The Committee recommends that the government in cooperation with local authorities assess fire tracks and breaks to determine if firebreaks and access tracks need to be wider and/or native vegetation removed so that it does not impinge on firebreaks or tracks.

The Committee recommends that the government in cooperation with local authorities prepare a management plan that includes firebreaks and access tracks in the region, including the location of current breaks and access tracks and where breaks and tracks need to be established.

The Committee recommends that the government establish designated fire safety areas within native vegetation and at road intersections.

The Committee recommends that training be provided to landholders to enable them to assist with prescribed burns.

The Committee recommends that the government, via the CFS, coordinate the preparation and implementation of native vegetation management plans that incorporate management of fuel loads and includes a prescribed burning regime for the area.

The OTSI should continue to conduct rail accident investigations on behalf of ITSRR and report directly to the Chief Executive of ITSRR.

A designated staff member at the RMC should act as the rail emergency management co-ordinator. He or she should be the sole point of contact at the RMC with other rail personnel involved in the rail accident and emergency services personnel during the rescue phase of the emergency response.

The RailCorp emergency response plan should be provided to all emergency response agencies. The officers of each emergency service should be trained in any rail specific features of the plan, so as to better ensure inter-agency co-ordination in the circumstances of an emergency.

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.

Communications procedures must be standardised throughout the rail network, so that all railway employees describe the same subject matter in an identical way.

The ITSRR should publish guidelines to be followed by accredited organisations.

The data and information management system should be compatible with any data and information management system established by the ATSB for the designated interstate rail network, provided that the establishment of a compatible system does not reduce the amount or quality of the information obtai

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 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.

All railway owners and operators should have a quality assurance program for the design and construction of rolling stock and regular review of construction to ensure that the rolling stock satisfies the original functional performance specifications.

The incident command system should clearly identify the roles of the rail commander, site controller, police commander and commanders of the other emergency services, and the way in which each is to work together during the recovery phase of any rail accident.

All emergency response personnel should be specifically trained in the features of railways which are relevant to their work, such as the location and means of operation of all emergency door releases on trains, the location and use of signal telephones, the methods by which electrical power can

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”.

All communications protocols must be strictly enforced by all accredited rail organisations.

The ITSRR should continue to participate in the development of a national system for rail safety regulation, provided that any ultimate agreement between the States and Territories and the Australian Government does not produce a safety outcome for New South Wales that is less than would be achie

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.

The role of the rail commander should be to provide support and assistance to the site controller and emergency services personnel until the rescue phase of the emergency response to any rail accident is completed.

All rail employees should be trained by their employer to commence any emergency communication with the words “Emergency, emergency, emergency”, thereafter to identify themselves, the train, its location, what has occurred, the approximate passenger load and whether death or injuries have occurre

Random alcohol testing should be continued.

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

Communications protocols and procedures should be standardised and mandated by regulations making them a condition of accreditation.

A safety management system regulation should be promulgated, specifying the requirements of safety management systems in all accredited organisations, using Annexure I to this report as a guide

RailCorp should undertake risk assessments of each of its activities as follows:
(a) identify the features of the system, subsystem or activities that are to be risk assessed and managed, to determine what makes the system work in terms of equipment, infrastructure and human factors;

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 examinati

The rail commander should have complete authority to direct and control any rail employees attending the site of a rail accident, in accordance with directions given or arrangements put in place by the site controller, until the rescue phase of the emergency response to the rail accident has been

Alcohol and drug testing should be mandatory for any train driver or guard involved in any accident or incident.

A training centre for emergency services personnel should be established by RailCorp. The emergency services personnel should be required to undertake training at such a centre, which should be equipped with features replicating railway infrastructure and rolling stock.

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.

Defects reporting, recording and rectification should be integrated with the RailCorp regimes for train maintenance.

RailCorp should establish an integrated safety management system which includes the following:
(a) a formal performance management system, incorporating measurable safety accountabilities and responsibilities for each managerial position;

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.

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.

A direct line of communication should be established between the RMC and Emergency Services Operations Control Centre by a “tie line” or otherwise, so as to ensure that in the case of a serious rail accident there is an open line of communication between the officer in charge of the management of

RailCorp should use its simulators in an interactive manner.

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”.

Procedures should be put in place by RailCorp to ensure that electrical power supply to the area of an accident can be immediately isolated, if necessary, in the event of a rail accident, so as to reduce any risk of exposure of emergency response personnel to injury or harm.

No RailCorp train should enter into revenue service or remain in service if, in the opinion of the driver in charge of that train, any defect in it creates a risk of injury.

RailCorp should establish a safety management system containing the 29 elements identified in the SMSEP report which is in volume 2 of this report.

Maintenance plans on all trains should be revised annually.

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.

RailCorp should continue its system of voluntary self-identification and rehabilitation of employees with alcohol or drug related problems.

A dedicated telephone line should be established by RailCorp between the RMC and any Emergency Services Control Centre for use during any emergency.

RailCorp should use its simulators to train drivers and guards in methods of dealing with degraded operations on the rail network.

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

A railway disaster plan, or rail displan, should be developed by RailCorp and the emergency services to ensure co-ordinated inter-agency response to rail accidents and incidents on the RailCorp network.

All reported train defects should be certified by a person in a supervisory position in RailCorp as having been rectified.

The ITSRR should ensure that RailCorp establishes a safety management system containing the 29 elements identified in the SMSEP report, and ensure the ongoing monitoring and improvement of the safety management system established.

The ITSRR should have permanent access to the RailCorp intranet.

The New South Wales Government should make the necessary arrangements with the Australian Government, including any necessary legislation, for the Australian Transport Safety Bureau (ATSB) to have the power to investigate all rail accidents occurring on the New South Wales rail network the invest

The RMC should be equipped by RailCorp with a transcriber system, or mimic board, or such other system as is necessary to enable identification of the precise location at any time of any train on the RailCorp network.

All emergency services stations should be provided with access keys to, and maps showing, all gates providing access to RailCorp tracks within their geographic area of responsibility.

Train driver and guard training should encourage teamwork and discourage authority gradients.

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.

The rail displan should include the use by all emergency response personnel of a uniform incident command system, involving procedures for such matters as the establishment of inner and outer perimeters, control of access to the site, orderly evacuation of injured passengers and the establishment

Train inspections should be carried out at the time of stabling RailCorp trains, as well as a part of train preparation prior to entering service.

Regular field training exercises should be conducted by RailCorp with the emergency services to ensure that the incident command system and rail displan are able to be fully implemented as quickly as possible and are reviewed and improved.

The ITSRR should ensure that OTSI, as a division of ITSRR, co-operates and assists the ATSB in the conduct of any independent investigation by the ATSB of any rail accident or incident in New South Wales.

All signal telephones must be maintained by RailCorp in proper working order.

All RMC communications related staff should be selected upon the basis of the ability to convey information clearly, accurately and concisely and to follow strict communications protocols.

RailCorp must establish a task analysis for particular categories of employees, to identify the specific skills and responsibility of those employees or groups of employees, and thereafter undertake a training needs analysis, to develop the skills required in particular areas.

RailCorp should develop a plan to be submitted to ITSRR to address the deficiencies in the safety culture of RailCorp, including:

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 rail displan should include provision for the appointment of a rail emergency management co-ordinator at the RMC, and an on-site rail commander with the sole function of assisting and supporting the emergency services during the rescue phase of the emergency response.

The ITSRR should develop standards for periodic medical examinations which include the following:

All accredited rail organisations should be required to re-apply every three years to ITSRR for accreditation.

There must be compatibility of communications systems throughout the rail network. It is essential that all train drivers, train controllers, signallers, train guards and supervisors of trackside work gangs in New South Wales be able to communicate using the same technology.

The RailCorp defects unit should be combined with the passenger fleet maintenance division of RailCorp.

Training should be based upon a needs analysis, to determine what skills a particular person will require to carry out the tasks of any position safely and efficiently, and instruction and practice, to acquire and demonstrate those skills.

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.

The rail displan should provide for the site controller to have complete control of the site, with other agencies co-ordinating with and supporting him or her, until the rescue phase of the emergency response has been completed.

The relevant legislation should be amended to provide expressly that OTSI and the Chief Investigator have the power to initiate a rail accident or incident investigation.

The risk of abuse of internal passenger emergency door releases should be further reduced by introducing significant penalties for any improper use of such an emergency facility.

There should be interoperability of communications equipment between all trains operating on the New South Wales rail network.

The location of the command post for site control at the scene of any rail accident should be identified by NSW Police by a distinctive flashing light.

RailCorp should employ a Chief Safety Information Officer to manage the collection, collation, and dissemination of safety information within RailCorp.

The position of team leader should be created by RailCorp to be responsible for a group of approximately 30 train drivers, with responsibility to ensure that each train driver’s training needs are being met and that any safety concerns of train drivers are being properly addressed.

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.

RailCorp should develop and implement an emergency response plan for management of all rail accidents. Such a plan should be subsumed by the rail displan in the case of serious accidents or incidents.

Any barriers to communication between OTSI and ITSRR should be removed, so as to ensure that any findings made by OTSI in relation to any investigation it conducts are reported immediately to ITSRR.

Satellite telephones should be provided by RailCorp to all rail commanders at any emergency.

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

RailCorp should establish clear safety accountability statements and reporting lines for all management positions.

All RailCorp operational personnel should be trained in the location and operation of external emergency door release mechanisms.

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

The RailCorp emergency response plan should include action checklists of the steps that each employee is required to take, and the order for specific employees to follow in case of emergency.

Legislation should be enacted and any necessary arrangements made, to enable the ATSB to review any reports of any investigation by a rail organisation or the OTSI into any serious incident or accident in New South Wales.

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

Staffing arrangements for ITSRR should be reviewed by it to ensure that adequate staff are employed in field positions, actively monitoring the safety of rail operations and compliance with conditions of accreditation.