Inquiry Search
Rec-ID | Code | Recommendation |
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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: |
REC324-4315 | 36 - Volunteers | The Community First Responders Program: That, to better coordinate community efforts to save life and property during a disaster, Government create a ‘Community First Responders Program’, funding appropriate community equipment and training, particularly in high-risk catchments along the east coast of NSW. This training would be delivered by combat and/or other appropriate government agencies. This program could support and empower community led initiatives such as disaster response, evacuation centres and the provision of services such as psychological first aid. |
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. |
Rec-ID | Code | Recommendation |
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REC317-4057 | 39 - Disaster Risk Management | The Australian Government should establish a standing entity that will enhance national natural disaster resilience and recovery, focused on long-term disaster risk reduction. |
REC317-4103 | 39 - Disaster Risk Management | Australian, state and territory governments should develop arrangements that facilitate greater inclusion of primary healthcare providers in disaster management, including: representation on relevant disaster committees and plans and providing training, education and other supports. |
REC317-4102 | 25 - Inquiry, audit, lessons management and after action review | Australian, state and territory governments should review Australian Medical Assistance Team capabilities and procedures and develop necessary training, exercising and other arrangements to build capacity for domestic deployments. |
REC317-4079 | 39 - Disaster Risk Management | Australian, state and territory governments, in consultation with local governments and the private sector, should review supply chain risks, and consider options to ensure supply of essential goods in times of natural disasters. |
REC317-4074 | 25 - Inquiry, audit, lessons management and after action review | The Australian Government should review the content of the Defence Assistance to the Civil Community manual to ensure consistency of language and application with a revised COMDISPLAN. |
REC317-4067 | 39 - Disaster Risk Management | State and territory governments should have a structured process to regularly assess the capacity and capability requirements of fire and emergency services, in light of both current and future natural disaster risk. |
REC317-4066 | 2 - Emergency powers | The Australian Government should make provision, in legislation, for a declaration of a state of national emergency. The declaration should include the following components: |
REC317-4062 | 39 - Disaster Risk Management | The National Disaster Risk Information Services Capability should include tools and systems to support operational and strategic decision making, including integrated climate and disaster risk scenarios tailored to various needs of relevant industry sectors and end users. |
REC317-4061 | 39 - Disaster Risk Management | Australian, state and territory governments should support the implementation of the National Disaster Risk Information Services Capability and aligned climate adaptation initiatives. |
Rec-ID | Code | Recommendation |
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REC301-2385 | 25 - Inquiry, audit, lessons management and after action review | TFS should initiate a policy review (seeking support from government as appropriate) to clearly identify what body or agency is responsible for planning, carrying out and enforcing fuel management on private property at a township level. If current arrangements are unclear or ineffective, TFS should request government to consider making this a statutory responsibility of TFS and provide any additional funding required to support this function. |
REC301-2392 | 39 - Disaster Risk Management | TFS should engage in discussions with government about the construction of purpose-built State Control Centre facilities for emergency management in Tasmania. |
REC301-2384 | 36 - Volunteers | TFS should pursue the creation of a cadre of volunteer remote area firefighters. In doing so the TFS should not consider itself limited to upskilling of current volunteer brigade members, but should carry out a cost benefit analysis of creating one or more remote area firefighting units based in urban areas, in order to tap into the potential of those members of the urban-based Tasmanian community who may have advanced knowledge and skills relating to navigation and survival in wilderness areas. |
Rec-ID | Code | Recommendation |
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REC297-1273 | 25 - Inquiry, audit, lessons management and after action review | That the State Emergency Management Committee allocates resources to reviewing all findings and recommendations in the Productivity Commission Report No. 74 relevant to Tasmania and, for those identified as relevant, actions taken and, if none, why not. |
REC297-1264 | 25 - Inquiry, audit, lessons management and after action review | That the Flood Warning Consultative Committee reviews flood classification levels in the Service Level Specifications with BoM specifically relating to flood level triggers on gauges. |
REC297-1259 | 25 - Inquiry, audit, lessons management and after action review | That DPIPWE examines the Forest Practice Code 2015 for relevance of its concepts to farming and other business activities near rivers, streams and naturally occurring dams and makes recommendations to Government accordingly. |
REC297-1258 | 25 - Inquiry, audit, lessons management and after action review | That DPIPWE examines the WMAwater report along with its own, analyses the differences, consults with the Forest Practices Authority and Environment Protection Authority, and proposes an appropriate course of action to Government. |
Rec-ID | Code | Recommendation |
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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. |
REC295-1327 | 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. |
REC295-1317 | 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. |
REC295-1315 | 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. |
REC295-1297 | 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. |
REC295-1276 | 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 |
Rec-ID | Code | Recommendation |
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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. |
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. |
Rec-ID | Code | Recommendation |
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REC287-1188 | 25 - Inquiry, audit, lessons management and after action review | The Tasmanian fire agencies commission a review into the efectiveness of aerial firefghting in the 2016 fires, in order to better understand and to document for future reference the cost-efectiveness of specifc fire suppression strategies and tactics in different vegetation types. The Review should include a comparative analysis of fire suppression options whether aerial or ground-based. |
REC287-1185 | 25 - Inquiry, audit, lessons management and after action review | The Tasmanian fire agencies take steps at a national level to share learnings from the 2016 fires about the administration of interstate assistance and support the codifcation of the workings, structure and reporting lines of an Interstate and International Liaison Unit for future complex deployments within Australia and New Zealand. |
Rec-ID | Code | Recommendation |
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REC264-1072 | 25 - Inquiry, audit, lessons management and after action review | The State empower and require the Auditor-General or another appropriate agency, to: • oversee the implementation of these recommendations and the commitments made by the State and GDF Suez during this Inquiry; and • report publicly every year for the next three years on the progress made in implementing recommendations and commitments. |
REC264-1087 | 25 - Inquiry, audit, lessons management and after action review | GDF Suez: • practice and ensures that, by taking a risk management approach, it is suitable for fire prevention, mitigation and suppression in all parts of the Hazelwood mine; and review its ‘Mine Fire Service Policy and Code of Practice’ so that it refects industry best • work plan for the Hazelwood mine. incorporate the revised ‘Mine Fire Service Policy and Code of Practice’ into the approved |
REC264-1086 | 25 - Inquiry, audit, lessons management and after action review | GDF Suez: • consequences of fire in the worked out areas of the Hazelwood mine, and an assessment of the most effective fre protection for the exposed coal surfaces; conduct, assisted by an independent consultant, a risk assessment of the likelihood and • controls are in place to eliminate or reduce the risk of fre; and prepare an implementation plan that ensures the most effective and reasonably practicable • implement the plan |
Rec-ID | Code | Recommendation |
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REC258-2556 | 25 - Inquiry, audit, lessons management and after action review | The Civil Aviation Safety Authority structures all regulations not yet made with the three-tier approach, and subsequently reviews all other Civil Aviation Safety Regulation Parts (in consultation with industry) to determine if they should be remade using the three-tier structure. |
REC258-2552 | 25 - Inquiry, audit, lessons management and after action review | The Civil Aviation Safety Authority implements a system of using third-party commercial audits as a supplementary tool to its surveillance system. |
REC258-2551 | 25 - Inquiry, audit, lessons management and after action review | The Civil Aviation Safety Authority assures consistency of audits across all regions, and delivers audit reports within an agreed timeframe. |
REC258-2560 | 29 - Operational Health and Safety | The Civil Aviation Safety Authority devolve to Designated Aviation Medical Examiners the ability to renew aviation medical certificates (for Classes 1, 2, and 3) where the applicant meets the required standard at the time of the medical examination. |
REC258-2549 | 25 - Inquiry, audit, lessons management and after action review | The Civil Aviation Safety Authority provides full disclosure of audit findings at audit exit briefings in accordance with international best practice. |
REC258-2528 | 25 - Inquiry, audit, lessons management and after action review | The Australian Transport Safety Bureau investigates as many fatal accidents in the sport and recreational aviation sector as its resources will allow. |
Rec-ID | Code | Recommendation |
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REC257-1548 | 25 - Inquiry, audit, lessons management and after action review | The Regional Director-Defence Support-Northern NSW, make contact with Deputy Commissioner ~~~~~ Director of Operational Services Rural Fire Service, to arrange a headquarters driven bipartite review of the events of 16 October 2013 with a review to mitigation of future fire events generally, and with specific reference to: |
REC257-1546 | 25 - Inquiry, audit, lessons management and after action review | Defence undertake a review of its ability to respond to a fire within Marrangaroo Training Area, whether bushfire or structural. The underlying assumption should be that the only response available to fight a fire within Marrangaroo Training Area will be provided by Defence. Further, such response must occur while a fire is in its initial stages. A review must either acknowledge the risk of fire occurring in th future, or upgrade Defence's firefighting capability at Marrangaroo Training Area. |
REC257-1539 | 25 - Inquiry, audit, lessons management and after action review | Defence Security Authority conduct an investigation into the whereabouts of items of anaccounted explosive ordnance issued to Defence Explosive Ordnance Training School Exercise Marrangaroo. |
Rec-ID | Code | Recommendation |
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REC256-1573 | 25 - Inquiry, audit, lessons management and after action review | The Australian Government should schedule an independent and public review of the progress of reforms to natural disaster funding arrangements five years after implementation has commenced. This review should examine the operation and efficacy of the arrangements, including the: |
Rec-ID | Code | Recommendation |
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REC247-0909 | 25 - Inquiry, audit, lessons management and after action review | That the plans for social recovery be reviewed, and plans and procedures are established ready for implementation. |
REC247-0951 | 25 - Inquiry, audit, lessons management and after action review | That an independent means of monitoring and reporting on the implementation of approved recommendations is established. |
REC247-0903 | 25 - Inquiry, audit, lessons management and after action review | That the role of Red Cross in emergency management plans and procedures for the activation of Red Cross be reviewed. |
REC247-0941 | 25 - Inquiry, audit, lessons management and after action review | That the Strategic Fuel Management Plan includes measurable targets and they are actively monitored and reported on to the community. |
REC247-0873 | 25 - Inquiry, audit, lessons management and after action review | If it is considered more information is required on action to suppress the fires in Dunalley and why fire operations did not continue, the Department of Justice should conduct an independent examination of this matter. |
REC247-0927 | 25 - Inquiry, audit, lessons management and after action review | That an accountability process be established for managing improvement in the emergency management arrangements, including annual State of Readiness Reports by relevant departments and agencies and on the overall emergency management arrangements. |
REC247-0857 | 2 - Emergency powers | That the Tasmania Emergency Management Plan enable, and all organisations with a role in emergency management activate, emergency plans at lower threshold events to practice their arrangements and achieve a ‘hot start’ in escalating events. |
REC247-0926 | 25 - Inquiry, audit, lessons management and after action review | That membership of the State Emergency Management Committee, and other processes to link in appropriate agencies and organisations to emergency management, be included in the recommended review of the emergency management arrangements. |
REC247-0856 | 2 - Emergency powers | That the Government reconsider the current position on emergency declarations in the Emergency Management Act 2006 and the Act is amended to provide: • a graduated scale of emergency declarations; • the ability to make a declaration when an emergency has occurred, is occurring or is about to occur; • the ability for the State Controller (or whatever the person in overall control of response and recovery operations is called) to make one or more declarations; • a declaration to enable access to all emergency powers. |
REC247-0923 | 25 - Inquiry, audit, lessons management and after action review | That a process be established for the timely implementation of approved recommendations from the 2009 Victorian Bushfires Royal Commission. |
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. |
REC244-2605 | 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. |
REC244-2617 | 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. |
REC244-2621 | 36 - Volunteers | Greater attention needs to be given to the recruitment and retention of volunteers in alignment with the National Emergency Management Volunteer Action Plan. |
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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REC239-2746 | 36 - Volunteers | That volunteers should be engaged to assist in determining what constitutes ‘fit for task’ and how that should be implemented. |
REC239-2724 | 25 - Inquiry, audit, lessons management and after action review | That the Queensland Fire and Rescue Service undertake a review of all standing orders, incident directives and guidelines regarding response protocols with a view to reducing risk to staff and other road users associated with urgent duty driving. |
REC239-2692 | 39 - Disaster Risk Management | That the Queensland Police Service Disaster Management Unit is to be permanently located at the State Disaster Coordination Centre to work on a day to day basis with the proposed new Department of Fire and Emergency Services. |
REC239-2764 | 25 - Inquiry, audit, lessons management and after action review | That the proposed efficiency review consider whether special service functions are core business, whether this practice is sustainable, and other options such as the use of casual employees. |
REC239-2739 | 36 - Volunteers | That the Queensland Police Service and the Department of Community Safety develop intuitive, easily accessible systems that reduce the administrative burden on volunteers and their time. Greater exploitation of technology to deliver intuitive, simple and practical systems is required. |
REC239-2691 | 39 - Disaster Risk Management | That the Commissioners of Police and the Queensland Fire and Rescue Service review the current district disaster boundaries as a matter of urgency in-line with the findings and recommendations of the Auditor–General’s report into the Queensland disaster management system. |
REC239-2763 | 25 - Inquiry, audit, lessons management and after action review | That the proposed efficiency review includes a focus on the rank structure of both the Queensland Police Service and the proposed Fire and Emergency Services. |
REC239-2738 | 36 - Volunteers | That the current employer and family recognition practices be reviewed with a view to meet the needs of volunteers, their families and their employers. |
REC239-2737 | 29 - Operational Health and Safety | That the workplace health and safety reporting system be reviewed to facilitate ease of reporting. |
REC239-2758 | 25 - Inquiry, audit, lessons management and after action review | That the Chief Executive Officer Portfolio Business leads an efficiency review of portfolio agencies beginning with the Queensland Police Service. |
REC239-2736 | 36 - Volunteers | That training for volunteers be reviewed to determine which courses require national standardisation. Organisational training should then address the remaining training needs. The review should take into account the risk exposure to government agencies if changes are to be made. |
REC239-2727 | 25 - Inquiry, audit, lessons management and after action review | That as part of its efficiency review, the Queensland Fire and Rescue Service instigate an independent review of commercial operations in terms of statutory obligations and current ‘full cost pricing’ methodology to ensure: |
REC239-2777 | 25 - Inquiry, audit, lessons management and after action review | That the review of this Queensland Fire and Rescue Services business unit be done in conjunction with the efficiency review proposed for the Queensland Police Service. |
REC239-2774 | 39 - Disaster Risk Management | Those final determinations of disaster management districts include consultation with the Local Government Association Queensland, the Queensland Fire and Rescue Service and other Government departments. |
REC239-2725 | 25 - Inquiry, audit, lessons management and after action review | That the Queensland Fire and Rescue Service community safety operations be joined in the efficiency review of the Queensland Police Service focussing on both the community safety outcomes achieved and the extent to which they support the Government’s economic priorities. |
REC239-2776 | 25 - Inquiry, audit, lessons management and after action review | That the proposed efficiency review of the Queensland Police Service examine whether: |
REC239-2711 | 39 - Disaster Risk Management | That the Inspector General Emergency Management be empowered to provide an assurance to Government that the disaster management system is both appropriate and capable of dealing with complex events. |
Rec-ID | Code | Recommendation |
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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. |
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. |
Rec-ID | Code | Recommendation |
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REC210-0726 | 25 - Inquiry, audit, lessons management and after action review | The Queensland Fire and Rescue Service should require that each region records in writing the results of its risk assessment undertaken as part of its annual review of its special operations functional plan. |
REC210-0761 | 2 - Emergency powers | The Queensland Government should consider whether to empower Seqwater, through the flood operations centre, to direct CS Energy to stop or delay releases from Splityard Creek Dam where a flood event is declared under the Manual of Operational Procedures for Flood Mitigation at Wivenhoe Dam and Somerset Dam. |
REC210-0762 | 25 - Inquiry, audit, lessons management and after action review | Seqwater should consider commissioning an investigation into the extent of cracking below the level of the upper gallery of Somerset Dam and the impact of any such cracking on the dam’s stability and, in turn, its operation. |
REC210-0754 | 2 - Emergency powers | As part of the longer term review of the Manual of Operational Procedures for Flood Mitigation at Wivenhoe Dam and Somerset Dam the Queensland Government should consider whether the dam operators should be able to extend the drawdown of the lake beyond seven days in order to reduce downstream bank slumping |
REC210-0743 | 25 - Inquiry, audit, lessons management and after action review | Seqwater should, in creating the new Wivenhoe and North Pine flood mitigation manuals, comprehensively consider: • the amount of discretion that is able to be exercised by the flood engineers and the senior flood engineers, and the description of the circumstances in which such discretion may be exercised • the circumstances in which it might be appropriate to release water in advance of an impending flood on the basis of forecasts from the Bureau of Meteorology • if strategies of the form of strategy W2 and W3 in Revision 7 are included in the revised manual, or any strategy defined as a ‘transition strategy’, when and how those strategies should be implemented • if the concept of ‘urban inundation’ is relevant to the operation of the dam, how it should be defined, and if the definition involves diverse concepts, how those concepts can be related back to the strategies, so that flood engineers can reach a clear understanding of their objectives and primary considerations • if the concept of ‘natural peak flow’ is relevant, how it should be defined. |
REC210-0727 | 2 - Emergency powers | The Disaster Management Act 2003 should be amended to give the chief executive of the department administering the Act (or his or her delegate) the authority to appoint an officer of Emergency Management Queensland to direct SES operations in extraordinary circumstances |
REC210-0738 | 25 - Inquiry, audit, lessons management and after action review | Seqwater should ensure that any future peer review process: • is co-ordinated by someone independent of those who wrote the report • entails the provision of all relevant information to the peer reviewers • permits sufficient time for the review • documents all contact between those whose actions are under review and the reviewers. |
REC210-0737 | 25 - Inquiry, audit, lessons management and after action review | The Department of Environment and Resource Management should ensure that an independent and appropriately qualified person immediately starts the task of reviewing the March flood event report to ensure that the review is completed before the start of the 2012/2013 wet season. |
REC210-0773 | 25 - Inquiry, audit, lessons management and after action review | The Department of Environment and Resource Management should prioritise dam safety audits according to risk. The risk assessment should be informed by criteria including: • structure and materials used in construction • age of the dam • time since last inspection • occurrence of a flood event since last audit and the size of that flood event • population at risk if the dam were to fail • experience and capability of dam owner • dam owner compliance history • time since last audit. |
REC210-0736 | 25 - Inquiry, audit, lessons management and after action review | Seqwater should ensure that proper support and oversight mechanisms are put in place around both the substantive and procedural aspects of drafting flood event reports. Seqwater should consider engaging consultants with expertise in the production of reports following significant events to advise on these mechanisms. Measures to be considered should include: • ensuring appropriate systems are in place to ensure the recollections of flood engineers and other parties are recorded immediately after the event, perhaps by engaging an external party to interview the flood engineers and other parties • ensuring that a methodology for writing the report is set out clearly in advance, in writing, and that the final report includes a statement of that methodology • putting in place systems to ensure that members of senior management have sufficient understanding of both the methodology and process by which the report is prepared to allow themselves to be satisfied that these are appropriate. |
REC210-0772 | 25 - Inquiry, audit, lessons management and after action review | Prior to each wet season, the Department of Environment and Resource Management should audit the compliance of each owner of a referable dam with the obligation to have an emergency action plan approved by the Queensland Government. |
Rec-ID | Code | Recommendation |
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REC207-2882 | 39 - Disaster Risk Management | Review disaster recovery and business continuity plans. |
Rec-ID | Code | Recommendation |
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REC205-1903 | 25 - Inquiry, audit, lessons management and after action review | The Australian Government should commission an independent public review of disaster prevention and recovery arrangements. This should be broader than the review currently being conducted by the Attorney-General’s Department. The review should cover the Natural Disaster Relief and Recovery Arrangements, as well as the funding mechanisms for disaster mitigation, including the National Partnership Agreement on Natural Disaster Resilience. This review should: |
REC205-1902 | 25 - Inquiry, audit, lessons management and after action review | The Council of Australian Governments should commission an independent public inquiry to develop an appropriate response to managing the risks of climate change to existing settlements. The inquiry should: |
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. |
Rec-ID | Code | Recommendation |
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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. |
REC200-1698 | 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. |
REC200-0381 | 2 - Emergency powers | The State Government amend section 50 of the Emergency Management Act 2005 to allow the Chair of the State Emergency Coordination Group to declare an emergency situation. |
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. |
REC200-0384 | 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. |
REC200-0361 | 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. |
REC200-1705 | 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‟ |
REC200-1732 | 25 - Inquiry, audit, lessons management and after action review | The State Government review implementation of the Special Inquiry's recommendations in two years. |
REC200-1722 | 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. |
Rec-ID | Code | Recommendation |
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REC199-0444 | 2 - Emergency powers | the state, as a matter of urgency, develop a multi-agency Incident Control Team capability to be readily available for statewide deployment to establish incident control or to relieve functioning control structures. |
REC199-0401 | 25 - Inquiry, audit, lessons management and after action review | the state task the Emergency Services Commissioner with the responsibility to establish an effective audit regime of the total flood warning system. |
REC199-0482 | 25 - Inquiry, audit, lessons management and after action review | the state task the Emergency Services Commissioner with the responsibility to develop and undertake the regular audit of emergency management plans at all levels. |
REC199-0422 | 36 - Volunteers | the state establish a process for volunteer community member accreditation to allow volunteers to provide flood information to the control agency during a flood event. This process should establish a base competency standard and provide appropriate emergency management and Australasian Inter-service Incident Management System training to accredited community volunteers. |
REC199-0450 | 25 - Inquiry, audit, lessons management and after action review | the state ensure that appropriate record management processes are developed and implemented and that these processes also provide record accountability for multi-agency operations. Agency processes should be standardised to the fullest extent possible |
REC199-0445 | 25 - Inquiry, audit, lessons management and after action review | the state develop and implement operational performance standards for each state agency involved in emergency management response and recovery and that: • each agency be assessed by the Emergency Services Commissioner periodically against these performance standards for both capability and capacity; and • where performance against these standards for either capability or capacity cannot be demonstrated by any agency – appropriate advice is communicated to the relevant Minister, departmental/agency head and State Emergency Response Coordinator; and – an action plan is developed and implemented to address the relevant capability or capacity deficiency in both the short and longer term. |
REC199-0428 | 25 - Inquiry, audit, lessons management and after action review | the state clarify which agency is responsible for collecting post-flood extent and related data. This should include: • the development of guidelines to ensure consistent standards are applied to post-flood data collection; and • an appropriate process to ensure funding availability for such activities. |
REC199-0407 | 25 - Inquiry, audit, lessons management and after action review | the state: • undertake a strategic review to identify areas at risk from flash or riverine flooding. Shortcomings in the flood gauging networks identified in the review should then be the focus of remedial action • seek to address as a priority any notable gaps in the total flood warning system as apparent in the 2010–11 floods (including south west Victoria, Wimmera and north central region) by enhancing mapping, gauging and education programs; and • seek a commitment from the Bureau of Meteorology to ensure any new gauges installed are utilised to enhance flood prediction capability and coverage. |
Rec-ID | Code | Recommendation |
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REC197-1735 | 36 - Volunteers | A. The CFA continue to explore and develop initiatives with modern information and communication technologies to maximise the benefits that they may bring to volunteer involvement in the CFA. |
REC197-1770 | 36 - Volunteers | The CFA, in consultation with the VFBV and volunteers, review the arrangements for the reimbursement of volunteer expenses. This review could be done in conjunction with the review of possible reimbursement of employers of CFA volunteers as recommended in Recommendation 5. |
REC197-1734 | 36 - Volunteers | A. Consideration be given to the VFBV being funded directly by Government rather than by the CFA. |
REC197-1745 | 36 - Volunteers | The CFA revisit with the UFU the arrangements relating to Community Education Firefighters/Fire Officers and the use of volunteers in this role. |
REC197-1742 | 36 - Volunteers | The CFA, in consultation with the VFBV and volunteers, develop initiatives and strategies that will maximise the involvement of young people as volunteers and their retention as volunteers. |
REC197-1740 | 36 - Volunteers | The CFA, in consultation with the VFBV and volunteers, develop and introduce an arrangement whereby a volunteer can transfer from one brigade to another and still remain a member of the CFA, without the need to resign. |
REC197-1733 | 25 - Inquiry, audit, lessons management and after action review | That a review of the Country Fire Authority Act 1958 and the Country Fire Authority Regulations 2004 be undertaken. |
REC197-1739 | 36 - Volunteers | The CFA, in consultation with the VFBV and volunteers, develop a systemic exit strategy, which ensures that relevant information is captured consistently across all brigades. |
Rec-ID | Code | Recommendation |
---|---|---|
REC189-2911 | 29 - Operational Health and Safety | The review team recommend that: |
REC189-2907 | 29 - Operational Health and Safety | a) For the purposes of designing and implementing its regulatory activities, National Offshore Petroleum Safety Authority (NOPSA) should continue to identify priority hazards and risks and their underlying causes, in consultation with the NOPSA Advisory Board and stakeholders (see Theme 9, Stakeholder engagement). |
REC189-2912 | 29 - Operational Health and Safety | The review team recommend that the safety case system be strengthened by including provisions for a design notification scheme along the lines of that under the British Offshore Safety Case Regulations. |
Rec-ID | Code | Recommendation |
---|---|---|
REC182-0133 | 29 - Operational Health and Safety | FESA reviews its approach to safety and safety culture. |
Rec-ID | Code | Recommendation |
---|---|---|
REC181-0216 | 25 - Inquiry, audit, lessons management and after action review | The State appoint an independent monitor or the Victorian Auditor-General to assess progress with implementing the Commission’s recommendations and report to the Parliament and the people of Victoria by 31 July 2012. |
REC181-0204 | 2 - Emergency powers | The State amend the Country Fire Authority Act 1958 to enable the Chief Officer to delegate the power to issue fire prevention notices. |
REC181-0176 | 29 - Operational Health and Safety | The Country Fire Authority and the Department of Sustainability and Environment adopt the title ‘safety officer’ (as opposed to ‘safety adviser’) and require without exception that a safety officer be appointed to every level 3 incident management team. |
REC181-0174 | 29 - Operational Health and Safety | The Country Fire Authority and the Department of Sustainability and Environment amend their procedures for investigating safety incidents and ‘near-misses’ to ensure that all dangerous incidents, including back-burns, are fully investigated and that all relevant people are consulted and informed of the results. |
REC181-0217 | 25 - Inquiry, audit, lessons management and after action review | The State consider the development of legislation for the conduct of inquiries in Victoria —in particular, the conduct of royal commissions. |
Rec-ID | Code | Recommendation |
---|---|---|
REC177-3293 | 29 - Operational Health and Safety | If a dispute arises between a licensee and a rig operator in relation to a well control issue, and is not resolved between them, the matter must be raised with the relevant regulator before discretionary operations proceed. |
REC177-3285 | 39 - Disaster Risk Management | Pre‐drilling assessments should include a risk assessment of the worst‐case blowout scenario. |
REC177-3344 | 25 - Inquiry, audit, lessons management and after action review | There should be a review to determine whether it is appropriate to introduce a rigorous civil penalty regime and/or substantially increase some or all of the penalties that can be imposed for breaches of legislative requirements relating to well integrity and safety. |
REC177-3321 | 29 - Operational Health and Safety | Careful consideration must be given to equipment compatibility as part of well construction design. |
REC177-3356 | 39 - Disaster Risk Management | The regulator should pre‐assess and review in a generic sense, and in conjunction with the offshore petroleum industry, available options for well control in the event of a blowout. Being ‘match fit’ in this sense will enable a quicker and more effective response in terms of safety assessment, and will ensure that expectations of both operator and regulator are more readily aligned. |
REC177-3345 | 2 - Emergency powers | NOPSA’s prohibition powers should be extended such that a prohibition notice can be issued where a NOPSA Occupational Health and Safety Inspector believes, on reasonable grounds, that an activity is occurring or may occur at a facility involving an immediate threat to the health or safety of a person. |
REC177-3288 | 29 - Operational Health and Safety | As soon as a risk of barrier failure arises, no other activities should take place in the well other than those directed to removal of the risk. |
REC177-3303 | 29 - Operational Health and Safety | Tracking and analysis of cementing problems/failures should occur to assess industry trends, principal causes, remedial techniques and so on. |
REC177-3330 | 39 - Disaster Risk Management | Decision‐making about well control issues should be professionalised. Industry participants must recognise that decision‐makers owe independent duties to the public, not just their employer or principal, in relation to well control. Risk management in the context of well control needs to be understood as an ethical/professional duty. Self‐regulation contemplates self‐regulation by the industry, not just by individual licensees and operators. |
REC177-3282 | 29 - Operational Health and Safety | If a risk assessment or compliance review is triggered by the happening of a predetermined event, specific consideration should be given to whether a ‘hold point’ should be introduced such that work must cease until the problem is resolved (and the subject of appropriate certification). |
REC177-3299 | 29 - Operational Health and Safety | Regulatory approval to rely on only one barrier should not be given unless (i) a proper risk assessment is carried out; (ii) exceptional circumstances exist; and (iii) risks involved are reduced to ‘as low as reasonably practicable’. The default position must be that well integrity must be assured. |
REC177-3291 | 39 - Disaster Risk Management | Removal of a barrier must be the subject of consultation between licensees and rig operators prior to removal. A proper risk assessment should be carried out and agreed upon, and documented in writing before removal. Joint written certification as to the appropriateness of removal should take place before removal. Senior onshore representatives of stakeholder entities should be involved in that certification process. |
REC144-3387 | 25 - Inquiry, audit, lessons management and after action review | In order that the ACT public can be reassured about the project management and financial planning in relation to the Fairbairn site as a proposed centralised accommodation facility for emergency services, the Auditor-General undertake a review of the project from a financial probity and project management perspective. |
REC177-3281 | 29 - Operational Health and Safety | Wellbore gas bubbling should be regarded as a trigger for independent review of well integrity. Industry and regulators should identify and document other triggers. |
REC177-3295 | 29 - Operational Health and Safety | Wells drilled into hydrocarbon zones should be treated as live wells, with the potential to blowout unless a documented risk assessment establishes otherwise. |
REC177-3289 | 39 - Disaster Risk Management | The use/type of barriers (including any change requests relating thereto) must be the subject of consultation between licensees and rig operators prior to installation. A proper risk assessment should be carried out, agreed upon, and documented in writing before installation. Joint written certification as to the appropriateness of the use of particular barriers should take place before installation. Senior onshore representatives of stakeholder entities should be involved in that certification process. |
REC177-3378 | 25 - Inquiry, audit, lessons management and after action review | In view of the numerous well integrity problems in all of the Montara Oilfield wells, the Minister should commission a detailed audit of all the other offshore wells operated by PTTEPAA to determine whether they too may suffer from well integrity problems. |
REC177-3279 | 29 - Operational Health and Safety | Well construction and management plans, and drilling programs, should include provision for testing and verifying the integrity of all barriers as soon as practicable after installation. |
REC177-3294 | 29 - Operational Health and Safety | Perceived time and cost savings relating to any matters impacting upon well control should be subjected to rigorous safety assessment. |
REC177-3286 | 39 - Disaster Risk Management | Problems which arise in the course of installing barriers must be the subject of consultation between licensees, rig operators, and contractors (if used). A proper risk assessment should then be carried out and remedial steps (including further testing/verification) should be agreed upon, and documented in writing before the performance of remedial work whenever practicable. Joint written certification as to resolution of the problem should take place before resumption of drilling operations. Senior onshore representatives of stakeholder entities should be involved in that certification process. |
REC177-3374 | 25 - Inquiry, audit, lessons management and after action review | The Minister should, as the JA for the offshore area of the Territory of Ashmore and Cartier Islands, undertake a review of PTTEPAA’s permit and licence to operate at the Montara Oilfield. |
REC177-3278 | 29 - Operational Health and Safety | Well construction and management plans should include provision(s) for reviewing the integrity of barriers at safety‐critical times or milestones, such as (i) prior to suspension involving departure of the rig from the platform; (ii) prior to re‐entry of a well after suspension; (iii) prior to removal of any barrier. |
Rec-ID | Code | Recommendation |
---|---|---|
REC165-0086 | 2 - Emergency powers | Suggested escalation trigger points be discussed with District Disaster Coordinators and Local Disaster Coordinators, and if considered practical and useful, be incorporated in Local, District and State Disaster Management Plans. |
REC165-0081 | 2 - Emergency powers | District and State levels utilise the current Act to make pre-emptive declarations of a disaster event (likely disasters) so as to be proactive in leading and controlling disaster events. All levels of the system should immediately notify other levels if they activate the Disaster Management arrangements. The Public Safety Preservation Act 1986 be amended to provide powers for Police Officers to provide an immediate response in the event of a rapid onset disaster event such as a landslide. |
Rec-ID | Code | Recommendation |
---|---|---|
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 |
---|---|---|
REC161-3030 | 25 - Inquiry, audit, lessons management and after action review | That National Offshore Petroleum Safety Authority review the risk assessment of pipelines. National Offshore Petroleum Safety Authority should focus, in particular, on the efficacy of anti-corrosion systems, and recognise potential interference effects and MAE escalation risks associated with adjacent pipelines and unlicenced pipes even if they fall outside its direct regulatory responsibilities. |
Rec-ID | Code | Recommendation |
---|---|---|
REC151-3107 | 2 - Emergency powers | Immunity be prescribed for persons (including volunteers) using force in the exercise of a power or function under the FES Act or carrying out any direction or requirement given or imposed at the scene of a fire or other emergency. |
REC151-3079 | 2 - Emergency powers | Crown Law opinion be obtained to determine whether the FES Act gives the Minister power to direct and control individual Chief Officers and if that provision does not exist then the FES Act be amended to include that power. |
REC151-3109 | 36 - Volunteers | As a matter of priority, SAFECOM examine what further measures can be taken to provide support and protection for volunteers as potential witnesses in public enquiries. |
REC151-3108 | 36 - Volunteers | Liability and immunity as these provisions apply in Section 127 be reassessed in terms of burden of proof so as to ensure the best protection for volunteers. |
Rec-ID | Code | Recommendation |
---|---|---|
REC149-3147 | 29 - Operational Health and Safety | As all stakeholders have responsibility for safe outcomes, decisions regarding target subjects for safety promotion need to have the support of all stakeholders including NOPSA and the workforce. Industry, which ultimately has the responsibility for managing risk as well as funding the promotion, should take a leadership role in implementation. |
REC149-3144 | 29 - Operational Health and Safety | The Safety Case proponent should be allowed some flexibility to involve appropriate experience matched with the proposed workforce competencies to enable the Safety Case to be developed with value adding processes. Subsequent to the hiring of the workforce Final Government Response Offshore Petroleum Safety Regulation Inquiry and 2008 Review of NOPSA Operational Activities and preferably before the commencement of operations a review of the Safety Case should take place with the new workforce to ensure they understand the accepted Safety Case, its risks and Safety Management Plan. |
REC149-3145 | 25 - Inquiry, audit, lessons management and after action review | NOPSA should consider an audit regime that targets Greenfields operations at commencement of operations. |
REC149-3139 | 39 - Disaster Risk Management | The industry should develop in conjunction with the Regulator a process for addressing the need to maintain the risk profile of a facility moving into extended life operation at the same risk profile as when it was within design life. |
REC149-3135 | 29 - Operational Health and Safety | The initial acceptance of a new facility Safety Case should be in conjunction with inspection of a facility upon commencement of operations. |
REC149-3128 | 29 - Operational Health and Safety | National Offshore Petroleum Safety Authority (NOPSA) should develop guidelines in consultation with stakeholders to provide clarity and consistency to the process which ultimately will result in better safety outcomes. |
Rec-ID | Code | Recommendation |
---|---|---|
REC148-3167 | 25 - Inquiry, audit, lessons management and after action review | That the facilities at Eastern Creek and Spotswood Quarantine Stations be reviewed by AQIS in consultation with experts in biosecurity and interested parties including state and territory governments, import agents, veterinarians, farriers, operators of private quarantine stations, and representatives of horse owners, horse racing organisations and equestrian organisations. There should in any event be constructed without delay, an adequate supply of hygienic, modern showering facilities and places of entry and exit to the stations and the horse sections of them that can be supervised and monitored continually. There should also be provided at those stations as soon as is practicable suitable means of electronic surveillance, including closed-circuit television; a secure place to store chemicals, drugs, instruments and equipment for use by people attending the quarantined horses, and a set of horse stalls and yards separate from the main stalls and yards to enable isolation of horses suffering from contagious or infectious diseases. These reviews should also consider the desirability of separate areas in quarantine stations to hold horses forming part of a single quarantine intake but that have been imported from different regions or have undergone pre-export quarantine in different places. The reviews should be carried out without delay, and the two quarantine stations should be upgraded in accordance with the recommendations of the reviews. |
REC148-3154 | 25 - Inquiry, audit, lessons management and after action review | That the officer responsible for the importation of horses arrange for Biosecurity Australia or another qualified body to inspect and review the activities and events that occur from the time horses enter pre-export quarantine until the time they arrive at an airport in Australia, in order to identify any biosecurity risks and recommend any necessary changes to import conditions or other requirements. This inspection and review shall be performed without delay for each country or region from which horses are imported to Australia, and it should take account of my other recommendations and comments in this report. |
REC148-3181 | 39 - Disaster Risk Management | That Biosecurity Australia undertake and complete within 12 months a non-regulated but formal import risk analysis relating to the importation of horses from the countries and regions from which Australia currently permits such importation, and make such recommendations for any changes to policies for importation as are warranted by its risk analysis to the officer responsible for the importation of horses and the Executive Director of AQIS. |
REC148-3182 | 25 - Inquiry, audit, lessons management and after action review | That Biosecurity Australia review that formal import risk analysis at least once every two years to take into account any relevant developments in scientific knowledge—specifically testing methods, vaccines, vaccination procedures and other matters that affect biosecurity. Reports on the reviews should be provided to the officer responsible for the importation of horses and should contain recommendations for any necessary changes to policies for importation. |
REC148-3175 | 25 - Inquiry, audit, lessons management and after action review | That the officer responsible for the importation of horses arrange for Biosecurity Australia to review, at least once every two years, the operating procedures to ensure that they adequately identify and manage the risk of entry and spread of equine influenza associated with the importation of horses into Australia. The outcome of each such review should be the subject of a written report and recommendations to the person responsible for the importation of horses and the Executive Director of AQIS. A determination should then be made as to whether any, and if so what, changes should be made to the operating procedures. |
REC148-3170 | 25 - Inquiry, audit, lessons management and after action review | That the officer responsible for the importation of horses arrange for Biosecurity Australia to conduct within six months, an inspection and review of the process of horse importation from the time horses arrive in Australia until the completion of their post-arrival quarantine in order to: |
Rec-ID | Code | Recommendation |
---|---|---|
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. |
REC121-3733 | 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. |
REC121-3739 | 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. |
REC121-3693 | 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. |
REC121-3706 | 29 - Operational Health and Safety | RailCorp should establish a comprehensive safety document management system. |
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. |
REC121-3757 | 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. |
REC121-3732 | 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. |
REC121-3764 | 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. |
REC121-3738 | 29 - Operational Health and Safety | All passenger trains must be fitted with an internal passenger emergency door release. |
REC121-3710 | 39 - Disaster Risk Management | The ITSRR should have permanent access to the RailCorp intranet. |
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. |
REC121-3702 | 29 - Operational Health and Safety | Random alcohol testing should be continued. |
REC121-3747 | 29 - Operational Health and Safety | All trains should have windows available through which passengers can escape. |
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. |
REC121-3731 | 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: |
REC121-3759 | 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: |
REC121-3737 | 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. |
REC121-3700 | 39 - Disaster Risk Management | Maintenance plans on all trains should be revised annually. |
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. |
REC121-3743 | 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. |
REC121-3711 | 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. |
REC121-3755 | 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. |
REC121-3768 | 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. |
REC121-3735 | 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. |
REC121-3681 | 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. |
REC121-3741 | 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. |
REC121-3684 | 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. |
REC121-3713 | 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. |
REC121-3709 | 29 - Operational Health and Safety | RailCorp should provide access to electronic versions of safety documentation for all operational staff at their workplace. |
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. |
REC121-3765 | 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. |
REC121-3734 | 29 - Operational Health and Safety | RailCorp should integrate its management of occupational health and safety into its overall safety management. |
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. |
REC121-3740 | 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. |
REC121-3683 | 39 - Disaster Risk Management | RailCorp should undertake risk assessments of each of its activities as follows: |
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. |
REC121-3707 | 29 - Operational Health and Safety | The safety document management system should provide for the distribution of electronic versions of safety documentation to relevant staff. |
REC121-3749 | 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”. |