Inquiry Search
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. |
REC002-4001 | 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. |
REC002-4011 | 32 - Doctrine, standards, and reform | The Commission feel that the 4th clause in the present Act, relating to the spacing of cut-throughs, should be amended to admit of any convenient or safe system of mining being pursued. This is a matter of detail that would be better out of the Act. The Commission would advise that the word should not occur at all, and that, if bratticing be used, or the air by some other satisfactory device be conveyed to the face, scope would be given to Managers to introduce systems of mining adapted to the circumstance of each particular coal-seam, with advantage to all concerned. |
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 |
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. |
REC258-2531 | 32 - Doctrine, standards, and reform | The Civil Aviation Safety Authority’s Board exercises full governance control. The nonexecutive directors should possess a range of appropriate skills and backgrounds in aviation, safety, management, risk, regulation, governance and government. |
REC258-2538 | 32 - Doctrine, standards, and reform | The Department of Infrastructure and Regional Development and Department of Defence (and appropriate agencies) establish an agreed policy position on safety oversight of civil operations into joint user and military airports. |
REC258-2562 | 32 - Doctrine, standards, and reform | The Civil Aviation Safety Authority amends the current Terms of Reference of the Industry Complaints Commissioner so that: |
REC258-2529 | 32 - Doctrine, standards, and reform | The Australian Transport Safety Bureau and the Civil Aviation Safety Authority utilise the provision in their bilateral Memorandum of Understanding to accredit CASA observers to ATSB investigations. |
REC258-2537 | 32 - Doctrine, standards, and reform | The Civil Aviation Safety Authority delegates responsibility for the day-to-day operational management of airspace to Airservices Australia, including the designation of air routes, short term designations of temporary Restricted Areas, and temporary changes to the classification of airspace for operational reasons. |
REC258-2559 | 15 - Inter-service cooperation | The Civil Aviation Safety Authority’s Director of Aviation Safety meet with industry sector leaders to jointly develop a plan for renewing a collaborative and effective Standards Consultative Committee. |
REC258-2527 | 32 - Doctrine, standards, and reform | The Department of Infrastructure and Regional Development plays a stronger policy role in the State Safety Program. |
REC258-2536 | 32 - Doctrine, standards, and reform | The Australian Transport Safety Bureau and the Civil Aviation Safety Authority amend the wording of their existing Memorandum of Understanding to make it more definitive about interaction, coordination, and cooperation. |
REC258-2555 | 32 - Doctrine, standards, and reform | The Civil Aviation Safety Authority changes the current two-tier regulatory framework (act and regulations) to a three-tier structure (act, regulations and standards), with: |
REC258-2535 | 32 - Doctrine, standards, and reform | Airservices Australia, in conjunction with the Department of Infrastructure and Regional Development and the Civil Aviation Safety Authority, reconsiders the policy on ‘Assessment of Priorities’ that stipulates that air traffic controllers sequence arriving aircraft based on category of operation, rather than on the accepted international practice of ‘first come, first served’. |
REC258-2554 | 32 - Doctrine, standards, and reform | Recreational Aviation Administration Organisations, in coordination with the Civil Aviation Safety Authority, develop mechanisms to ensure all aircraft to be regulated under CASR Part 149 are registered. |
REC258-2533 | 32 - Doctrine, standards, and reform | The Civil Aviation Safety Authority: |
Rec-ID | Code | Recommendation |
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REC236-2807 | 32 - Doctrine, standards, and reform | The committee recommends that the Aeronautical Information Package (AIP) En Route Supplement Australia (ERSA) is updated to reflect the need for caution with regard to Norfolk Island forecasts where the actual conditions can change rapidly and vary from forecasts. |
REC236-2784 | 32 - Doctrine, standards, and reform | The committee recommends that the minister, in issuing a new Statement of Expectations to the ATSB, valid from 1 July 2013, make it clear that safety in aviation operations involving passengers (fare paying or those with no control over the flight they are on, e.g. air ambulance) is to be accorded equal priority irrespective of flight classification. |
REC236-2794 | 32 - Doctrine, standards, and reform | The committee recommends that CASA, in consultation with an Emergency Medical Services industry representative group (eg. Royal Flying Doctor Service, air ambulance operators, rotary wing rescue providers) consider the merit, form and standards of a new category of operations for Emergency Medical Services. The minister should require CASA to approve the industry plan unless there is a clear safety case not to. Scope for industry to assist as part of an audit team should also be investigated where standardisation is an issue. This should be completed within 12 months and the outcome reported publicly. |
REC236-2804 | 32 - Doctrine, standards, and reform | The committee recommends that Airservices Australia discuss the safety case for providing a hazard alert service with Fijian and New Zealand ATC (and any other relevant jurisdictions) and encourage them to adopt this practice. |
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. |
REC236-2803 | 32 - Doctrine, standards, and reform | The committee recommends that the government consider setting a time limit for agencies to implement or reject recommendations, beyond which ministerial oversight is required where the agencies concerned must report to the minister why the recommendation has not been implemented or that, with ministerial approval, it has been formally rejected. |
REC236-2789 | 32 - Doctrine, standards, and reform | The committee recommends that the Transport Safety Investigation Act 2003 be amended to require that the Chief Commissioner of the ATSB be able to demonstrate extensive aviation safety expertise and experience as a prerequisite for the selection process. |
REC236-2802 | 32 - Doctrine, standards, and reform | The committee recommends that where the consideration and implementation of an ATSB recommendation may be protracted, the requirement for regular updates (for example 6 monthly) should be included in the TSI Act. |
REC236-2786 | 32 - Doctrine, standards, and reform | The committee recommends that the ATSB be required to document investigative avenues that were explored and then discarded, providing detailed explanations as to why. |
REC236-2798 | 32 - Doctrine, standards, and reform | The committee recommends that, where relevant, the ATSB include thorough human factors analysis and discussion in future investigation reports. Where human factors are not considered relevant, the ATSB should include a statement explaining why. |
REC236-2785 | 32 - Doctrine, standards, and reform | The committee recommends that the ATSB move away from its current approach of forecasting the probability of future events and focus on the analysis of factors which allowed the accident under investigation to occur. This would enable the industry to identify, assess and implement lessons relevant to their own operations. |
REC236-2796 | 32 - Doctrine, standards, and reform | The committee recommends that the ATSB-CASA Memorandum of Understanding be re-drafted to remove any ambiguity in relation to information that should be shared between the agencies in relation to aviation accident investigations, to require CASA to: |
Rec-ID | Code | Recommendation |
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REC227-2857 | 21 - Role of Commonwealth Government | I recommend that the Commonwealth ensure that there is a mooring buoy which will enable the mooring of SIEVs to take place and free up the Christmas Island response vessel for ongoing surveillance duties. |
REC227-2855 | 32 - Doctrine, standards, and reform | I recommend that arrangements be put in place which would remove the requirements for Masters of Volunteer Marine Rescue vessels to hold a commercial certificate of competency. Operators could then be qualified through the FESA Volunteer Marine Rescue Training pathway as skippers and crew. This would increase the number of available skippers in the event of a search and rescue incident and would make appropriate training easier to arrange. |
REC227-2853 | 21 - Role of Commonwealth Government | I recommend that the Commonwealth liaise closely with representatives of the Christmas Island VMRS prior to purchasing or replacing any vessels for the VMRS in the future. |
REC227-2852 | 21 - Role of Commonwealth Government | I recommend that the Commonwealth and the Shire of Christmas Island take steps to ensure that the Ethel Beach boat ramp is significantly upgraded, that it should be provided with shelter in the form of a rock groyne or similar buffer and that provision should be made so that a person can walk beside the ramp on a stable footing; or If this is not considered likely to be effective in providing an appropriate means of deploying a rescue vessel in adverse conditions, such other action be taken as is necessary to ensure that there is a means of deploying a rescue vessel in adverse conditions. |
REC227-2847 | 15 - Inter-service cooperation | I recommend that Border Protection Command implement a surveillance strategy, possibly with the assistance of other Commonwealth authorities and organisations on the island such as the AFP, which heightens its coverage at times when the weather and sea conditions are rough. |
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. |
REC208-0530 | 32 - Doctrine, standards, and reform | That, if necessary, regulation be amended to require Health to approve any script used by any party concerned, for door knocking or other information dissemination, if Health is not the first source of information to affected residents. |
REC208-0529 | 32 - Doctrine, standards, and reform | That, when developing requirements concerning pollution incident response management plans pursuant to the recent legislative amendments, the Office of Environment and Hertiage include appropriate definitions as to the meaning of ‘immediately’, and when ‘material harm to the environment is caused or threatened’. |
REC208-0528 | 32 - Doctrine, standards, and reform | That, as part of the Pollution Incident Management Response Plan to be developed for Orica’s Kooragang Island site, or by another appropriate mechanism, the Office of Environment and Heritage ensure that Orica’s incident-response procedures address the need to consider all relevant factors when assessing potential impacts, including the height and force of emissions as well as the location of any onsite fallout and whether there are off-site impacts following all serious incidents. |
Rec-ID | Code | Recommendation |
---|---|---|
REC189-2913 | 21 - Role of Commonwealth Government | In developing and improving its policies and practices for stakeholder engagement, NOPSA should ensure that: |
REC189-2910 | 21 - Role of Commonwealth Government | NOPSA should: |
REC189-2909 | 32 - Doctrine, standards, and reform | Equipping the regulator with a wider range of compliance tools under the legislation should continue to be a policy priority. The aim should be to enhance the regulator’s capacity to secure compliance in an appropriately graduated way. The opportunity should be taken to ensure that the regulator and inspectors can, in appropriate cases, bring proceedings that do not require referral to the Commonwealth Director of Public Prosecutions, such as actions for civil penalties or injunctions. |
REC189-2908 | 21 - Role of Commonwealth Government | To ensure that NOPSEMA is in a strong position to perform its functions effectively: |
REC189-2906 | 21 - Role of Commonwealth Government | In order to improve the effectiveness of National Offshore Petroleum Safety and Environmental Management Authority (NOPSEMA), with similar benefits for State or Territory regulators, attention should be given to the following actions. |
REC189-2914 | 32 - Doctrine, standards, and reform | The review team recommend that: |
Rec-ID | Code | Recommendation |
---|---|---|
REC158-3440 | 32 - Doctrine, standards, and reform | That the Water Division Emergency Response Plan is amended, by the Water Division emergency response coordinator, to provide a framework to coordinate a marine response that crosses declared port water boundaries and requires resource coordination and prioritisation. |
REC158-3447 | 15 - Inter-service cooperation | That emergency services are required to work directly with port/channel managers and the nominated marine safety authority to ensure that a training and exercise regime is established to enable emergency services personnel to develop and maintain the skills and knowledge relevant to marine emergency management. |
REC158-3434 | 32 - Doctrine, standards, and reform | That the accountability relationship between Harbour Masters and the Director of Marine Safety is strengthened in the relevant legislation. |
REC158-3439 | 32 - Doctrine, standards, and reform | That the port marine emergency management arrangements are integrated with the Victorian Water Division Emergency Response Plan. |
REC158-3446 | 15 - Inter-service cooperation | That emergency services are required to work directly with port/channel managers and the nominated marine safety authority to identify and ensure availability of marine resources necessary for emergency services to meet their statutory obligations in responding to marine emergencies (this recommendation should be read in conjunction with recommendation 26 & 27). |
REC158-3427 | 32 - Doctrine, standards, and reform | That the standards and guidelines determined by the nominated marine safety authority require port/channel managers to conduct a marine emergency risk assessment using AS/NZ 4360:2004 Risk Management and, in addition, must require port/channel managers to: |
REC158-3453 | 32 - Doctrine, standards, and reform | That, where applicable, consideration is given to legislative amendment that will enable the findings of this report to be applied to areas inside State waters but outside commercial port waters. |
REC158-3438 | 32 - Doctrine, standards, and reform | That the port/channel managers coordinate marine emergency management planning in the port and are required to ensure that individual port stakeholder marine emergency management arrangements plans are integrated with the whole of port marine emergency management arrangements. |
REC158-3445 | 15 - Inter-service cooperation | That emergency services are required to work directly with ports and the nominated marine safety authority when ports are preparing marine emergency response arrangements. |
REC158-3426 | 32 - Doctrine, standards, and reform | That the nominated marine safety authority, in consultation with the Emergency Services Commissioner, senior emergency services personnel and relevant port stakeholders, is responsible for establishing appropriate performance standards, risk management guidelines and good practice guidelines for marine emergency management. |
REC158-3451 | 37 - Funding | That port/channel managers should be able, within the general context of the pricing/cost recovery arrangements established under the Port Services Act 1995 and pricing determinations made by the Essential Services Commission, to recover the reasonable costs of meeting their statutory obligations (as per recommendation 26) through charges for prescribed service applied to port users. |
REC158-3437 | 32 - Doctrine, standards, and reform | That port/channel managers coordinate marine emergency planning for the port and are required to ensure that marine emergency arrangements are integrated with whole of port emergency management plans. |
REC158-3444 | 15 - Inter-service cooperation | That the Office of the Emergency Services Commissioner ensures that an emergency services multi-agency working group is established to develop a specialist marine emergency response capability for Victoria based on the multi-agency Urban Search and Rescue (USAR) model. The specialist personnel should be required to have: |
REC158-3425 | 32 - Doctrine, standards, and reform | Consequential or complementary amendments to the Emergency Management Act are required to ensure that: |
REC158-3450 | 37 - Funding | That emergency services are responsible for funding the development of the emergency services marine emergency response capacity/capability to meet their statutory obligations. |
REC158-3436 | 32 - Doctrine, standards, and reform | That Harbour Masters are the designated principle marine specialists within the port and work directly with emergency services to provide advice and the interface with the marine legislative powers, to manage a marine emergency. |
REC158-3441 | 32 - Doctrine, standards, and reform | That, where practical, risk assessments, emergency planning, training and exercising are integrated to minimise duplication of effort. |
REC158-3424 | 32 - Doctrine, standards, and reform | That legislation is prepared by the Department of Transport to ensure marine emergency management arrangements are clarified and provide: |
REC158-3449 | 37 - Funding | That port/channel managers are responsible for funding the preparation of marine emergency risk assessments and marine emergency response arrangements and ensuring the availability of identified marine resources in support of response to a marine emergency, to meet their statutory obligations. |
REC158-3435 | 32 - Doctrine, standards, and reform | That Harbour Masters have the appropriate powers, authority, accountability, skills, responsibility and indemnity to provide a coordinated response of marine resources in support of emergency services, except where the nominated marine safety authority is the control agency for a marine pollution or marine casualty emergency. |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC149-3146 | 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. |
REC149-3132 | 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. |
REC149-3143 | 21 - Role of Commonwealth Government | The role of the advisory Board, namely to give advice to Ministers and NOPSA when asked, should be made clear to Board members and all stakeholders. The Board and NOPSA should consider the need for a clear description of who does what based on the legislated responsibilities of the NOPSA CEO. |
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. |
REC149-3141 | 32 - Doctrine, standards, and reform | NOPSA should complete the next revision of Safety Case guidelines in consultation and agreement with stakeholders and continue its program to achieve consistency with a firmer hand from the CEO and management. |
REC149-3130 | 32 - Doctrine, standards, and reform | The regulations pertaining to vessels of opportunity or their interpretation should be changed to facilitate a risk based approach to regulation. This approach will be consistent with the approach taken in other jurisdictions. |
REC149-3140 | 32 - Doctrine, standards, and reform | The industry should provide advice to NOPSA on where the regulations do not provide sufficient clarity and consider developing broad policy/process guidelines in consultation with the regulator to provide clarity and consistency. Regulators should not take personal views or preferences. |
REC149-3129 | 32 - Doctrine, standards, and reform | The consequences of the disapplication of the Navigation Act 1912 should be analysed, the actual consequences identified and unintended consequences addressed. |
REC149-3134 | 32 - Doctrine, standards, and reform | Improved and agreed guidelines for Safety Case application and assessment, including suggested structure and content, would alleviate many current problems related to Safety Case processes. |
Rec-ID | Code | Recommendation |
---|---|---|
REC137-3531 | 32 - Doctrine, standards, and reform | I recommend that CASA consider creating firm guidelines that require consideration of workload, lines of authority, potential conflicts of interest and any other factors that impact upon the ability of “key personnel” to discharge their responsibilities within an aviation organisation when its officers are approving appointments to those positions. |
REC137-3533 | 21 - Role of Commonwealth Government | Accordingly I recommend that the Federal Minister for Transport, consider engaging an external consultant to assess whether high level intervention is warranted. |
Rec-ID | Code | Recommendation |
---|---|---|
REC121-3662 | 32 - Doctrine, standards, and reform | The rail displan should provide for the site controller to have complete control of the site, with other agencies co-ordinating with and supporting him or her, until the rescue phase of the emergency response has been completed. |
REC121-3705 | 32 - Doctrine, standards, and reform | The ITSRR should develop standards for periodic medical examinations which include the following: |
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. |
REC121-3750 | 32 - Doctrine, standards, and reform | ITSRR should initiate and/or participate in the development of a national standard for crashworthiness of all passenger trains. |
REC121-3690 | 32 - Doctrine, standards, and reform | All communications protocols must be strictly enforced by all accredited rail organisations. |
REC121-3769 | 32 - Doctrine, standards, and reform | The ITSRR should continue to participate in the development of a national system for rail safety regulation, provided that any ultimate agreement between the States and Territories and the Australian Government does not produce a safety outcome for New South Wales that is less than would be achieved by the implementation of all the recommendations contained in this report. |
REC121-3661 | 32 - Doctrine, standards, and reform | The rail displan should include provision for the appointment of a rail emergency management co-ordinator at the RMC, and an on-site rail commander with the sole function of assisting and supporting the emergency services during the rescue phase of the emergency response. |
REC121-3701 | 32 - Doctrine, standards, and reform | Train inspections should be carried out at the time of stabling RailCorp trains, as well as a part of train preparation prior to entering service. |
REC121-3674 | 32 - Doctrine, standards, and reform | Uniform verbal descriptions identifying that power has been isolated should be developed by RailCorp and utilised by all railway personnel, electrical service providers and all emergency response personnel. |
REC121-3736 | 32 - Doctrine, standards, and reform | The RailCorp passenger containment policy must be abandoned. |
REC121-3688 | 32 - Doctrine, standards, and reform | Communications procedures must be standardised throughout the rail network, so that all railway employees describe the same subject matter in an identical way. |
REC121-3763 | 32 - Doctrine, standards, and reform | The ITSRR should publish guidelines to be followed by accredited organisations. |
REC121-3660 | 32 - Doctrine, standards, and reform | The rail displan should include the use by all emergency response personnel of a uniform incident command system, involving procedures for such matters as the establishment of inner and outer perimeters, control of access to the site, orderly evacuation of injured passengers and the establishment of a staging area remote from the accident site, in a unified command structure with the site controller co-ordinating the various emergency services through representatives of each service. |
REC121-3699 | 32 - Doctrine, standards, and reform | All reported train defects should be certified by a person in a supervisory position in RailCorp as having been rectified. |
REC121-3773 | 32 - Doctrine, standards, and reform | The ITSRR should ensure that RailCorp establishes a safety management system containing the 29 elements identified in the SMSEP report, and ensure the ongoing monitoring and improvement of the safety management system established. |
REC121-3671 | 32 - Doctrine, standards, and reform | The RailCorp emergency response plan should include a requirement for the debriefing of all senior rail and emergency response personnel involved in any rail accident, so as to determine the way or ways in which emergency response arrangements for rail accidents can be continually improved, and thereafter implement such improvements. |
REC121-3730 | 32 - Doctrine, standards, and reform | Legislation should be enacted and any necessary arrangements made, to enable the ATSB to review any reports of any investigation by a rail organisation or the OTSI into any serious incident or accident in New South Wales. |
REC121-3686 | 32 - Doctrine, standards, and reform | The standard in relation to the collection and use of data from data loggers should provide that such information must be accessed in the circumstances of any accident or incident and can be accessed to monitor driver performance generally. |
REC121-3762 | 32 - Doctrine, standards, and reform | The Chief Executive of ITSRR should have sole accountability and responsibility for the regulation of rail safety in New South Wales. |
REC121-3659 | 32 - Doctrine, standards, and reform | A railway disaster plan, or rail displan, should be developed by RailCorp and the emergency services to ensure co-ordinated inter-agency response to rail accidents and incidents on the RailCorp network. |
REC121-3698 | 32 - Doctrine, standards, and reform | No RailCorp train should enter into revenue service or remain in service if, in the opinion of the driver in charge of that train, any defect in it creates a risk of injury. |
REC121-3772 | 32 - Doctrine, standards, and reform | RailCorp should establish a safety management system containing the 29 elements identified in the SMSEP report which is in volume 2 of this report. |
REC121-3668 | 32 - Doctrine, standards, and reform | The RailCorp emergency response plan should include action checklists of the steps that each employee is required to take, and the order for specific employees to follow in case of emergency. |
REC121-3728 | 32 - Doctrine, standards, and reform | Any barriers to communication between OTSI and ITSRR should be removed, so as to ensure that any findings made by OTSI in relation to any investigation it conducts are reported immediately to ITSRR. |
REC121-3685 | 32 - Doctrine, standards, and reform | The ITSRR should impose a standard in relation to the collection and use of data from data loggers. |
REC121-3761 | 32 - Doctrine, standards, and reform | Legislative changes should be enacted to ensure the complete independence of ITSRR from the Minister for Transport Services. |
REC121-3655 | 32 - Doctrine, standards, and reform | Procedures should be put in place by RailCorp to ensure that electrical power supply to the area of an accident can be immediately isolated, if necessary, in the event of a rail accident, so as to reduce any risk of exposure of emergency response personnel to injury or harm. |
REC121-3696 | 32 - Doctrine, standards, and reform | Defects reporting, recording and rectification should be integrated with the RailCorp regimes for train maintenance. |
REC121-3771 | 32 - Doctrine, standards, and reform | RailCorp should establish an integrated safety management system which includes the following: |
REC121-3667 | 32 - Doctrine, standards, and reform | RailCorp should develop and implement an emergency response plan for management of all rail accidents. Such a plan should be subsumed by the rail displan in the case of serious accidents or incidents. |
REC121-3727 | 32 - Doctrine, standards, and reform | The relevant legislation should be amended to provide expressly that OTSI and the Chief Investigator have the power to initiate a rail accident or incident investigation. |
REC121-3679 | 32 - Doctrine, standards, and reform | The rail safety regulator should set standards for the design, manufacture, testing and commissioning of rolling stock to ensure that the rolling stock is fit for its purpose. |
REC121-3760 | 32 - Doctrine, standards, and reform | The Advisory Board established under the Transport Legislation Amendment (Safety and Reliability) Act 2003 must be abolished. |
REC121-3692 | 32 - Doctrine, standards, and reform | Communications protocols and procedures should be standardised and mandated by regulations making them a condition of accreditation. |
REC121-3770 | 32 - Doctrine, standards, and reform | A safety management system regulation should be promulgated, specifying the requirements of safety management systems in all accredited organisations, using Annexure I to this report as a guide |
Rec-ID | Code | Recommendation |
---|---|---|
REC008-3991 | 32 - Doctrine, standards, and reform | The Commission recommends that the provisios of section 185 of the "Mining Act 1905" relating to exits from coal mines be extended to metalliferous mines employing more than 20 men in any one shift. |
Rec-ID | Code | Recommendation |
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REC004-3993 | 32 - Doctrine, standards, and reform | That in any case where there is primá facie evidence of a fire, creating damage to the extent of $100 or upwards in value, having been caused by the escape of particles of lighted matter from a locomotive engine, or by the action of railway employes in burning off grass or other inflammable material along any line of railway, a Special Board of Inquiry shall investigate and report on the subject, such Board to consist of a Police Magistrate as Chairman, with a railway officer and a competent person chosen from outside the State service as members. |
REC004-4000 | 32 - Doctrine, standards, and reform | That section 22 of the Police Offences Act 1890 be amended, to enable the burning of grass and debris along the railway lines in the summer season to be carried out at an earlier hour than two o'clock in the afternoon, when, in the judgement of the railway inspectors, it is safe and necessary to do so. |
REC004-3995 | 32 - Doctrine, standards, and reform | That the standard double arrester, fitted to the locomotives during the summer months, be subjected to more careful daily inspection before and after each journey during such months, in addition to the present periodical examination by the locomotive foreman and boiler inspector; and that any omission of this duty on the part of the running staff be severely punished. |