By December 2023, the Rural Fire Service should: report annually on fleet allocations to RFS Districts, and identify the ways in which fleet resources align with district-level fire risks 

By December 2023, the Rural Fire Service should: develop performance measures to assess the performance and capabilities of the fleet in each RFS District by recording and publicly reporting on: fire response times and fire response outcomes; and, completions of fire hazard reduction works.

The Inspector-General of Emergency Management recommends Queensland Fire and Emergency Services review the Queensland Emergency Alert Manual – M.1.174 in its entirety by 1 November 2023. The manual should specifically address the authorising environment, legislative obligations and the capability and complexities of the Emergency Alert system.

The Inspector-General of Emergency Management recommends Queensland Fire and Emergency Services review the Queensland Emergency Alert Manual – M.1.174 in its entirety by 1 November 2023. The manual should specifically address the authorising environment, legislative obligations and the capability and complexities of the Emergency Alert system.

The Inspector-General of Emergency Management recommends that Queensland Fire and Emergency Services review and update the State Disaster Risk Report, including re-evaluating the risk of flooding by all types. Queensland Fire and Emergency Services should publish the updated State Disaster Risk Report by 1 November 2023.  

We recommend that DEWLP and CFA (in consultation with FRV) systemically documents and publicly reports reasons why it does not complete planned burns.

We recommend that DEWLP and CFA (in consultation with FRV) develops financial reporting to monitor fuel management costs and estimate future costs.

The Inspector-General for Emergency Management recommends that the Department of Environment, Land, Water and Planning (or the single entity referenced in Recommendation 4) – in conjunction with legislated fuel management organisations – develop a common set of objectives, metrics and reporting requirements for fuel management that form part of a compulsory regime that enables the Victorian Government to report publicly on a holistic fuel management program. The reporting requirements should:
a) apply to all organisations with a legislated role in fuel management; across public and private land (all land tenures); and at all levels – state, regional and municipal
b) include residual risk where appropriate - however, complementary metrics should be developed if residual risk cannot be determined. 

The Australian Government should establish accountability and assurance mechanisms to promote continuous improvement and best practice in natural disaster arrangements. 

That, in order to ensure firefighter sustenance is of sufficient volume and quality, the NSW RFS reviews food standards and procedures in consultation with volunteers. The review should include catering service standards, including food safety, as well as the viability of sourcing commercial contracts and providing 12-hour food packs to firefighters.

That, to ensure firefighters can access mental health support through GPs, Government work with the Commonwealth Government to:
a) provide a free mental health screen to firefighters post-fire event and waive any gap payments if additional treatment is required
b) create a new Medicare Benefits Scheme item number to enable Governments to track demand for mental health services from firefighters over time and ensure an appropriate level of support is available.

That, in order to ensure all NSW RFS members can access the mental health support they need, the NSW RFS expands in-house mental health support for members.

Documenting results and recommendations from disaster recovery tests.

A single point of truth be established for accurately capturing and reporting on disaster management group activation levels for any given timeframe. 

The Department of Housing and Public Works should be included within Local Disaster Management Group evacuation centre planning and plans and assist with decision making around the relocation of evacuees from evacuation centres.

Fatigue management strategies and guidance should be improved to ensure sustainable staffing practices are incorporated into disaster management planning.

Complete sets of daily-report books should be provided, and kept in the mine or office, to be overlooked by the Inspector during his periodical visits.

I recommend that the Commonwealth Attorney-General liaise with ASIO to develop a policy to ensure that where correspondence is received by a government agency, minister or public office holder, from a non government entity, and that correspondence is relevant to the security assessments of the author, the correspondence be referred to: ASIO; and a Fixated Threat Assessment Centre.

I recommend that ASIO liaise with the Fixated Threat Assessment Centre with a view to both agencies cooperating in the identification, assessment and management of fixated, radicalised individuals.

I recommend that: the Commonwealth Attorney-General and ASIO confer with the Australian Psychological Society regarding the restrictions in clause A 5 2 of the Code of Ethics (2007) with respect to radicalisation, terrorism and politically motivated violence; and the Australian Psychological Society consider amending clause A 5 2 of the Code of Ethics (2007) to enable psychologists to report risks of a terrorist nature.

Implement a social marking program to promote improved respiratory etiquette and hygiene.

Personal protective equipment (masks, gowns, gloves, goggles) – review fit-testing vs fit-checking.

The report recommends that Ambulance Tasmania outline what KPIs are measured and provide targets or benchmarks to define what is good or poor performance.

The report recommends that regional summary reports of clinical reviews be standardised to facilitate review and comparison across regions.

The report recommends that Ambulance Tasmania collects data to allow regular and meaningful comparison of clinical outcomes at the regional level, to better allocate resources and to rapidly identify problems.

The committee recommends that the Australian Government recognise the need to enhance protection and conservation efforts in the Tasmanian Wilderness World Heritage Area by allocating increased funding:
• to the Parks and Wildlife Service, Tasmania, for appropriate management activities and resources; and
• for research projects aimed at providing qualitative and quantitative data specific to climate-related and ecological threats to the Tasmanian Wilderness World Heritage Area (such as dry lightning strike).

The committee recommends that the Australian Government commit to long-term funding for the the National Aerial Firefighting Centre of an amount that is at least equal to government's current contribution, rising in line with the Consumer Price Index

The committee recommends that the Australian Government, in conjunction with state and territory governments, investigate a national remote area firefighting capability, to support Australian fire agencies.

The committee recommends that the Australian Government: • recognise that climate change has increased fire conditions in south-eastern Australia and the risk to natural and cultural values in the Tasmanian Wilderness World Heritage Area; and • report annually to the World Heritage Committee on the state of conservation in the Tasmanian Wilderness World Heritage Area.

SACFS and the BoM review current weather, fuel loads and curing rates to determine the most appropriate and accurate forecast is prepared, issued and validated against current conditions.

The Australian National Audit Office (ANAO) recommends that the Attorney‐General’s Department significantly improve the administration of disaster relief and recovery funding by:
(a) adopting more timely processes for developing, finalising and promulgating disaster funding guidelines and advisories; and
(b) implementing administrative arrangements that provide it with greater details of the amounts included in expenditure claims, including project specific information.

To provide improved oversight and assurance in its administration of the Natural Disaster Relief and Recovery Arrangements, the Australian National Audit Office (ANAO) recommends that the Attorney‐General’s Department:
(a) obtain project level information from states and territories to enable more informed analysis of claim amounts; and
(b) implement a risk‐based approach to examining the eligibility and value for money of a sample of recovery and reconstruction projects.

CFA and VICSES should: implement risk management processes within regions, districts, brigades and units to understand and manage the local risks associated with their volunteer workforces

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.

Within three years, the Australian Government should develop and implement a framework for untied grants for community recovery assistance to state and territory governments. This framework should take into account factors such as the type, location and scale of a disaster, and the number of people affected.

The ANAO recommends that the Department of Defence take steps to strengthen the priority afforded by Defence units to meeting these reporting requirements.

Western Australia Health should require service providers to report more comprehensive performance data using additional cost and clinical indicators

Western Australia Health should include in contracts minimum standards for emergency and secondary ambulance services and effective mechanisms to monitor these

St John Ambulance should develop quantitative performance targets for community paramedics and report these to Western Australia Health

That Government agencies work closely with the Bureau of Meteorology and radio stations that broadcast emergency service announcements, to ensure the earliest possible determination of, and communications about, dangerous bushfire conditions.

That Rural Fire Service Queensland in consultation with the Rural Fire Brigades Association Queensland will undertake a full review of the medical and health protocols to support the new Volunteer organisation.

That the First Officer or Brigade Officer retain the ability to seek assistance from any person whose services are available at the fire. Any person appointed to provide this assistance should be protected under relevant Workplace Health and Safety and Workcover legislation.

That the number of Bushfire Safety Officer positions be, over time, increased so that one BSO operates out of each District office.

That the Department of Health publicly reports a comprehensive suite of performance information, including:
- response performance across all priority codes, including Code 2 (urgent) incidents and against response targets
- results of clinical audits and reviews

That the Department of Health enhances management reporting processes over complaints by recording the number and nature of complaints, following up outstanding complaints formally and reporting complaints data to executive management.

That Queensland Corrective Service continues to develop its proposed recidivism index as a priority, including place and program based measures.

That should the Mobile Strategy in its current form be approved by government the CEO Portfolio Business and the Deputy Commissioner Operations:
- monitor the success of the mobility strategy
- report on a quarterly basis to government on the achievement of the identified saving presented as part of the mobility strategy business plan (1414 FTE $174 million)
- report on the achievement of the increased frontline police numbers from this initiative of 1,587 FTE on a quarterly basis.

That Queensland Corrective Service, in consultation with key partners in the criminal justice and social services sectors, develops specific performance indicators focused on efficiencies and customer/stakeholder outcomes across the criminal justice system.

That the roll-out of the mobile service program business case mentioned earlier
- Be specific about gateways and milestones; and
- If the new technology enables improved data, the Queensland Police Service revisit previous statistical reporting and identify any major anomalies.

That the Queensland Police Service Commissioner addresses the situation regarding statistical reporting. The Commissioner, in collaboration with the Chief Executive Officer Portfolio Business and the Queensland Fire and Rescue Service Commissioner should also examine the opportunity to acquire the services of a qualified and experienced Chief Information Officer or Chief Digital Officer in line with other Queensland and Australian government agencies.

That the workplace health and safety reporting system be reviewed to facilitate ease of reporting.

Recommendation: That the CEO Portfolio Business collaborates with the two portfolio Commissioners to:
- develop an analytical tool to identify the most appropriate level of service
- identify the need for new or enhanced services
- reduce the level of resources where appropriate
- identify current anomalies regarding service delivery and therefore opportunities for rationalisation of stations
- consider collocation with other services as a first principle before committing to new capital projects.

The Chief Executive Officer Portfolio Business establishes a set of performance indicators to provide a transparent process for government to monitor its performance.

The committee recommends that in relation to mandatory and confidential reporting, the default position should be that no identifying details should be provided or disclosed. However, if there is a clear risk to safety then the ATSB, CASA and industry representatives should develop a process that contains appropriate checks and balances.

The committee recommends that where a safety action has not been completed before a report being issued that a recommendation should be made. If it has been completed the report should include details of the action, who was involved and how it was resolved.

The committee recommends that the ATSB prepare and release publicly a list of all its identified safety issues and the actions which are being taken or have been taken to address them. The ATSB should indicate its progress in monitoring the actions every 6 months and report every 12 months to Parliament.

To strengthen its oversight of Queensland reconstruction progress, the Australian National Audit Office (ANAO)  recommends that the National Disaster Recovery Taskforce:
(a) monitor revisions to scheduled project completion dates, and raise with the Queensland Reconstruction Authority any issues and anomalies, as appropriate; and
(b) adopt a more pro‐active approach to requesting timely progress and completion reporting documentation from the Queensland Reconstruction Authority according to planned and reported actual completion dates.

The Australian National Audit Office (ANAO) recommends that the Australian Government Reconstruction Inspectorate and the National Disaster Recovery Taskforce seek to maximise the benefits from their value for money review activities by obtaining more timely and comprehensive information on project progress and completion from the Queensland Reconstruction Authority, to enable the preliminary value for money assessments to be finalised based on the scope and cost of works that were actually delivered (rather than estimates).

Having regard to the terms of the Torres Strait Treaty, the Department of Health and Ageing, Queensland Health, AusAID and the Papua New Guinea Government:
- establish a set of protocols and procedures for the identification and treatment of tuberculosis and other infectious diseases in Papua New Guinea and the Torres Strait Islands; and
- consider what clinical services should be available in both Papua New Guinea and Australia for the identification and treatment of tuberculosis and other infectious diseases.

The Australian Government work with the state and territory governments to assess the viability of providing a centralised refugee and migrant health service in each state and territory, which would automatically refer people who move from immigration detention into the wider Australian community.

The Australian Government coordinate the development of a highly skilled workforce which can respond effectively to a sustained pandemic in Australia.

The Commonwealth Government support the growth of vaccine development and production capacity for vaccines in Australia, to enhance Australia’s preparedness to respond to outbreaks of infectious disease in Australia, and in particular, pandemic influenza.

The Australian National Audit Office (ANAO) recommends that the Department of Regional Australia, Local Government, Arts and Sport improve its monitoring of the delivery of the Natural Disaster Recovery Work Plans for Queensland and Victoria by:
(a) seeking from each state the project level data that is required to report to Ministers on reconstruction progress in the manner required by each National Partnership Agreement (or as may otherwise be agreed); and
(b) undertaking analysis of relevant data that has been reported by each state over time to identify significant trends and other matters of importance, and updating this analysis as and when further data is reported.

The Territory and Municipal Services Directorate, as part of its Bushfire Operations Plan monitoring and reporting, should assess and publicly report on cumulative progress against broader outcomes identified in the Regional Fire Management Plans and the Strategic Bushfire Management Plan.

I recommend that the Commonwealth ensure that there is a mooring buoy which will enable the mooring of SIEVs to take place and free up the Christmas Island response vessel for ongoing surveillance duties. 

I recommend that the Commonwealth liaise closely with representatives of the Christmas Island VMRS prior to purchasing or replacing any vessels for the VMRS in the future. 

I recommend that the Commonwealth and the Shire of Christmas Island take steps to ensure that the Ethel Beach boat ramp is significantly upgraded, that it should be provided with shelter in the form of a rock groyne or similar buffer and that provision should be made so that a person can walk beside the ramp on a stable footing; or If this is not considered likely to be effective in providing an appropriate means of deploying a rescue vessel in adverse conditions, such other action be taken as is necessary to ensure that there is a means of deploying a rescue vessel in adverse conditions. 

The Ministers for Emergency Services, Environment and Police ensure their departments include in their annual reports the expenditure they have incurred on preparing their staff for critical incidents, and for managing their response to these incidents.

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.

The Minister for Health immediately establish the road trauma counselling service to be funded by the Road Trauma Trust Account.

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.

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.

The Western Australian Government amend current State occupational health and safety legislation so that it includes a definition for ‘health’ that includes psychological health.

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.

Housing should use risk based analysis of its tenant and property information, job order data and quality assurance results to better inform target setting for KPIs, job order controls, and the sampling used for completed work inspections before and after payment. This analysis should synthesise information from all sources and include a risk assessment of tenants and properties, as well as consideration of the various types of maintenance work being done (emergency, priority and routine, and planned maintenance).

Housing should further develop its Head Contractor key performance indicators to include quality, cost and tenant satisfaction. Currently performance reporting is focused entirely on timeliness indicators.

That the Department of Sustainability and Environment continue to invest in the auditing of Victoria’s levee systems, both public and private, so that the Victoria Flood Database contains reliable and up to date data, including information on levees’ location, height, condition and ongoing viability for flood protection.

Carriers, councils and the Australian Communications and Media Authority should take into account the risk of flooding when considering the placement of telecommunications facilities.

Boost the number of frontline meteorologists to build response capacity in regional forecasting centres.

Centralise media services and establish protocols for media activity.

Lower yield options identified by the Bureau:
(a) Reduce staffing at remote observing stations
(b) Close the training facility at Broadmeadows, Victoria
(c) Consolidate forecasting functions for Northern Queensland
(d) Outsource the Bureau’s library

Explore options to limit forecaster intervention in site-specific web forecasts.

Lower yield options identified by the Bureau:
(a) Reduce staffing at remote observing stations
(b) Close the training facility at Broadmeadows, Victoria
(c) Consolidate forecasting functions for Northern Queensland
(d) Outsource the Bureau’s library

Explore use of social media to enhance data gathering from authorised and informal sources and to disseminate weather information

Complete workforce planning project and succession plans as a matter of urgency.

Fund delivery of improved seasonal forecasting services by:
(c) Identifying potential offsets from government beneficiaries of any additional investment in seasonal forecasting services
(d) Undertaking market research to establish industry willingness to pay for enhanced seasonal forecasting services

Improved seasonal forecasting capabilities: 
(a) Improved presentation of existing products
(b) Enhanced capability – keeping pace with international standards

Focus the Bureau’s evolving environmental information role on natural hazards in the first instance.

Phase out seasonal prediction development and modelling and rely on products generated elsewhere

Upgrade to the Bureau’s supercomputing capacity:
(a) Status quo
(b) Step change
(c) Further enhancements

Boost the Bureau’s flood warning capacity by:
(a) Increasing the number of frontline hydrologists
(b) Upgrading the flood monitoring system

Cease or reduce the Ionospheric Prediction Service or offer it as a commercial service.

Additional frontline meteorologists and specialised centres and systems:
(a) Enhanced severe weather units
(b) National extreme weather centres
(c) Integrated all-hazards decision system
(d) Enhanced observation network

The Committee recommends that the Minister for Financial Services and Superannuation immediately establish a joint industry-Government action group to address evidence of the rising costs and market failure of insurance premiums across Australia.

The Committee recommends that the Australian Government investigate ways to reduce the cost of calling 1300 numbers from mobile telephones in areas of natural disasters.

The Committee recommends that the Australian Government work with the Insurance Council of Australia to make the following amendments to the General Insurance Code of Practice by 1 July 2012:
- remove the clauses that set aside the Code standards in times of disasters;
- require insurers to refrain from advising policyholders against making a claim under their insurance policy, and incorporate a ‘right to claim’ so that policyholders who contact their insurer about their eligibility to make a claim are offered the opportunity to lodge a claim and have it assessed fully;
- ensure that a full explanation of the claims-handling process, including the right to escalate decisions to internal dispute and external dispute resolution systems, is given when policyholders lodge a claim;
- ensure that an acknowledgement of the claims lodgement, contact details of the claims officer, and expected timeframes for the claims-handling process are provided to policyholders in writing;
- require that copies of external expert reports used in the determination of a claim to be provided to claimants within 10 days of request; and
- introduce the following minimum standards for claims handling in times of exceptional circumstances such as declared disasters:
⇒ a timeframe for informing claimants of the progress of the claim;
⇒ a timeframe for advising claimants if an external expert has been appointed;
⇒ assurance that external experts are fully qualified to undertake assessments;
⇒ an undertaking to provide claimants with information about the qualifications, employer, and role of external experts that are appointed to assist with their claim;
⇒ a maximum timeframe of 12 weeks for external experts to provide reports;
⇒ a maximum timeframe for accepting or denying a claim;
⇒ a timeframe for responding to requests for information;
⇒ an undertaking to communicate all decisions about insurance claims to the claimant in writing with clear and explicit reasons relating to their particular claim; and
⇒ a timeframe for informing claimants of the progress of their complaint or dispute.

The Board of Tourism WA should take action to ensure that it reviews the quality of Board papers that are submitted to it by the executive of Tourism WA.

FESA needs to place greater priority on the appointment of Safety Advisors to Level 3 incidents as is reflected in WESTPLAN Bushfire.

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‟

the Bureau of Meteorology undertake a review of its radar coverage in the context of flash and riverine flood warnings for Victoria, with a particular focus on known gap areas such as the Horsham/Nhill region.

the state review the potential for National Registration and Inquiry System 6 to provide a single point of information collection to both register individuals and plan the delivery of recovery services. If the review determines National Registration and Inquiry System 6 is unable to fulfil this function, the state should work with the commonwealth and other states to implement the necessary changes to National Registration and Inquiry System 6. If National Registration and Inquiry System 6 is unable to be developed as a single information collection system: the state should develop and implement a single point of information collection system, including how information obtained from outreach activities can be incorporated into this system and how such information may be linked into the Rapid Impact Assessment process.

the Bureau of Meteorology should present water levels in both local datum and Australian Height Datum (gauge zero) for all its published information and warnings

the commonwealth consider including (as part of its review of standards for aged care services) requirements for: • robust ‘all hazards’ evacuation plans that include current after-hour contact details of people who are able to make authoritative decisions during an emergency; and • rehearsal of those plans.

the state and the Bureau of Meteorology liaise to ensure the existence of appropriate quality control processes for gauges and contingency measures in the event that gauges are damaged during flood events.

the Bureau of Meteorology expand its volunteer amateur weather watch groups to enhance its weather and flood information gathering procedures.

the state engage with the Bureau of Meteorology to establish a joint initiative to review existing flash flood warning systems in Victoria and identify where additional systems are needed, with a particular focus on urban centres with a history of flash flooding. This review should seek to achieve outcomes similar to those implemented in NSW. Subject to those outcomes being implemented, the state should determine which agency is responsible for flash flood warnings.

the Bureau of Meteorology provide Incident Control Centres with real-time access to flood data held by the Bureau of Meteorology. This will require Bureau of Meteorology staff making themselves available to respond to enquiries from Incident Control Centres during a flood event.

the state and commonwealth undertake a review into the appropriate institutional arrangements for the forecasting and predictions function currently undertaken by Melbourne Water for the Port Phillip and Westernport region.

the Bureau of Meteorology adjust its flood prediction models to incorporate water storage conditions (to enable it to issue more timely and useful flood predictions for communities based downstream of water storages).

The Fire Services Commissioner requests the Federal Government to revise the National SEWS Guidelines

The Committee recommends that Parliament establish a standing committee for natural disasters. The purpose of this committee would be to ensure that Government agencies and emergency services are fully prepared to deal with natural disasters and to provide an opportunity for Members of Parliament, as opposed to Cabinet, to have input into disaster management.

That the Queensland Reconstruction Authority consider extending the suite of internal performance indicators being used as the Authority matures.

To ensure that NOPSEMA is in a strong position to perform its functions effectively:
a) NOPSA (and NOPSEMA) should continue and strengthen ongoing, constructive engagement, directly and through their representatives, with the industry and the offshore workforce;
b) agreed legislative changes should be given priority attention, including the issues of when its jurisdiction ceases to apply and the proposed updating of the compliance tools available to it under the legislation;
c) consideration should be given to providing for the recovery of costs for NOPSA’s work undertaken on a safety case that is formally submitted but (a) withdrawn before a decision is made on it, or (b) rejected.

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).
b) NOPSA should consult Safe Work Australia about how the National OHS Strategy 2002-12 and its forthcoming replacement may assist strategic planning over safety performance and its measurement in the offshore oil and gas industry.

In order to improve the effectiveness of National Offshore Petroleum Safety and Environmental Management Authority (NOPSEMA), with similar benefits for State or Territory regulators, attention should be given to the following actions.
a) Ministers should consider developing an overarching national understanding under which Commonwealth and State or NT regulators are expected to work cooperatively in respect of a large or complex Offshore Petroleum and Greenhouse Gas Storage (OPGGS) project or activity that requires their regulatory attention in their respective jurisdictions.
b) The aim of that cooperation would be to ensure that, as far as possible:
i. information about such projects is shared,
ii. regulatory actions are co-ordinated under a regulatory plan relating to the project or activity;
iii. approvals and other necessary steps in each jurisdiction occur speedily, 
iv. possible regulatory gaps or inconsistencies arising from the crossjurisdictional nature of the project or activity are identified and addressed; and
v. there is continuous improvement in the cooperative regulatory inter-action.
c) The understanding would provide a framework for MOUs or similar arrangements between regulators and provide accountability by requiring annual reporting to Ministers on:
i. the OPGGS projects or activities that had come within the scope and application of the MOUs or similar arrangement;
ii. how well the MOUs or other arrangements were working;
iii. what action had been taken or should be taken to improve regulatory cooperation;
iv. whether any significant regulatory gaps or inconsistencies had been identified.
d) To allow for a smooth transition to the Ministerial understanding and supporting regulatory cooperation, the understanding should be developed for early consideration by Ministers.

In developing and improving its policies and practices for stakeholder engagement, NOPSA should ensure that:
a) they are underpinned by a clearly stated commitment to representative, tripartite and consultative engagement (this could be included in a service charter 5);
b) a clear program for stakeholder engagement be developed and implemented as part of NOPSA’s Annual Operating Plan, with appropriate preliminary scoping of stakeholder needs and issues and the outcomes of such engagement analysed and reported to the Advisory Board

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.

NOPSA should:
a) maintain effective policies and procedures that ensure that NOPSA inspectors and other decision makers interpret and apply the OPGGS legislation and NOPSA’s policies fairly and consistently in similar circumstances; and
b) periodically examine consistency in regulatory decision making and the exercise of regulatory powers, for example, by audits or surveys.

The review team recommend that:
a) NOPSA examine, in consultation with industry stakeholders, developing a program of workshops based on the safety case guidance notes, to provide further face to face information to operators about complying with safety case regulatory requirements;
b) NOPSA should explain to the industry the reasons for the policy of not considering an application for the acceptance of a new safety case until an existing application has been decided and invite proposals for managing the process in a way that reduces the risk of delay; and
c) NOPSA should invite APPEA, IADC and IMCA to organise occasional forums specifically for consultants who prepare safety cases at which NOPSA (or NOPSEMA) can explain current safety case processes and content requirements and respond to any issues raised by the participating consultants.

That a national agency sponsored by the Commonwealth Government be established to undertake national coordination of flood risk management and to operate the system of premium discounts and the flood risk reinsurance facility. The Agency would:
• coordinate flood mapping across the country (while leaving responsibility for undertaking flood mapping in the hands of State and Territory governments and local authorities);
• introduce national guidelines for flood risk mapping and classifications, prepared in consultation with producers and users of flood risk information;
• act as a national repository of flood risk information, primarily through collating and analysing information collected by others;
• continue development of the Insurance Council of Australia’s National Flood Information Database or an equivalent developed by the Agency;
• monitor the effectiveness of flood risk mitigation initiatives across the country and advise on priorities for flood risk mitigation;
• publish and disseminate flood risk information in forms appropriate to various groups of users; and
• oversee the quality of flood risk information.

That an agency sponsored by the Commonwealth Government be created to manage the national coordination of flood risk management and to operate a system of premium discounts and a flood risk reinsurance facility, supported by a funding guarantee from the Commonwealth.

The committee recommends the Commonwealth Government require guaranteed access to emergency call services for people with a disability at all times.

FESA reviews its approach to safety and safety culture.

The Commonwealth, states and territories continue to pursue the National Action Plan to Reduce Bushfire Arson in Australia, giving priority to producing a nationally consistent framework for data collection and evaluating current and proposed programs in order to identify and share best-practice approaches.

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.

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.

The Department of Human Services should create evaluation guidelines for recovery operations, including links to planning. 

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).

A single, independent regulatory body should be created, looking after safety as a primary objective, well integrity and environmental approvals. Industry policy and resource development and promotion activities should reside in government departments and not with the regulatory agency. The regulatory agency should be empowered (if that is necessary) to pass relevant petroleum information to government departments to assist them to perform the policy roles.

Licensees should be subject to an express obligation to inform regulators of problems which arise in the course of installing barriers, even if they consider that well integrity is not thereby compromised. The information should be provided by way of special report, rather than included in a standard reporting document (such as a DDR). The information provided should include risk assessment details.

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.

In any future similar blowout or offshore emergency situation, the Minister appoint (through either a NOPR or the relevant Department) a senior public servant to establish and oversight a central coordinating body that will facilitate interaction between regulators, industry, AMSA and the owner/operator. Primary responsibility for stopping a blowout should remain with the owner/operator but should be subject to direction from the central coordinating body in consultation with stakeholders (including the owner/operator).

In carrying out a review of PTTEPAA’s permit and licence, the Minister should have regard to this Report, particularly (i) the adverse findings set out in this Chapter; and (ii) the extent to which PTTEPAA has implemented the Action Plan submitted to the Inquiry, or otherwise addressed the matters canvassed in this Report.

Wellbore gas bubbling should be regarded as a trigger for independent review of well integrity. Industry and regulators should identify and document other triggers.

The Minister should appoint a senior policy adviser to investigate and report on the best means to implement the recommendations contained in this Chapter 3 of this report.

Wells drilled into hydrocarbon zones should be treated as live wells, with the potential to blowout unless a documented risk assessment establishes otherwise.

In the future, and in the interests of ensuring that all possible well control options are comprehensively pursued to exhaustion, decisions as to well control response options should be the result of collaboration between the regulator and the operator rather than leaving one party to make unilateral judgements as to the appropriateness of various well control operations. The regulator should provide transparent and contemporaneous explanations to the public of all well control options under consideration at any particular time.

For the purposes of that review, the Minister should issue a ‘show cause’ notice to PTTEPAA under s 276 of the OPGGS Act.

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.

Perceived time and cost savings relating to any matters impacting upon well control should be subjected to rigorous safety assessment.

In the meantime, the Minister should:
a. consider revoking the existing delegation to the Director of Energy, NT DoR providing the functions and powers of the DA under the OPGGS Act and Regulations specified in item 1 of the Schedule to that instrument (the Minister’s DA powers and functions) and transferring this delegation to either NOPSA, RET, or a DA from another state;
b. enquire into whether the other DAs to whom he has delegated his functions and powers relating to well integrity are adequately fulfilling their roles; and
c. consider amendments to the OPGGS Act to enable DAs to be given direction as to the performance of their regulatory roles.

OSCPs should be endorsed by AMSA prior to regulatory approval to ensure that they align with the National Plan. Once field operations commence, the capability of operators should be assessed against their plans, and exercises conducted to ensure the plans remain effective.

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.

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.

Responsibility for well integrity should be moved to NOPSA (as also proposed by the Productivity Commission).

Careful consideration must be given to equipment compatibility as part of well construction design.

The Government should examine the scope for a single environment plan to meet the regulatory requirements of both the OPGGS Act and the EPBC Act. This could possibly be achieved by way of bilateral agreements and accreditation arrangements and/or legislative amendment.

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.

The proposal of the Productivity Commission’s Research Report (Review of Regulatory Burden on the Upstream Petroleum (Oil and Gas) Sector, April 2009) to establish a NOPR should be pursued at a minimum.

The successful installation of every barrier should be the subject of written verification within and between licensees and rig operators; and should be the subject of explicit reporting to the relevant regulator(s).

Tracking and analysis of cementing problems/failures should occur to assess industry trends, principal causes, remedial techniques and so on.

The body established to undertake a central coordination and facilitation role in the event of any future blowout in Commonwealth waters should undertake to make all relevant information publically available from one, authoritative and easy to access source.

The Commonwealth Government examine potential new arrangements for Commonwealth involvement in the development and implementation of a national policy for bushfire management.

The Commonwealth publish all fuel reduction plans and related audit findings on a national database.

The Commonwealth co-ordinate a standing national arson forum between fire and law enforcement agencies to be held every two years.

A strategically located Staging Area serviced with check in/out personnel should be considered as early as possible at incidents involving an extended attack.

The Department of Premier and Cabinet and Victoria Police, in consultation with departments, should standardise reporting on training exercises conducted under Part 6 of the Act and the CIP framework to promote greater consistency and to enable better identification of lessons learned and continuous improvement.

The Department of Premier and Cabinet should lead the development of a performance management framework for measuring, monitoring and reporting on the implementation of Part 6 of the Act and the CIP framework. The framework should include key indicators, targets and reporting arrangements for assessing the extent to which departments, agencies and industry have fulfilled their obligations, as well as measures for monitoring achievement of joint objectives.

Reports on the training exercises should be retained in an appropriately secured central repository so that consolidated results of the exercises can be drawn together effectively. 

To improve the governance arrangements for business continuity management (BCM) in Centrelink ,the Australian National Audit Office (ANAO)
recommends that:
(a) the recently constituted Business Continuity, Crisis Management and Security Sub committee be provided with regular reports on IT business continuity
issues; and
(b) Centrelink review existing BC and risk management planning and implementation activities to identify areas where coordination and collaboration could be further improved.

The ANAO recommends that Centrelink:
(a) develop performance measures against which its business continuity management preparation and response can be regularly monitored and assessed by the Business Continuity, Crisis Management and Security Sub-committee; and
(b) provide reports to the Business Continuity, Crisis Management and Security Sub-committee on the findings and implementation of there commendations of post–implementation review reports on business continuity incidents, including IT-related incidents.

The ANAO recommends that the Business Continuity, Crisis Management and Security Sub committee:
(a) endorse an annual program of scheduled testing for business continuity plans, including relevant Disaster Recovery Plans for all services and systems assessed by the agency as being business critical; and
(b) receive performance reports on the completion and key results of plan testing.

In order to identify key business processes and provide for the regular comparative assessment of Maximum Allowable Outage periods (MAOs), the ANAO recommends that Centrelink:
(a) commission a formal Business Criticality Review of its operations, including National Support Office, Area Offices and its service delivery channels; and
(b) establish a process for the annual review and endorsement of MAOs determined by branches to ensure that they represent a collective view on the relative criticality of the services that Centrelink provides.

The ANAO recommends that Centrelink develop and promulgate a business continuity plan (BCP) template and require business units to develop BCPs that identify:
(a) risks to the business/service and their impact, based on the respective business impact analysis; and
(b) risk treatments and business resumption tasks to manage these risks, which can then be tested on a regular basis.

ACTAS should develop a comprehensive performance management framework that includes key performance indicators and targets aligned to its service delivery activities, to help inform management and stakeholders of its performance.

ACTAS should develop a set of standards to measure and monitor patient satisfaction, so that improvements to the service can be made, based on patient satisfaction information.

ACTAS should establish a clinical information database that:
• enables the tracking and analysis of patient care records;
• facilitates improvements to the clinical care of patients; and
• provides an evidence based dataset to inform the future planning of the delivery of ambulance services.

ACTAS should implement systems to enable the accurate collection and measurement of non-emergency ambulance service bookings to facilitate monitoring of performance and the provision of accurate advice to Government.

ACTAS should log all emergency calls on CAD to document non-ambulance dispatch decisions, and to provide more complete data on demand.

That the nominated marine safety authority is required to ensure that incident notification and data recording requirements for Victorian commercial ports are consistent and adhered to.

That the nominated marine safety authority, in consultation with the Emergency Services Commissioner and senior emergency services personnel, is responsible for monitoring the implementation and auditing against appropriate performance standards, risk management guidelines and good practice guidelines.

The Bureau of Meteorology contact list for severe weather warning be strategically managed in consultation with Emergency Service Organisations, to identify critical contacts. The Bureau of Meteorology must ensure the detail for these critical contacts remains up to date.

That the Department of Sustainability and Environment, Department of Primary Industries, Parks Victoria & VicForests separately cost, and report, annual expenditure on fuel reduction burning, ecological burning and regeneration burning in their Annual Reports.

The Department of Sustainability and Environment should report its performance against the increased prescribed burning target in its annual report, which should also include the following details:
- the total area treated within each fuel management zone for each region;
- the total number of burns conducted within each fuel management zone for each region; and
- the extent to which planned ecological and fuel reduction outcomes were met for prescribed burns within each fuel management zone for each region (e.g. a summary of the results of the post-burn assessments to be conducted in accordance with recommendation 2.3 above).

That all information pertaining to current and planned prescribed burns be published more prominently on the Department of Sustainability and Environment’s website, with a single prominent link to this material on the website homepage.

That the details of any variation or amendment of a Fire Operations Plan, including: the carrying forward or postponement of burns within the three-year period covered by a Fire Operations Plan; the carry over, removal or rescheduling of burns between past, present and future Fire Operations Plans; and the alteration of burn boundaries (including alterations of less than 25 per cent); should appear on the Department of Sustainability and Environment’s website at the time of the change and be included in the Fire Operations Plan for the following year.

That finalised Fire Operations Plans be made publicly available in their entirety (with the exception of any private information) on the Department of Sustainability and Environment’s website and in hard-copy, and that this requirement be clearly stated in future Codes of Practice. This should include the “district burns list”, or its future equivalents, and a map which shows the corresponding burns for each Fire District. Each map should be provided in a format which can be downloaded directly from the Department’s website without the need for further data manipulation by the user. An identical hardcopy version of the map for each Fire District should be also be available to members of the public on request and free of charge.

QFRS introduce a system to collate and analyse performance information for use in management reporting and to support effective decision making processes. 

QFRS implement a system to monitor the condition and safety of brigade buildings and equipment. 

The current KPI measures used by the Regulator and industry need to be reassessed and the performance indicators need to be related to the risk profiles of the industry. The industry needs to develop the indicators, which need to be agreed and measured by the industry in discussion with other stakeholders. The KPI's selected should be published in comparison with the worldwide offshore industry and with other industries. NOPSA should continue discussions with Australian Safety and Compensation Council (ASCC) with a view to adopting their goals. 

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.

The initial acceptance of a new facility Safety Case should be in conjunction with inspection of a facility upon commencement of operations.

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. 

The role of the advisory Board, namely to give advice to Ministers and NOPSA when asked, should be made clear to Board members and all stakeholders. The Board and NOPSA should consider the need for a clear description of who does what based on the legislated responsibilities of the NOPSA CEO.

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.

That, in the absence of other satisfactory government controlled and operated post-arrival quarantine stations becoming available before the options to renew the leases of Eastern Creek and Spotswood Quarantine Stations expire, those options be exercised.

That the person holding the position of Inspector General of Horse Importation may be removed in the following circumstances only:
(a) automatically
(i) on bankruptcy or on an application to take the benefit of a law for
the relief of bankruptcy
(ii) on conviction for an indictable offence
or
(iii) on loss or suspension of any licence or authority to practise his or her regular profession
(b) by dismissal by the Governor-General in Council for proved misconduct in or relating directly or indirectly to the performance of his or her duties
(c) by resignation in writing to the Minister responsible for quarantine
(d) on certification by two medical practitioners of mental or physical
incapacity to perform the duties of Inspector General.

That there continue to be in Australia government controlled and operated post-arrival quarantine stations for horses.

That the person holding the position of Inspector General of Horse
Importation:
(a) be appointed by the Governor-General in Council following public advertisement
(b) be appointed for a term of five years only or for such lesser term as may remain at the time of appointment
(c) receive such remuneration and other benefits as fixed or recommended by the Remuneration Tribunal
(d) be a person with expertise in equine affairs and with such other qualifications and experience as the Governor-General in Council considers appropriate
(e) not hold or take other employment or consultancies that might give rise to an actual or perceived conflict of interest with the duties of Inspector General
(f) be obliged to submit to any medical examination reasonably required by the Minister responsible for quarantine before or during the term of appointment for the purpose of assessing his or her suitability for the position
(g) shall not be, or have been within the two years immediately preceding the appointment, employed or engaged by the Department of Agriculture, Fisheries and Forestry.

That there be similar facilities for the unloading and transfer of horses at any other airport in Australia that might receive horses imported from places other than New Zealand.

That the Secretary of the Department of Agriculture, Fisheries and Forestry designate, without delay, a Senior Executive Service officer to be primarily responsible and accountable for the importation of horses into Australia and to that end to have the power to exercise all necessary authority.

That there be provided without delay at Sydney (Kingsford Smith) and Tullamarine Airports facilities to enable people who might have had contact with imported horses to shower and change their clothes, under supervision, before leaving the airport.

That the officer responsible for the importation of horses prepare a report to the Executive Director of AQIS that:
(a) identifies (by category) all non-AQIS personnel involved in the importation of horses, including post-arrival quarantine, from countries other than New Zealand
(b) identifies the requirements in respect of biosecurity that AQIS has of those people
(c) identifies the source of those requirements—for example, by import conditions, agreement or understanding, whether formal or informal, with AQIS, and compliance agreement under s. 66B of the Quarantine Act 1908
(d) assesses whether compliance with those requirements can be and is adequately being enforced
(e) recommends measures to be taken to rectify any shortcomings.

That facilities for the unloading and transferring of horses at Tullamarine Airport in Melbourne be constructed urgently, upon advice of experts in biosecurity containment, to enable adequate biosecurity precautions to be taken effectively and to minimise the risk of injury to horses and those handling them.

That each government controlled and operated quarantine station have sufficient staff to carry out properly all activities and measures required by the current operating procedures dealing with the quarantine of horses.

That there be established the position of Inspector General of Horse Importation, the duties of that position being:
(a) to check, by inspection and audit at least once every 30 months, that operations and procedures at each approved pre-export quarantine premises are documented and being complied with
(b) to check, by inspection and audit from time to time at the Inspector General’s discretion, that import conditions covering the period until horses arrive at an airport in Australia are being complied with
(c) to check, by inspection and audit at least once every 30 months, that operations and procedures applying from when horses arrive at an airport in Australia until the completion of post-arrival quarantine are documented and being complied with
(d) to report in writing at least once every 12 months to the Minister responsible for quarantine on the results of such inspections and audits and such other related matters as the Inspector General thinks necessary.

That the facilities for unloading and transferring of horses at Sydney (Kingsford Smith) Airport be upgraded without delay, following the advice of experts in biosecurity containment, so as to enable appropriate biosecurity precautions to be taken effectively and to minimise the risk of injury to horses and those handling them. The facilities should include at least one padded box or stall sound-proofed to the extent that it is reasonable to do so.

The Australian National Audit Office (ANAO) recommends that, in order to assist management decision making and to inform Parliament about performance, Emergency Management Australia (EMA) develop and report appropriate measures for its key emergency management activities and outcomes.

The committee recommends the Australian Government strengthen CASA's governance framework and administrative capability by:
• introducing a small board of up to five members to provide enhanced oversight and strategic direction for CASA; and
• undertaking a review of CASA's funding arrangements to ensure CASA is equipped to deal with new regulatory challenges.

The Committee notes the importance of mitigation measures in addressing climate change impacts and accordingly recommends that the Australian Government continue to take urgent action to ensure that Australia can best contribute to a reduction in global greenhouse gas emissions.

Formation of a subcommittee of the DHHS Tasmanian Medical Retrieval Services Committee to identify risk exposures, system problems and potential solutions. The subcommittee should review data, problem cases, system issues and generate a risk register. Meetings should occur at least quarterly.

Accordingly I recommend that the Federal Minister for Transport, consider engaging an external consultant to assess whether high level intervention is warranted. 

This Report should be considered for publication so that the insights, data, conclusions and recommendations are available within Queensland and other jurisdictions to assist with disaster management issues in the future.

To improve the management of the National Medical Stockpile, the ANAO recommends that the Department of Health and Ageing incorporate into its governance framework:
(a) an assessment of the risks associated with the Stockpile in a risk management plan that is periodically reviewed; and
(b) a performance management and reporting framework for the Stockpile.

We recommend that NSW Health continue with its good work and establish a performance management framework with targets and indicators to assess progress in preparing for infectious disease emergencies.

That, as a matter of principle, the NSW Government provide public reports on the lessons learned from emergency exercises which it manages or in which it participates. If necessary, such reports should exclude material which might jeopardise security.

That the Department of Primary Industries should ensure the roles and capacities of Rural Lands Protection Boards and industry are effectively monitored to enable assessment of the effectiveness of animal health programs.

That the Department of Primary Industries make every effort to meet its targets for the TSE program and encourage public and private sector veterinarians across the State to submit samples. The Department should include reports on its performance against these targets in annual reports.

That the Department’s performance against tactical and strategic benchmarks be regularly reported in annual reports or animal and plant health emergency evaluation reports and compared to other jurisdictions where possible.

Random alcohol testing should be continued.

All trains should have windows available through which passengers can escape.

RailCorp should develop a plan to be submitted to ITSRR to address the deficiencies in the safety culture of RailCorp, including:
(a) the means whereby RailCorp proposes to ensure that all its operational, administrative and managerial staff consider the safety implications of any decision or action undertaken by them;
(b) the means whereby any distrust between management and operational staff is removed and replaced by a culture in which the whole organisation is motivated towards the safe conduct of its transportation activities;
(c) the means whereby RailCorp proposes to implement a just culture instead of a blame culture;
(d) the means whereby RailCorp proposes to establish and implement accountability and responsibility of individuals for the safety of the activities that they undertake;
(e) the means whereby RailCorp proposes to measure the safety performance of all individuals with accountabilities and responsibilities for safety, for the purpose of determining whether their level of safety performance is satisfactory;
(f) the means whereby the Board of Directors, the Chief Executive and the Group General Managers intend, by their actions and behaviour, to foster the development of a safety culture in the organisation;
(g) the means whereby RailCorp proposes to reward employees for bringing safety issues to the attention of management, and the means whereby the management of the organisation proposes to track the safety issues raised, to ensure continual safety improvement;
(h) the means, generally, whereby RailCorp intends to replace the present culture of on-time running with a culture encouraging safe, efficient and reliable provision of rail services;
(i) the means whereby RailCorp proposes to ensure that communications protocols are followed by the employees of the RMC and all other employees engaged in safety critical work;
(j) the means whereby RailCorp proposes to set safety targets for the reduction of incidents overall, and incidents in particular classes, and the means whereby the relevant information is to be kept and collated for the purpose of measuring safety performance in those areas;
(k) the means whereby employees responsible for particular areas are rewarded for safety improvements in their areas of activity;
(l) the means whereby RailCorp intends to integrate safety in all aspects and at all levels of the transportation activities which it undertakes;
(m) the means whereby RailCorp proposes to train staff in processes of hazard analysis and risk management relevant to the particular activities that they conduct; and
(n) the means whereby RailCorp is to integrate the management of safety in all aspects into the general management of its business undertaking.

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:
(a) assign responsibility for particular aspects of the project to identifiable employees;
(b) ensure that each person to whom such an aspect of the program has been assigned has the time and resources to undertake the tasks each is required to perform;
(c) identify the period of time during which such persons are required to achieve the desired safety outcome for the particular aspect of the program;
(d) specify a clearly defined scope of work to be undertaken, a schedule setting out when such work is to be completed, and institute a system of measuring whether or not the objectives have been achieved in the time specified; and
(e) report to the Chief Executive of RailCorp on a monthly basis on each aspect of the program, and the Chief Executive is to report on a monthly basis to the RailCorp Board and to ITSRR, on the progress of each program.

There must be a minimum of two independent methods of self-initiated emergency escape for passengers from all trains at all times.

The ATSB should deliver any report of any such rail accident which it investigates to the Board of any rail organisation involved in the accident, ITSRR and the Minister for Transport Services.

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.

All passenger trains operating in New South Wales must have the external emergency door release clearly marked with the words “Emergency Door Release”.

The Minister for Transport Services should retain, independently of ITSRR, safety auditors to provide a report to the Minister confirming or qualifying the contents of each such ITSRR quarterly report.

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.

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.

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.

RailCorp and ITSRR should co-operate with national programs for the collection, collation, trend analysis and dissemination of safety critical information.

RailCorp should progressively implement, within a reasonable time, level 2 automatic train protection with the features identified in chapter 8 of this report.

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.

The Minister for Transport Services must table in Parliament, each such quarterly report by ITSRR.

RailCorp should provide access to electronic versions of safety documentation for all operational staff at their workplace.

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.

RailCorp should integrate its management of occupational health and safety into its overall safety management.

All train drivers’ defects reports should be entered by RailCorp into a computerised record and tracked to finalisation.

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.

The internal passenger emergency door release should be fitted with a facility which prevents it from operating unless the train is stationary.

The ITSRR must provide a quarterly report to the Minister for Transport Services on the progress made by RailCorp in implementing these recommendations, including:
(a) a statement as to whether or not the recommendation has been implemented and, if so, is working effectively; and
(b) if the recommendation has not been implemented, the me

The safety document management system should provide for the distribution of electronic versions of safety documentation to relevant staff.

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”.

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.

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.

All reports of the Chief Investigator of OTSI should be delivered, upon completion and without being reviewed, to ITSRR and the Minister for Transport Services.

RailCorp should establish a comprehensive safety document management system.

All new rail cars must have appropriate signage and lighting identifying escape routes in the case of emergency.

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.

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.

All passenger trains must be fitted with an internal passenger emergency door release.

All ATSB accident investigation reports should be made public.

It is recommended that providers supply data to the Board:
- for each rescue attended, the location and type of incident, turnout time, response time and time when available for re- tasking (page 30)
- on the cost of rescue (page 25).

That the Prime Minister’s Science, Engineering and Innovation Council requests that the Australian Government, through the Australian Emergency Management Committee, develops an effective pathway to incorporate hazard science into emergency management policy.

Consolidate the Australian Government decision to establish an Australian Tsunami Warning System through a long-term government commitment to ensure a sustainable and effective national tsunami warning system beyond the current four-year initiative.

The ANAO recommends that, to provide better information to contribute to strategic assessments, decisions and reporting, the Attorney-General’s Department, with input and guidance from the Department of the Prime Minister and Cabinet:
a) centrally coordinate and amalgamate the issues and recommendations arising from the various reviews and exercises; and
b) provide strategic analyses of this information.

The ANAO recommends that, to ensure the outcomes of evaluations are effectively used to enhance the national counter-terrorism arrangements, the Attorney-General’s Department and the Department of the Prime Minister and Cabinet take appropriate measures to ensure:
a) the continuous improvement process for the counter-terrorism arrangements is strengthened and made transparent. Key areas for improvement in this regard include:
• a more strategic approach to the determination of desired outcomes,
• a more strategic and systematic approach to the setting of evaluation objectives and performance information and assessment mechanisms,
• increased analysis of actual performance against objectives, and
• amoresystematicmonitoringandfollow-up of evaluation outcomes and recommendations; and
b) sufficient and skilled resources are assigned to undertake the data management and analysis required.

Related to recommendation 16, the Working Group recommends that the likelihood and consequences be systematically assessed by appropriate agencies that would include Geoscience Australia, the Bureau of Meteorology, CSIRO and the Department of Agriculture, Fisheries and Forestry among others. The range of hazards to be considered should include but not be limited to;
• Tsunami
• Bushfire (working with the Bushfire CRC)
• Severe storm
• Flood
• Cyclonic wind and storm surge
• Earthquake
• Temperature extremes and the impact of climatic change
• Disease threat – human, animal and flora/fauna 

That the success of current buffers in terms of assisting suppression operations be continually reviewed, evaluated and documented.

That DSE and CFA continue to stress firefighter safety as their highest priority for incident managers and fire ground supervisors

That if ‘link’ burns continue to be used, then on-site weather sequences and fuel conditions marking successful (‘within explicit prescription’) and unsuccessful burns be documented. 

That instances where demand for air support outstrips the supply of State Fleet Aircraft available are recorded. 

That the joint agencies introduce a system of performance measures for reporting the effectiveness of aircraft in firefighting operations.

That DSE:
• Provide further training and/or field staff for the routine acquisition and reporting of geographic data (maps of fire extent for prescribed and unplanned fires) and fuel-array data (quantity, type, condition and arrangement before and after fire as in the Overall Fuel Hazard Guide).
• Routinely and explicitly report on measures of the effectiveness of the prescribed burning program.
• Measure the total area subject to prescribed burning treatment in each Fire Management Zone each year along with the average proportion of that area successfully burned.
• Develop an explicit, routine system of evaluation, analysis and reporting of the effects of prescribed burning in relation to environmental outcomes such as conservation of flora and fauna and water quality.
• Train more crews, use Project Firefighters more extensively (and CFA members or MFESB firefighters where appropriate), to undertake prescribed burning.

That the creation of buffers by chaining and then burning swaths of mallee be explicitly monitored for:
• The risk of fire escapes during their establishment;
• Their effectiveness as a barrier to unplanned fire under various weather and fuel conditions; and
• Any adverse environmental effects such as soil mobilisation and loss of biodiversity.

The Committee recommends in acknowledgement of the expertise that the Commonwealth can bring to the Australasian Fire Authorities Council and of funding already supplied to the Council for the development of a National Aerial Firefighting Strategy, that the current status of Emergency Management Australia on AFAC as an associate member be upgraded to full membership and that full membership also be extended to the Department of Defence.

The Committee recommends that the Commonwealth Attorney-General engage the Commonwealth, states and territories in a review of occupational health and safety legislation as it affects the proper and effective functioning of bush fire services.

The Committee recommends that the functions and administration of Emergency Management Australia be reviewed to develop an organisation that is proactive and involved in the development and implementation of national policy on emergency response.

The Committee recommends that the Department of Transport and Regional Services review its record keeping practices to show the type of emergency for which assistance is provided through the Natural Disaster
Relief Arrangements.

The Committee recommends that performance monitoring standards be established, reviewed and maintained through a common reporting system by the Minister for Police and Emergency Services.