Inquiry Search
Rec-ID | Code | Recommendation |
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REC324-4303 | 39 - Disaster Risk Management | Risk-based approach to calculating flood planning: That, to take account of greater knowledge of climate change, Government reinforce its adoption of a risk-based approach to calculating the flood planning level for planning purposes and, through the NSWRA, immediately start a process of revising all flood planning level calculations in the state’s high-risk catchments. Flood planning level re-determinations for all high-risk catchments should be completed within 3 years. These revised flood planning levels will need to be factored into all development applications (in-progress and new) in those high-risk catchments. The risk profile of high-risk catchments should be revisited at appropriate time intervals to check that levels are current. A review should take place if there has been a significant trigger event (i.e. changed rainfall, development) or at least every 5 years. As well as reviewing the flood planning level, this 5-yearly review should include reviewing any floodplain lease conditions and adjusting them as necessary in the light of better knowledge of climate change impacts. In working out a tolerable, risk-based flood planning level, consideration should be given to the PMF, 1% AEP, 0.02% AEP, existing development, approved but not yet constructed developments, and existing and approved but not yet constructed evacuation routes. |
REC324-4305 | 39 - Disaster Risk Management | Cost benefit framework:That, to enable a more systematic prioritisation of investment options in risk mitigation before, during and immediately following a natural disaster event, Government adopt and utilise a Disaster Cost Benefit Framework. This Framework will enable Government to estimate the investment required for any given disaster, starting with flood events, and will enable the fast allocation of funding based on detailed and rapid analysis of flood and property modification, mitigation, preparation, response and finance related options including: |
REC324-4307 | 9 - Community education | Flood education: That, to build disaster resilience in future generations as floods and other natural disasters are a fact of Australian life, the Department of Education should design, implement and deliver an evidence-based, targeted education campaign (like sun exposure) in schools (new disaster curriculum). |
Rec-ID | Code | Recommendation |
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REC323-4258 | 39 - Disaster Risk Management | That the NSW Government significantly increase its investment in flood mitigation and preparation, including its support of local governments to do the same, by: • increasing ongoing, long term funding and access to technical guidance and assistance for local councils • ensuring that land-use planning and development takes a risk-based approach. |
Rec-ID | Code | Recommendation |
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REC295-1317 | 25 - Inquiry, audit, lessons management and after action review | Review representation in the State Emergency Centre including: a) determining if there is a more suitable functional support group e.g. the Procurement Functional Support Group, to replace the Logistics Functional Support Group, and if so, Chief Procurement Officer, DPC, has responsibility for the management of this role within the State Emergency Centre. b) That when the State Crisis Centre is not operating from a physical location, a State Crisis Centre liaison officer is attached to the State Emergency Centre. |
REC295-1276 | 25 - Inquiry, audit, lessons management and after action review | That SA Health undertake a review of their emergency management arrangements. Health State Controllers should be consulted during this review and arrangements should be consistent throughout the department and across the State and compatible with State emergency management arrangements and information systems |
REC295-1315 | 25 - Inquiry, audit, lessons management and after action review | That a review of the role and effectiveness of the State Emergency Management Committee (SEMC) including: the legislative functions; membership including the chair; roles and responsibilities; and, SEMC Advisory Groups be undertaken. |
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. |
REC295-1297 | 25 - Inquiry, audit, lessons management and after action review | Engage an independent business analyst to review the current call, receipt and dispatch process for emergency services i.e. the Metropolitan Fire Service, Country Fire Service and State Emergency Service, from the initial call for assistance through to response of emergency service resources, including the allocation and coordination of multiple taskings. |
REC295-1328 | 25 - Inquiry, audit, lessons management and after action review | Update the SEMP Part 3, Annex F ‘Debriefs’ to provide more guidance regarding the types of debriefs, when they are required to be undertaken and at what level and guidance for undertaking and recording debriefs, and implementing lessons identified. |
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. |
REC295-1327 | 25 - Inquiry, audit, lessons management and after action review | Establish a lessons management capability across the SA emergency management sector to collect, analyse and track lessons identified during debriefs and reviews following events and other sources such as interstate and oversees reviews and inquiries. |
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. |
Rec-ID | Code | Recommendation |
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REC291-1249 | 25 - Inquiry, audit, lessons management and after action review | The Department of the Premier and Cabinet to conduct an independent review of the current arrangement for the management and distribution of the Emergency Services Levy. The review will have the specific purpose of: · seeking input from key entities including the Departments of Treasury, Finance, Fire and Emergency Services, Lands, and Parks and Wildlife, WA Local Government Association, and the Office of Bushfire Risk Management. · ensuring the arrangement has the flexibility and agility to deal with emerging bushfire risk priorities. · establishing a budget process that enables a shift in investment towards prevention, mitigation and building community resilience and capability. |
REC291-1233 | 25 - Inquiry, audit, lessons management and after action review | The State Government to explore options for streamlining the functions and the independence of the State Emergency Management Committee Secretariat and the Office of Bushfire Risk Management with a view to including an inspectorate function, and appointing a person who is dedicated to that role. The purpose is to provide assurance and reporting, and to inquire into, monitor and report transparently on emergency management standards, preparedness, capability, service delivery and investment performance outcomes. Within two years of the establishment of this arrangement the State Government to review and assess whether it is meeting the desired outcomes. |
Rec-ID | Code | Recommendation |
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REC280-1396 | 25 - Inquiry, audit, lessons management and after action review | That the Minister for Police and Emergency Services review the communications technologies used by the NSW Rural Fire Service, Fire and Rescue NSW, the NSW National Parks and Wildlife Service and Forestry NSW during fire fighting operations, to ensure that systems are standardised and effective. Within this context, the potential value of satellite phone technology should be investigated. |
REC280-1388 | 25 - Inquiry, audit, lessons management and after action review | That the NSW Rural Fire Service: |
REC280-1379 | 9 - Community education | That the NSW Rural Fire Service develop and implement a comprehensive community education campaign aimed at increasing community understanding of and support for hazard reduction burns. |
Rec-ID | Code | Recommendation |
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REC273-1144 | 7 - Inter-agency communication | That SACFS consider a review to develop an effective interagency messaging system and agency resource management system. |
Rec-ID | Code | Recommendation |
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REC261-1508 | 25 - Inquiry, audit, lessons management and after action review | That the NSW Rural Fire Service review its procedures, systems and infrastructure for notifying community members of bush fires, both when a fire has broken out and as it proceeds, to ensure the provision of timely and adequate information. |
REC261-1505 | 25 - Inquiry, audit, lessons management and after action review | That the NSW Rural Fire Service: |
REC261-1496 | 9 - Community education | That the NSW Rural Fire Service develop and implement a comprehensive community education campaign aimed at increasing community understanding of and support for hazard reduction burns. |
Rec-ID | Code | Recommendation |
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REC244-2600 | 25 - Inquiry, audit, lessons management and after action review | An external audit of shared services performed by SAFECOM and services now provided by the three ESOs which have the potential to be shared, be undertaken to determine the most efficient and cost effective way such services can be delivered to the sector. The three ESO Chiefs need to have input into this process. |
REC244-2631 | 25 - Inquiry, audit, lessons management and after action review | Review Section 134 to ensure that it is not a deterrent to a group of farm fire units operating at an incident. |
REC244-2620 | 25 - Inquiry, audit, lessons management and after action review | Review employment conditions under the F&ES Act to align with those under the Public Sector Act unless there is a compelling reason to the contrary. |
REC244-2617 | 25 - Inquiry, audit, lessons management and after action review | When judging major incidents in the future, consideration be given to Eburn and Dover’s proposal to establish processes with a statutory basis that sufficiently balance the community’s interests in ensuring that true lessons, including lessons of error or neglect, are identified, whilst also protecting members of the emergency services. Processes need to be developed for emergency services such as those used in aviation and medicine, to facilitate open and honest disclosure of errors. |
REC244-2605 | 39 - Disaster Risk Management | A thorough consultative process be developed and implemented between the CFS and local government. This will determine how bushfire management planning can enable improved process and practice to mitigate bushfire risk, and ensure that fire permits are issued and complied with. |
REC244-2601 | 25 - Inquiry, audit, lessons management and after action review | That an independent review of the operational and geographic boundaries of the ESOs be conducted recognising the limitations of the current governance structures to adequately address such issues. Such a review needs to be performed periodically, but not less than every 8 years. |
Rec-ID | Code | Recommendation |
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REC242-2643 | 25 - Inquiry, audit, lessons management and after action review | That the Government consult broadly upon and review impediments to volunteering in the community and establish a taskforce to assist in removing barriers to volunteering, particularly with respect to: |
Rec-ID | Code | Recommendation |
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REC237-0829 | 9 - Community education | That Bush Fire Risk Management Plans be posted on the NSW Rural Fire Service website. |
REC237-0828 | 9 - Community education | That the NSW Rural Fire Service develop a strategy to better inform the community and NSW Rural Fire Service members about the NSW bush fire management system and its components. |
REC237-0830 | 9 - Community education | That Bush Fire Risk Management Plans be tabled at Local Emergency Management Committees for comment. |
Rec-ID | Code | Recommendation |
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REC223-0523 | 25 - Inquiry, audit, lessons management and after action review | The Government consider enacting legislation to facilitate the review of all future major incidents, including but not limited to fire, earthquake, storm and marine inundation, and the emergency response to them. |
REC223-0522 | 25 - Inquiry, audit, lessons management and after action review | The response operation to the Margaret River bushfire in November 2011 be the subject of a review with independent oversight. |
REC223-0521 | 9 - Community education | The Department of Environment and Conservation develop and implement a strategy to better inform the community about the complexities and decisions surrounding prescribed burns when they are undertaken in the rural urban area. |
REC223-0516 | 25 - Inquiry, audit, lessons management and after action review | The Department of Environment and Conservation review its implementation of the findings of the Ferguson Review conducted in 2010. |
Rec-ID | Code | Recommendation |
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REC222-1848 | 29 - Operational Health and Safety | The Western Australian Government amend current State occupational health and safety legislation so that it includes a definition for ‘health’ that includes psychological health. |
REC222-1859 | 29 - Operational Health and Safety | The Attorney General and the Ministers for Health and Mental Health fund their departments to establish a peer support program by the end of 2013 for their staff undertaking stressful tasks during a disaster or critical incident. |
REC222-1847 | 25 - Inquiry, audit, lessons management and after action review | The Ministers for Emergency Services, Environment and Police ensure their departments undertake a formal review by 30 June 2013 of the welfare services addressing stress and trauma provided to both their career and volunteer members. |
REC222-1858 | 29 - Operational Health and Safety | The Ministers for Environment, Police, Child Protection and Emergency Services fund additional chaplaincy services, particularly for staff and volunteers based in rural and regional Western Australia. |
REC222-1852 | 29 - Operational Health and Safety | The Minister for Health immediately establish the road trauma counselling service to be funded by the Road Trauma Trust Account. |
REC222-1850 | 29 - Operational Health and Safety | The Ministers for Emergency Services, Environment and Police ensure that their departments develop as a high priority a computer system for tracking their staff and the number of traumatic events they have attended over a particular period. |
REC222-1869 | 25 - Inquiry, audit, lessons management and after action review | The Ministers for Emergency Services, Environment and Police ensure their departments include provisions for regular external audits of invoices for payment in their next round of Employee Assistance Program contract negotiations. |
REC222-1849 | 29 - Operational Health and Safety | Departmental chief executives of the Western Australia Police, Department of Environment and Conservation and the Fire and Emergency Services Authority should be made personally responsible for the psychological health (as a result of critical incident trauma) of their staff and volunteers. This obligation should be reflected in their performance agreements. |
REC222-1862 | 25 - Inquiry, audit, lessons management and after action review | The Minister for Emergency Services request the State Emergency Management Committee to review by June 2013 the sharing of data between the State’s emergency response agencies using the WebEOC software and any further enhancements that can be made to this process. |
Rec-ID | Code | Recommendation |
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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. |
REC208-0526 | 25 - Inquiry, audit, lessons management and after action review | That OEH’s testing procedures for determining the impact of pollution incidents incorporate additional requirements for the checking and verification of results before those results are released. |
Rec-ID | Code | Recommendation |
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REC204-1916 | 25 - Inquiry, audit, lessons management and after action review | Local Emergency Management Committee (LEMC) processes should be reviewed to ensure that: |
REC204-1913 | 25 - Inquiry, audit, lessons management and after action review | The Department of the Attorney General consider conducting a review of the Civil Liability Act 2002 (WA) in light of the 2011 Kimberley Ultramarathon. Such a review should consider issues such as the effectiveness given to competitor waivers under the Act and the potential difficulties of establishing proceedings and enforcing a judgement against foreign‐based providers of recreational activities. |
REC204-1908 | 39 - Disaster Risk Management | As part of the current revision of its contract template for sponsorship agreements, Tourism WA should ensure that: |
Rec-ID | Code | Recommendation |
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REC202-0512 | 9 - Community education | The Minister for Emergency Services commission an independent report to Parliament by June 2012 on an assessment of the success of FESA’s Total Fire Ban community education campaign in improving the community’s knowledge on this issue. |
REC202-0493 | 25 - Inquiry, audit, lessons management and after action review | The Minister for Emergency Services report to Parliament every six months on the progress made in completing all of the outstanding Recommendations of the Keelty Report. |
REC202-0511 | 9 - Community education | The Minister for Emergency Services commission an independent report to Parliament by June 2012 on the best practices in other jurisdictions to increase the rate of residents likely to be effected by a bushfire who properly prepare their properties before the bushfire season. |
REC202-0510 | 9 - Community education | The Minister for Emergency Services and the Minister for Local Government provide additional resources to FESA, DEC and WALGA in the 2012-13 Budget to improve the Western Australian community’s knowledge of bushfire safety and to allow these agencies to involve the public in their exercises. |
REC202-0505 | 7 - Inter-agency communication | The Minister for Emergency Services makes it a priority that the annual budgets of FESA and WA Police are sufficient to bring forward the completion dates of the current radio projects now underway. |
REC202-0497 | 25 - Inquiry, audit, lessons management and after action review | The Minister for Local Government have urgent discussions with the Western Australian Local Government Association (WALGA) as to why they are not supporting the full Recommendations addressed to local government in the Keelty Report. The Minister ensure that by May 2012 WALGA and its member councils have the resources to fully implement theimplementation of the Recommendations. |
REC202-0495 | 25 - Inquiry, audit, lessons management and after action review | At the conclusion to the 2011-12 bushfire season, the Minister for Emergency Services institute a thorough review of the operations of FESA, the Police and DEC in protecting the State from bushfires and other natural disasters, with a primary focus on: · staffing levels; · equipment levels and coordination; and · training needs. The Minister report to Parliament by June 2012 on any changes that need to be made to the current departmental structures to optimise the State’s preparedness for the 2012-13 bushfire season. |
Rec-ID | Code | Recommendation |
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REC201-0257 | 29 - Operational Health and Safety | FESA needs to place greater priority on the appointment of Safety Advisors to Level 3 incidents as is reflected in WESTPLAN Bushfire. |
REC201-0252 | 7 - Inter-agency communication | FESA must actively manage the transition to WAERN and provide alternative means for regional crews to communicate when in areas where WAERN is not operated. |
Rec-ID | Code | Recommendation |
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REC200-1705 | 29 - Operational Health and Safety | The Fire and Emergency Services Authority (FESA) review its program to decommission vehicles and ensure that when such vehicles are offered during an incident that FESA staff adhere to FESA‟s own policy of „Use of Private Vehicles in Fires‟ |
REC200-0349 | 9 - Community education | The Fire and Emergency Services Authority work in partnership with Main Roads Western Australia and local governments to develop and implement a comprehensive strategy for the use of mobile variable message boards to alert the community to the declaration of a total fire ban and what it means. |
REC200-1685 | 9 - Community education | The Fire and Emergency Services Authority (FESA) review its distribution of information material, including Prepare. Act. Survive. FESA should also consider including the community in pre-season exercising, in consultation with the Department for Child Protection and local governments. |
REC200-1701 | 25 - Inquiry, audit, lessons management and after action review | The Fire and Emergency Services Authority convene a facilitated debriefing session between the families who remained behind to protect their properties, and the incident controllers. |
REC200-0348 | 9 - Community education | The Fire and Emergency Services Authority consider alternative wording to Total Fire Ban that ensures people gain a more complete understanding of what actions are prohibited. |
REC200-0392 | 25 - Inquiry, audit, lessons management and after action review | The State Government review implementation of the Special Inquiry’s Recommendations in two years. |
REC200-1684 | 9 - Community education | The Fire and Emergency Services Authority, in partnership with local governments, conduct more focused pre-season bushfire education, which emphasises: |
REC200-1698 | 39 - Disaster Risk Management | The Fire and Emergency Services Authority, the Department of Environment and Conservation and local governments jointly develop a single, integrated system for fuel load assessment and management. |
REC200-0347 | 9 - Community education | The Department of Education oversee the provision of bushfire education in schools that are located in bushfire prone areas, ensuring that all schools in these areas incorporate key bushfire messages in their curriculum. |
REC200-1732 | 25 - Inquiry, audit, lessons management and after action review | The State Government review implementation of the Special Inquiry's recommendations in two years. |
REC200-0384 | 25 - Inquiry, audit, lessons management and after action review | Emergency Management Western Australia develop mechanisms to calculate the estimated total cost of a fire to the community. |
REC200-1688 | 9 - Community education | The Department of Education oversee the provision of bushfire education in schools that are located in bushfire prone areas, ensuring that all schools in these areas incorporate key bushfire messages in their curriculum. |
REC200-0344 | 9 - Community education | The Fire and Emergency Services Authority (FESA) review its distribution of information material, including Prepare. Act. Survive. FESA should also consider including the community in pre-season exercising, in consultation with the Department for Child Protection and local governments. |
REC200-1722 | 39 - Disaster Risk Management | Emergency Management Western Australia and the State Emergency Management Committee amend WESTPLAN-BUSHFIRE to require State Emergency Coordination Group meetings to be held at the State Coordination Centre in West Leederville. |
REC200-0372 | 7 - Inter-agency communication | FESA and local governments jointly review radio communications capability prior to the 2011/12 bushfire season with a view to improving the current delivery of service to firefighters. |
REC200-1687 | 9 - Community education | The Fire and Emergency Services Authority work in partnership with the Real Estate Institute of Western Australia to develop a package of information for new residents moving into bushfire prone areas, and a process to ensure this information is provided through real estate agents. |
REC200-0343 | 9 - Community education | The Fire and Emergency Services Authority, in partnership with local governments, conduct more focused pre-season bushfire education, which emphasises: Water supply is not guaranteed during a bushfire Power supply is not guaranteed during a bushfire Saving life will be a priority over saving property so expect to be evacuated Once evacuated, access to affected areas may not be possible for several days Water ‘bombing’ by aircraft cannot be guaranteed in bushfire SMS warnings are advice only and may not be timely. |
REC200-1713 | 7 - Inter-agency communication | The Department for Child Protection, the Western Australian Police and the Fire and Emergency Services Authority develop improved arrangements for communicating the loss of home and possessions to persons gathered at evacuation centres with a view to increasing privacy. |
REC200-0361 | 25 - Inquiry, audit, lessons management and after action review | The Fire and Emergency Services Authority convene a facilitated debriefing session between the families who remained behind to protect their properties, and the incident controllers. This session should include open discussion and explain the decisions of all parties – including how the incident controllers determined priorities, and why residents chose not follow their advice to evacuate. The learning outcomes should be promulgated across all agencies and incorporated in future level 3 incident controller training programs. |
REC200-1686 | 9 - Community education | Local governments continue to include information on bushfire risk and preparedness with rates notices. |
Rec-ID | Code | Recommendation |
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REC182-0133 | 29 - Operational Health and Safety | FESA reviews its approach to safety and safety culture. |
REC182-0132 | 9 - Community education | FESA implements an education and awareness campaign to promote the purpose and utility of community information systems. |
REC182-0127 | 9 - Community education | FESA strengthens its planning process to ensure learnings are incorporated and communicated, levels of preparedness are linked to threat analyses and public awareness and education activities are sustained. |
REC182-0126 | 9 - Community education | FESA promotes a whole-of-community approach, involving FESA, Local Governments and the community, in fire prevention functions, activities and planning. |
Rec-ID | Code | Recommendation |
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REC164-0074 | 9 - Community education | SERCon consider a review of existing community-based educational programs, with a view to informing the community |
REC164-0073 | 25 - Inquiry, audit, lessons management and after action review | SERCon consider that the proposed State Recovery Committee provide an interim report to government on these and |
Rec-ID | Code | Recommendation |
---|---|---|
REC143-3579 | 9 - Community education | That FESA develop comprehensive internet-based information including but not limited to detail of WANDRA objectives, assistance measures, administering agencies, eligibility criteria (where applicable) and application forms. |
Rec-ID | Code | Recommendation |
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REC128-3598 | 25 - Inquiry, audit, lessons management and after action review | That the Department of Primary Industries incorporates reviews of plans and operating procedures as a result of emergency incidents and exercises and ensures that there is adequate commitment from all participants in the review process. |
REC128-3615 | 9 - Community education | That the Department of Primary Industries should continue to raise awareness among producers of OJD risks and the operation of Sheep Health Statements. |
REC128-3613 | 9 - Community education | That the Department of Primary Industries and Rural Lands Protection Boards employ outreach activities to alert these small producers to their responsibilities and improve their awareness of animal and plant pests and diseases. |
Rec-ID | Code | Recommendation |
---|---|---|
REC122-3796 | 9 - Community education | The Committee recommends that the government undertake public education programs to increase the awareness of the community to bushfires, the role fire plays in ecosystems and what steps they should take to minimise the impact of a fire. |
REC122-3797 | 9 - Community education | The Committee recommends that the Native Vegetation Council continue to seek mechanisms to interact with, and educate the individual farmer and landholder with respect to the Native Vegetation Act, its regulations and exemptions. |
Rec-ID | Code | Recommendation |
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REC121-3683 | 39 - Disaster Risk Management | RailCorp should undertake risk assessments of each of its activities as follows: |
REC121-3733 | 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. |
REC121-3758 | 25 - Inquiry, audit, lessons management and after action review | Following completion of any external audit, a corrective action plan to remedy any identified safety deficiencies should be developed by RailCorp, implemented and followed up within the business groups affected, to ensure appropriate and timely completion of the action plan, by a formal examination of the effectiveness of the controls put in place. Senior management personnel should certify that the corrective action plan has been implemented and is effective. Senior management personnel should be accountable for any such certification. |
REC121-3700 | 39 - Disaster Risk Management | Maintenance plans on all trains should be revised annually. |
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. |
REC121-3710 | 39 - Disaster Risk Management | The ITSRR should have permanent access to the RailCorp intranet. |
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. |
REC121-3682 | 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. |
REC121-3732 | 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. |
REC121-3757 | 25 - Inquiry, audit, lessons management and after action review | RailCorp should conduct internal and external safety audits to evaluate the adequacy of its safety management system and to ensure that any risk control measures are effective. |
REC121-3694 | 25 - Inquiry, audit, lessons management and after action review | The ITSRR should conduct random audits of accredited rail organisations for compliance with communications protocols. |
REC121-3738 | 29 - Operational Health and Safety | All passenger trains must be fitted with an internal passenger emergency door release. |
REC121-3768 | 25 - Inquiry, audit, lessons management and after action review | The ITSRR, when considering a re-application for accreditation, should conduct a field audit of the organisation to ensure that it is carrying on its activities in accordance with the basis upon which it seeks accreditation. |
REC121-3709 | 29 - Operational Health and Safety | RailCorp should provide access to electronic versions of safety documentation for all operational staff at their workplace. |
REC121-3747 | 29 - Operational Health and Safety | All trains should have windows available through which passengers can escape. |
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. |
REC121-3731 | 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: |
REC121-3755 | 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. |
REC121-3693 | 25 - Inquiry, audit, lessons management and after action review | ITSRR should ensure that, as a condition of accreditation, each of these recommendations is carried into effect and should audit against them to enforce compliance. |
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. |
REC121-3765 | 25 - Inquiry, audit, lessons management and after action review | The ITSRR should conduct field audits to satisfy itself that all accredited rail organisations conduct their activities in accordance with the safety management system on the basis of which each was accredited. |
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. |
REC121-3743 | 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”. |
REC121-3726 | 25 - Inquiry, audit, lessons management and after action review | The OTSI should continue to conduct rail accident investigations on behalf of ITSRR and report directly to the Chief Executive of ITSRR. |
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. |
REC121-3680 | 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. |
REC121-3691 | 25 - Inquiry, audit, lessons management and after action review | The ITSRR should audit the RMC to ensure communications protocols are being followed. The sanction for non-compliance with communications protocols should be identical to that in the aviation industry and involve immediate removal from duty. Any RailCorp employee not following communications protocols should be required to undertake further training. If, following return to duties after such training, the officer continues to fail to comply with communications protocols, that officer is not to be employed in communications related work. |
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. |
REC121-3764 | 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. |
REC121-3706 | 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. |
REC121-3713 | 25 - Inquiry, audit, lessons management and after action review | Recommendations one to seven of the final report of the Special Commission of Inquiry into the Glenbrook Rail Accident should be fully implemented, save that the random auditing referred to in recommendations five and seven should be carried out by ITSRR. |
REC121-3753 | 25 - Inquiry, audit, lessons management and after action review | The RailCorp Board should establish independent external safety auditing processes to regularly audit and report to the Board on the implementation of an integrated safety management system by RailCorp and on safety performance generally. |
REC121-3684 | 39 - Disaster Risk Management | The ITSRR should conduct its own risk assessment in relation to the risk of any such high consequence, low probability accident and, if necessary, direct RailCorp to conduct a further risk assessment to reduce the level of residual risk to a level ITSRR regards as acceptable. |
REC121-3734 | 29 - Operational Health and Safety | RailCorp should integrate its management of occupational health and safety into its overall safety management. |
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: |
REC121-3702 | 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. |
REC121-3711 | 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. |
REC121-3749 | 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”. |