Part 3, Annex C, of the SEMP ‘Public Information and Warnings’ to: a) clarify the role and responsibilities of the Public Information Functional Support Group and control agencies in relation to public information b) define requirements and processes for liaising with the community, including holding community meetings |
REC295-1298 | 12 - EM agency and authority | That the State Emergency Service, in consultation with key stakeholders, identify and implement a robust system and procedures for prioritising, allocating and coordinating multiple tasks. |
REC295-1313 | 16 - Training and behaviour | That regular training and exercising is conducted for all State Emergency Centre participants including Liaison Officers. |
REC295-1325 | 12 - EM agency and authority | Review and reinstate the State Emergency Management Training Officer and State Emergency Management Planning Officer (capability development) positions to operate with a broad, strategic and leadership focus. |
REC295-1296 | 8 - Communications and warnings | That the SES in collaboration with MFS Communications Centre (Comcen) investigate and implement options to reduce the number of calls coming into the Comcen, (particularly on 132500). Options could include better utilisation of the available options on the Interactive Voice Recording and community education to increase community resilience. |
REC295-1306 | 9 - Community education | Develop practical policy outcomes to support resilience (e.g. the 72- hour model) and promote this broadly to community through media, awareness campaigns, policies etc. Research should be undertaken to gain insight into the types of messaging and activities that have the most impact on sustained behaviour change within the community before committing to a particular model. |
REC295-1324 | 16 - Training and behaviour | Establish a State incident management and emergency management training capability which provides for: a) consistent training across the State b) personal development and endorsement processes for roles c) identification, recruitment and development of personnel from other government agencies; and d) incident management and State emergency centre functional role training and development across all sectors. e) skills maintenance including upskills, refresher training and exercises f)incident and strategic leadership training g) consistent training for inter-agency liaison officers at all levels |
REC295-1284 | 16 - Training and behaviour | Deliver consistent and regular training in the use of the SA Government Radio Network to all users to maximise the efficiency and effectiveness of the network in times of emergency e.g. reduce the issues associated with network busy signals. |
REC295-1303 | 16 - Training and behaviour | That the State Emergency Service be provided with resources to enable them to deliver swiftwater awareness training to all first responders including emergency services, SA Police and council crews. |
REC295-1322 | 12 - EM agency and authority | Consider opportunities to identify synergies between the incident management systems used in SA being the, Australasian Interservice Incident Management System (AIIMS) and ICCS Plus. This might include joint training and exercising in roles that are common across both systems. |
REC295-1274 | 35 - Business and Industry in relation to industry | That relevant agencies, such as the Department of State Development, SA Police and emergency services, collaborate to establish an education campaign to encourage businesses in South Australia to develop Business Continuity Plans which, among other potential hazards such as flood and fire, also take into account the potential impact of an extended power outage. |
REC295-1300 | 17 - Assets and technology | That the State Emergency Service explores options for providing suitable personal protective clothing to personnel from supporting emergency services during major flooding events and sandbagging operations. |
REC295-1321 | 16 - Training and behaviour | Through the Emergency Management Workforce Project, identify and provide training and development for SA’s emergency management sector personnel (government agencies, and non-government agencies including volunteers). State Emergency Management Committee should consider supporting recommendations from stage two of the project when the project report is tabled. |
REC295-1335 | 12 - EM agency and authority | Explore alternative emergency management models including the alternative model proposed above to establish a South Australian Emergency Management Office and State Relief and Recovery Office within the South Australian Fire and Emergency Services Commission, to ensure that all the objects and guiding principles of the Emergency Management Act 2004, and State Emergency Management Plan are addressed efficiently and effectively. |
Rec-ID | Code | Recommendation |
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REC281-1205 | 16 - Training and behaviour | Department of Premier and Cabinet Regional Coordinators: Continue to build the capability of the Department of Premier and Cabinet Regional Coordinator role in recovery operations by providing: · on the ground support for Regional Coordinators during recovery operations by REMOs or OEM Recovery Team · training and developmental opportunities for Regional Coordinators to prepare them for working in the disaster recovery environment. |
Rec-ID | Code | Recommendation |
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REC272-1421 | 16 - Training and behaviour | In conjunction with the Queensland Fire and Emergency Services review of guidelines, the Public Safety Business Agency should consider reviewing the cyclone shelter management training package to include guidance to the shelter management team on their roles and responsibilities, and powers available under legislation and how these may be exercised. |
REC272-1418 | 12 - EM agency and authority | Queensland Fire and Emergency Services should consider examining regulatory provisions to improve disaster management and business continuity planning for aged care providers. |
REC272-1414 | 12 - EM agency and authority | Queensland Fire and Emergency Services coordinate the development of an integrated risk based approach to disaster management planning for Queensland that is consistent with the Standard and applicable at all levels of the arrangements. |
Rec-ID | Code | Recommendation |
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REC267-1159 | 9 - Community education | Improving Community Preparedness and Resilience |
REC267-1157 | 35 - Business and Industry in relation to industry | Improvements to the Targeting of Government Support to Build Primary Industry Resilience |
REC267-1150 | 9 - Community education | Media Engagement Consideration should be given on future recovery operations to adopting a more structured approach to media engagement, with regular media briefings undertaken at a frequency dependent upon the phase of the recovery activities and the level of media interest. These briefings could be conducted at different locations around the region, if appropriate, and would provide the opportunity for communication of key messages and provide journalists with the opportunity to ask questions regarding the recovery. This could be complemented by media coverage of community engagement visits. For all recovery operations, |
Rec-ID | Code | Recommendation |
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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. |
REC258-2534 | 16 - Training and behaviour | The Civil Aviation Safety Authority develops a staff exchange program with industry. |
REC258-2546 | 12 - EM agency and authority | The Civil Aviation Safety Authority changes its organisational structure to a client-oriented output model. |
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. |
REC258-2545 | 12 - EM agency and authority | The Australian Transport Safety Bureau transfers its safety education function to the Civil Aviation Safety Authority. |
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: |
REC258-2542 | 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. |
REC258-2553 | 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. |
REC258-2541 | 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: |
REC258-2548 | 17 - Assets and technology | The Civil Aviation Safety Authority shares the risk assessment outputs of Sky Sentinel, its computerised risk assessment system, with the applicable authorisation holder. |
Rec-ID | Code | Recommendation |
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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. |
REC236-2788 | 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 |
REC236-2787 | 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. |
REC236-2797 | 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. |
Rec-ID | Code | Recommendation |
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REC227-2851 | 17 - Assets and technology | I recommend that consideration should be given to acquiring two personal water craft for deployment by appropriately trained and equipped staff of the AFP or the VMRS or both on Christmas Island. |
REC227-2850 | 17 - Assets and technology | I recommend that the AFP be provided with a search and rescue vessel which is suitable to the specific conditions of Christmas Island. I further recommend that steps be taken to ensure that if for any reason the search and rescue vessel is not available, there is a replacement vessel on Christmas Island capable of providing an emergency response in difficult sea conditions. |
REC227-2848 | 17 - Assets and technology | I recommend that the AFP take steps to determine whether access can be obtained to the National Search and Rescue Council endorsed SARMAP program covering the Australian Search and Rescue Region as well as adjoining tiles for Indonesia. Steps should be taken to ensure that if possible coverage would include high traffic areas where SIEVs enter the Australian Search and Rescue region allowing timely search and rescue plans to be drawn up for any potential incidents. |
REC227-2859 | 17 - Assets and technology | I recommend that the issue of RHIB jet intake protection be allocated a high priority and that there be ongoing investigation of possible solutions to reduce the problem. |
REC227-2846 | 17 - Assets and technology | I recommend that Border Protection Command continues to examine ways of improving its surveillance capability around Christmas Island so that the risk of SIEVs arriving undetected is reduced. |
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. |
REC208-0524 | 8 - Communications and warnings | That the Premier issue clear and unambiguous guidelines to all Government Ministers specifying the timing of notifications to the public of any matters that may affect public health or safety. |
Rec-ID | Code | Recommendation |
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REC158-3431 | 17 - Assets and technology | That port/channel managers are required to identify in the declared asset system (in conjunction with the emergency services) critical Level 1 declared assets and other Level 2 declared assets, that may be required in support of a marine emergency within the port, and that identified resource availability, accessibility and call out time is recorded. |
REC158-3430 | 17 - Assets and technology | That the nominated marine safety authority is responsible for development of a declared asset system and is required to ensure that port/channel managers utilise and maintain the declared asset system. |
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. |
REC158-3432 | 17 - Assets and technology | That port/channel managers are required to ensure, through service agreements, licensing, direct acquisition or other means as appropriate, the availability of the critical Level 1declared assets. |
Rec-ID | Code | Recommendation |
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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. |
REC149-3137 | 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. |
REC149-3133 | 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. |
Rec-ID | Code | Recommendation |
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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. |
REC137-3530 | 16 - Training and behaviour | I recommend that Civil Aviation Safety Authority (CASA) expedite the introduction of mandatory crew resource management training. |
Rec-ID | Code | Recommendation |
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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. |
REC121-3716 | 16 - Training and behaviour | Train driver and guard training should encourage teamwork and discourage authority gradients. |
REC121-3669 | 16 - Training and behaviour | All operational rail staff should be trained by RailCorp in the action check list relevant to each. |
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. |
REC121-3678 | 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. |
REC121-3715 | 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. |
REC121-3658 | 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. |
REC121-3744 | 16 - Training and behaviour | All RailCorp operational personnel should be trained in the location and operation of external emergency door release mechanisms. |
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. |
REC121-3766 | 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. |
REC121-3714 | 16 - Training and behaviour | RailCorp should use its simulators in an interactive manner. |
REC121-3656 | 17 - Assets and technology | Satellite telephones should be provided by RailCorp to all rail commanders at any emergency. |
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. |
REC121-3675 | 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. |
REC121-3756 | 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. |
REC121-3708 | 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. |
REC121-3654 | 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. |
REC121-3718 | 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. |
REC121-3672 | 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. |
REC121-3752 | 12 - EM agency and authority | RailCorp should establish clear safety accountability statements and reporting lines for all management positions. |
REC121-3700 | 12 - EM agency and authority | The RailCorp defects unit should be combined with the passenger fleet maintenance division of RailCorp. |
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. |
REC121-3717 | 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. |
REC121-3670 | 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. |
REC121-3751 | 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. |
Rec-ID | Code | Recommendation |
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REC008-3985 | 17 - Assets and technology | The Commission recommends that conductors carrying currents at medium pressure should not be encased in wood in damp places. |
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. |
REC008-3990 | 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. |
REC008-3989 | 17 - Assets and technology | The Commission recommends that there be continuous supervision of every chamber in which electrical machinery is worked by currents of medium pressure. |
REC008-3987 | 17 - Assets and technology | The Commission recommends that systematic tests be made and recorded of apparatus and circuits as a precaution against fire and so that any gradual deterioration of the system may be detected. |
REC008-3986 | 17 - Assets and technology | The Commission recommends that every precaution be taken to keep water off electrical machinery. |
Rec-ID | Code | Recommendation |
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REC004-3992 | 17 - Assets and technology | That the use of a spark-arrester and cinder-arrester by the Railway Department shall not constitute a defence to an action for damage caused by fire escaping from a locomotive, unless the Department proves that such spark-arrester and cinder-arrester were in a thoroughly efficient condition when the fire took place. |
REC004-3996 | 17 - Assets and technology | That the standard pattern of cinder arrester be affixed to the ash-pans in all locomotives during the summer months. |
REC004-3994 | 17 - Assets and technology | That the Railway Department, while gradually reducing the number of different types of locomotives, should steadily keep in view the adoption of English and American railway practice, by providing engines with larger boilers, fire boxers, and smoke-boxes, and with wide blast-pipes, in order to insure ample steaming power with a minimum of forced draught. |