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;

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

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 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.

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.

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

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.

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 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 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 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.

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.

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.

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.

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 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.

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

Maintenance plans on all trains should be revised annually.

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

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

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.

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

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”.

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 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 have permanent access to the RailCorp intranet.

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.

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

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

Random alcohol testing should be continued.

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

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

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

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

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.

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

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.

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.

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”.

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;

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.

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).

It is recommended that the Board: 
- require the Chief Executive of each rescue provider to certify on an annual basis that all rescue units comply with the Board’s accreditation standards (page 31)

It is recommended that the Board:
- collect data on rescue performance and cost over the next 12 months to inform the planning process (page 19)

It is recommended that the Board develop response time standards for metropolitan and rural rescue services to guide committees in determining the number, type and location of rescue units (page 25).

It is recommended that the Board:
- include time standards for responding to an incident in accreditation standards (page 29)
􏰀- revisit the need for specific accreditation criteria for various rescue activities (page 29).

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.

Establish a Regional Centre of Excellence for Tsunamis to focus Australian and international science/research and collaboration on the challenge of understanding tsunamis and mitigating their consequences.

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 the Attorney-General’s Department better monitor and account for the expenditure of individual exercise costs under the National Capability Development Exercise Programme, through:

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:

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:

The ANAO recommends that the Attorney-General’s Department, in consultation with the Department of the Prime Minister and Cabinet and the National Counter- Terrorism Committee, pursue the adoption of a more strategic approach to determining the National Capability Development Exercise Programme s

The ANAO recommends that the Attorney-General’s Department, in conjunction with the National Counter-Terrorism Committee’s exercise management advisers, explore options for the incorporation of more contemporary and varied testing and training aids in the National Capability Development Exercise

The ANAO recommends that the Attorney-General’s Department, in consultation with the Department of the Prime Minister and Cabinet and the National Counter-Terrorism Committee, pursue a more strategic and systematic approach to the measurement of performance via the National Capability Development

The ANAO recommends that the Attorney-General’s Department, in consultation with the Department of the Prime Minister and Cabinet and the National Counter-Terrorism Committee:

The ANAO recommends that the Attorney-General’s Department, in consultation with the National Counter-Terrorism Committee, strengthens the reporting on the National Capability Development Exercise Programme through:

The ANAO recommends that the Attorney-General’s Department, in consultation with the Department of the Prime Minister and Cabinet and the National Counter-Terrorism Committee, seek to create systematic mechanisms for better targeting and evaluating inter- agency coordination within the National C

The Working Group recommends that agreed national protocols be developed to manage the integration of overseas workers and international aid into an affected jurisdiction. 

The Working Group recommends that the Australian Government and the States/Territories use the survey templates compiled in each of their jurisdictions during the capability review workshops, and the scenarios to consider their current and future capabilities, to respond to and recover from large

The whole of government disaster plan should also be written in such a way as to manage continuity of national government, ensure delivery of key services for which the Australian Government has responsibility and establish (or document existing) command and control mechanisms. 

The Working Group recommends that the adequacy of existing national mortuary capability to meet the likely demands of a catastrophic disaster be assessed by State/Territory Coroners.

The Working Group recommends that jurisdictions review their emergency management arrangements (plans, legislation, etc) to ensure that they are able to mitigate, respond to and recover from disasters, and maximise the duration of self reliance that can be achieved.

The Working Group recommends that all States/Territories and the Australian Government should regularly (annually) test their continuity of executive government plans and contingencies. 

The Working Group recommends that the results of the scenario modeling be presented to the Australian Emergency Management Committee (AEMC) upon completion, and that AEMC form Sub Working Groups of State/Territory emergency management representatives as appropriate to be tasked with considering r

The Working Group recommends that the National Recovery Coordinators Group approach the Investment and Financial Services Association Limited, with a view to identifying the most appropriate way of engaging the life insurance industry in the recovery process.

The Working Group recommends that participants in the exercises designed to test continuity of executive government plans and procedures should be the office holders themselves. 

The Working Group recommends that Emergency Management Australia and the jurisdictions through the AEMC develop a three year rolling national exercise strategy aimed at testing the response and recovery aspects of large scale disasters. 

The Working Group recommends that each jurisdiction; 
• Examine the interdependency of essential services provided by the private sector, utilising where possible other existing programs such as the National Critical Infrastructure Protection Initiative

The Working Group recommends that jurisdictions plan for the logistics of supply and delivery of meals to large numbers of homebound persons in an attempt to identify possible ways of resolving existing shortcomings. 

The Working Group recommends that State/Territory Recovery Committees review their membership to ensure that it is reflective of community needs, including representation from the Insurance Disaster Response Organisation. 

The Working Group recommends that jurisdictions identify appropriate commercial organisations/bodies able to ensure maintenance of supply of food items and packaged water to commercial outlets in times of disaster. 

The Working Group recommends that potential shortfalls in the capacity to deal with large numbers of unprotected children and other special needs groups in a catastrophic event be referred to the Disaster Recovery Sub Committee of Community Services Ministers’ Advisory Council (CSMAC) for conside

The Working Group recommends that the Australian Government consider developing an overarching whole of government disaster plan that clearly articulates authority, roles and responsibilities of agencies, inter-departmental committees and key officials, to link the range of existing Australian Go

The Working Group recommends that the Australian Government investigate, in consultation with the finance and banking sector, the development of arrangements to ensure that essential transactions can continue in the event of a catastrophic failure of the banking system that includes access to cas

The Working Group recommends that the National Recovery Coordinators Group considers the issue of emergency relief centres in the context of catastrophic disaster with a view to assisting jurisdictions to plan for the need to accommodate thousands of people following a disaster. 

The Working group recommends that the Australian Government take a leadership role with regard to addressing the national capability issues identified within this review.

The Working Group recommends that States/Territories consider their ability to house large numbers of domestic pets, and where necessary, develop plans and arrangements that facilitate this need. 

The Working Group recommends the Australian Emergency Management Committee note that: 
• The Catastrophic Disasters Emergency Management Capability Review should be seen as the first phase of a multi-faceted work program

The Working Group recommends that Emergency Management Australia (EMA) facilitate national discussions into the capability of States/Territories to ensure thorough collaborative systems and plans for inter-jurisdictional resource interoperability exist, and where this has not already occurred at

The Working Group recommends support for ongoing research into natural hazard risks and an improved understanding of emergency management capability.
The research program should include:

The Working Group recommends that appropriate building/surveyor peak bodies be identified, and that discussions be held between the emergency management sector and those peak bodies at State/Territory and national level with a view to:

The Working Group recommends that the Commonwealth Attorney General’s Department hold discussions with the Commonwealth Department of Communications, Information, Technology and the Arts regarding the Integrated Public Telephone Network Database (IPND) being made accessible for use in times of em

The Working Group recommends that EMA convene a national forum to explore community information and warning needs in catastrophic disasters, to review existing information and warning systems, and to identify possible technologies and techniques that might be used to enhance community needs in di

The Working Group recommends that the national forum mentioned in recommendation 13 consider the ongoing need for dissemination of information on a national basis both during and following a catastrophic disaster and also identify strategies to ensure the ability of this to be facilitated.