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 Committee recommends that the Native Vegetation Council provide landholders with assistance for applications for prescribed burning (via a guide, a proforma or staff).

The Committee recommends that government consider options for assistance (including cost sharing) for farmers to fence native vegetation areas on private property affected by the Wangary fire.

The Committee recommends that the government provide authority to a single community representative body to authorise clearing of native vegetation for fire management. (The community representative body must incorporate the CFS, DEH, Native Vegetation Council and local council)

The Committee recommends that the government undertake public education programs to increase the awareness of the community to bushfires, the role fire plays in ecosystems and what steps they should take to minimise the impact of a fire.

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 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 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 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.

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 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 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:

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.

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.

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 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.

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

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.

All emergency services personnel should be trained in the location and operation of emergency door release mechanisms on all rail cars.

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.

The RailCorp emergency response plan should include a requirement for the debriefing of all senior rail and emergency response personnel involved in any rail accident, so as to determine the way or ways in which emergency response arrangements for rail accidents can be continually improved, and t

The RailCorp passenger containment policy must be abandoned.

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.

RailCorp should make it a condition of employment that all level 2 managers have or obtain a formal qualification in system safety management.

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

Uniform verbal descriptions identifying that power has been isolated should be developed by RailCorp and utilised by all railway personnel, electrical service providers and all emergency response personnel.

ITSRR should initiate and/or participate in the development of a national standard for crashworthiness of all passenger trains.

All ATSB accident investigation reports should be made public.

The ITSRR should audit the RMC to ensure communications protocols are being followed. The sanction for non-compliance with communications protocols should be identical to that in the aviation industry and involve immediate removal from duty.

Staff at the Rail Management Centre (RMC) should receive training from RailCorp to enable them to quickly and accurately assess that an emergency has occurred and to provide precise and reliable information to emergency response personnel about the location of the emergency, the available access

RailCorp should ensure that where the safety competency of any manager is deficient such manager is required to undertake professional development courses to raise his or her safety competency level to an adequate standard.

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

The rail safety regulator should set standards for the design, manufacture, testing and commissioning of rolling stock to ensure that the rolling stock is fit for its purpose.

The Advisory Board established under the Transport Legislation Amendment (Safety and Reliability) Act 2003 must be abolished.

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.

ITSRR should ensure that, as a condition of accreditation, each of these recommendations is carried into effect and should audit against them to enforce compliance.

All train guards should be trained by RailCorp in the use of the Metronet radio and instructed to use it in any emergency.

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.

The ITSRR should impose a standard in relation to the collection and use of data from data loggers.

Legislative changes should be enacted to ensure the complete independence of ITSRR from the Minister for Transport Services.

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

The ITSRR should conduct random audits of accredited rail organisations for compliance with communications protocols.

All operational rail staff should be trained by RailCorp in the action check list relevant to each.

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 standard in relation to the collection and use of data from data loggers should provide that such information must be accessed in the circumstances of any accident or incident and can be accessed to monitor driver performance generally.

The Chief Executive of ITSRR should have sole accountability and responsibility for the regulation of rail safety in New South Wales.

The ITSRR should establish a data and information management system, containing all data and information that it requires, to continually monitor the safety of the New South Wales rail system.

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

Recommendations one to seven of the final report of the Special Commission of Inquiry into the Glenbrook Rail Accident should be fully implemented, save that the random auditing referred to in recommendations five and seven should be carried out by ITSRR.

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.