Inquiry Search
Rec-ID | Code | Recommendation |
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REC002-4013 | 19 - Offences | Infringement of the regulations by either party should be followed by a summary form of justice, instituted before two Magistrates. |
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. |
REC002-4006 | 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. |
REC002-4002 | 19 - Offences | Where safety-lamps are necessary - gas being present for (say) one month after being found in dangerous quantity - they should be securely locked by a man duly appointed, and tampering with them must be punishable by a simple and inexpensive process of law. |
Rec-ID | Code | Recommendation |
---|---|---|
REC295-1308 | 24 - Govt responsibility | That the Department of the Premier and Cabinet revise the ministerial documents relating to emergency management. |
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. |
REC295-1319 | 24 - Govt responsibility | That a single emergency service multi-agency control centre be established with sufficient capacity and capability to deal with all types of emergency incidents in SA. Also consider Police and State Emergency Centre. |
REC295-1299 | 17 - Assets and technology | That systems for Automatic Vehicle Location and personnel tracking be implemented within the emergency services sector. |
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 |
REC295-1307 | 20 - Role of police | That, as with earthquake, SA Police be designated the Control Agency under the State Emergency Management Plan for black system events or other major power outages. |
REC295-1283 | 7 - Inter-agency communication | Consider bringing other agencies onto the SA Government Radio Network, in particular, Department of Education and Child Development and local government, to support more effective coordination and provide a reliable communications contingency during emergencies. |
REC295-1318 | 24 - Govt responsibility | That the recommendation made following the Pinery bushfire, ‘to review control facilities at State, region and incident level’, be expanded to include all emergency services facilities that will be utilised for major incidents other than bushfire e.g. flood and earthquake and to also be extended into metropolitan areas, and implemented. |
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. |
REC295-1326 | 14 - Incident Mgt Teams | Establish a State-wide resourcing capability to support incident management teams, regional coordination centres, zone emergency centres, relief centres, recovery centres and State control centres. some of the features of such a capability should include: a) multi-agency, cross-government, State-wide pool of incident management and emergency management personnel building on the State incident management team concept currently facilitated by the Country Fire Service, and expanded to include all hazards, multiagency teams with a roster that provides year-round coverage b) a system that enables staff and volunteers from any agency to identify their availability for upcoming shifts c) a rostering system that enables one or more incident management teams, staging areas, regional coordination centres, State control centres and relief centres to develop, maintain and distribute rosters and structure charts in a more coordinated manner d) identifying areas of expertise for key incident and emergency management functions (e.g. public information, alerts and warning, media liaison, logistics and resource management) that would benefit from a coordinated and resource pooling approach and take steps to implement (consider the Mapping Functional Support Group model as a potential service delivery model). |
REC295-1305 | 18 - Access to fire ground | That the annexure to the State Emergency Management Plan, ‘Traffic management during emergencies’, be updated to include: responsibilities and processes for road closures; and, Department of Planning, Transport and Infrastructure requirements in regards to provision of road closure information, notification of changes in road closure status and publishing of that information. |
REC295-1278 | 20 - Role of police | That SA Police develop an evacuation plan for the Adelaide Central Business District (CBD) which includes: |
REC295-1316 | 24 - Govt responsibility | That the position of Deputy Director, Office for Digital Government is dedicated to the Office for Digital Government; and that people throughout DPC are identified and trained to perform appropriate roles within the State Crisis Centre |
REC295-1291 | 24 - Govt responsibility | That the Flood Reform Task Group, as proposed by the Department |
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 |
REC295-1304 | 20 - Role of police | That SA Police, as the control agency for search and rescue, and State Emergency Service who have the responsibility for providing search and rescue services under the State Emergency Management Plan, develop a swiftwater rescue capability plan that describes key swiftwater risk locations, roles and responsibilities of emergency services, State swiftwater resources and dispatch arrangements. |
REC295-1313 | 16 - Training and behaviour | That regular training and exercising is conducted for all State Emergency Centre participants including Liaison Officers. |
REC295-1288 | 24 - Govt responsibility | That Attorney General’s Department explore options to overcome fatigue and welfare issues of SAGRN staff associated with emergency events of extended duration. |
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. |
REC295-1303 | 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. |
REC295-1312 | 24 - Govt responsibility | That the Department of Education and Child Development be included as a member of State Emergency Management Council and represented in the State Emergency Centre. |
REC295-1285 | 7 - Inter-agency communication | Identify, document and communicate contingency arrangements and procedures for emergency services in the event SA Government Radio Network paging is turned off to conserve power, or other loss of paging capacity. |
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 |
REC295-1300 | 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. |
Rec-ID | Code | Recommendation |
---|---|---|
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 |
---|---|---|
REC267-1149 | 15 - Inter-service cooperation | PES External Surge Program The success of the PES External Surge Program and the willingness of participants to deploy at short notice to support the recovery effort is commendable, as is the readiness of their supervisors to release them from their duties to enable deployment. The Program, supported by an appropriate training program, is one that should be sustained as part of the whole of Government recovery readiness effort. |
REC267-1151 | 24 - Govt responsibility | Government Communications Coordination |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
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 |
---|---|---|
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. |
REC121-3767 | 24 - Govt responsibility | All accredited rail organisations should be required to re-apply every three years to ITSRR for accreditation. |
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. |
REC121-3711 | 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. |
REC121-3744 | 16 - Training and behaviour | All RailCorp operational personnel should be trained in the location and operation of external emergency door release mechanisms. |
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. |
REC121-3718 | 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. |
REC121-3751 | 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. |
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. |
REC121-3732 | 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. |
REC121-3738 | 29 - Operational Health and Safety | All passenger trains must be fitted with an internal passenger emergency door release. |
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. |
REC121-3663 | 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. |
REC121-3709 | 29 - Operational Health and Safety | RailCorp should provide access to electronic versions of safety documentation for all operational staff at their workplace. |
REC121-3743 | 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”. |
REC121-3670 | 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. |
REC121-3717 | 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. |
REC121-3749 | 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”. |
REC121-3680 | 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. |
REC121-3731 | 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: |
REC121-3737 | 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. |
REC121-3759 | 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: |
REC121-3656 | 17 - Assets and technology | Satellite telephones should be provided by RailCorp to all rail commanders at any emergency. |
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. |
REC121-3742 | 19 - Offences | The risk of abuse of internal passenger emergency door releases should be further reduced by introducing significant penalties for any improper use of such an emergency facility. It should be a criminal offence for anyone to use or tamper improperly with an emergency escape facility in a train. |
REC121-3669 | 16 - Training and behaviour | All operational rail staff should be trained by RailCorp in the action check list relevant to each. |
REC121-3716 | 16 - Training and behaviour | Train driver and guard training should encourage teamwork and discourage authority gradients. |
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. |
REC121-3677 | 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. |
REC121-3721 | 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. |
REC121-3735 | 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. |
REC121-3756 | 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. |
REC121-3654 | 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. |
REC121-3706 | 29 - Operational Health and Safety | RailCorp should establish a comprehensive safety document management system. |
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. |
REC121-3666 | 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. |
REC121-3715 | 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. |
REC121-3747 | 29 - Operational Health and Safety | All trains should have windows available through which passengers can escape. |
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. |
REC121-3720 | 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. |
REC121-3734 | 29 - Operational Health and Safety | RailCorp should integrate its management of occupational health and safety into its overall safety management. |
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. |
REC121-3702 | 29 - Operational Health and Safety | Random alcohol testing should be continued. |
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. |
REC121-3665 | 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. |
REC121-3714 | 16 - Training and behaviour | RailCorp should use its simulators in an interactive manner. |
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. |
REC121-3675 | 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. |
REC121-3719 | 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. |
REC121-3754 | 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. |
REC121-3650 | 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. |
REC121-3682 | 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. |
REC121-3733 | 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. |