INQ121

TitleLong
Special Commission of Inquiry into the Waterfall Rail Accident,Volume 1 & Volume 2.
INQAuthor
The Honourable Peter Aloysius McInerney QC
Year
InquiryType
DisasterType
State
Status

Recommendations for this Inquiry

INQ-ref REC-UID CODE SubCode SrcNUM Recommendation
INQ121 REC121-3713 A - Responsibility 25 - Inquiry, audit, lessons management and after action review Recommendation 65

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.

INQ121 REC121-3730 E - Agency Organisation 32 - Doctrine, standards, and reform Recommendation 82

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.

INQ121 REC121-3731 E - Agency Organisation 29 - Operational Health and Safety Recommendation 83

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

INQ121 REC121-3732 E - Agency Organisation 29 - Operational Health and Safety Recommendation 84

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.

INQ121 REC121-3733 E - Agency Organisation 29 - Operational Health and Safety Recommendation 85

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.

INQ121 REC121-3734 E - Agency Organisation 29 - Operational Health and Safety Recommendation 86

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

INQ121 REC121-3735 E - Agency Organisation 29 - Operational Health and Safety Recommendation 87

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.

INQ121 REC121-3736 E - Agency Organisation 32 - Doctrine, standards, and reform Recommendation 88

The RailCorp passenger containment policy must be abandoned.

INQ121 REC121-3737 E - Agency Organisation 29 - Operational Health and Safety Recommendation 89

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

INQ121 REC121-3738 E - Agency Organisation 29 - Operational Health and Safety Recommendation 90

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

INQ121 REC121-3739 E - Agency Organisation 29 - Operational Health and Safety Recommendation 91

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.

INQ121 REC121-3740 E - Agency Organisation 29 - Operational Health and Safety Recommendation 92

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

INQ121 REC121-3741 E - Agency Organisation 29 - Operational Health and Safety Recommendation 93

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.

INQ121 REC121-3742 A - Responsibility 19 - Offences Recommendation 94

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.

INQ121 REC121-3729 A - Responsibility 38 - Agency/Department Reporting Recommendation 81

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.

INQ121 REC121-3728 E - Agency Organisation 32 - Doctrine, standards, and reform Recommendation 80

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.

INQ121 REC121-3727 E - Agency Organisation 32 - Doctrine, standards, and reform Recommendation 79

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.

INQ121 REC121-3714 E - Agency Organisation 16 - Training and behaviour Recommendation 66

RailCorp should use its simulators in an interactive manner.

INQ121 REC121-3715 E - Agency Organisation 16 - Training and behaviour Recommendation 67

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

INQ121 REC121-3716 E - Agency Organisation 16 - Training and behaviour Recommendation 68

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

INQ121 REC121-3717 E - Agency Organisation 16 - Training and behaviour Recommendation 69

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.

INQ121 REC121-3718 E - Agency Organisation 16 - Training and behaviour Recommendation 70

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.

INQ121 REC121-3719 E - Agency Organisation 16 - Training and behaviour Recommendation 71

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.

INQ121 REC121-3720 A - Responsibility 24 - Govt responsibility Recommendation 72

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

INQ121 REC121-3721 A - Responsibility 24 - Govt responsibility Recommendation 73

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.

INQ121 REC121-3722 A - Responsibility 38 - Agency/Department Reporting Recommendation 74

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.

INQ121 REC121-3723 A - Responsibility 38 - Agency/Department Reporting Recommendation 75

All ATSB accident investigation reports should be made public.

INQ121 REC121-3724 F - Research and technology 13 - Mapping and data quality Recommendation 76

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.

INQ121 REC121-3725 F - Research and technology 13 - Mapping and data quality Recommendation 77

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

INQ121 REC121-3726 A - Responsibility 25 - Inquiry, audit, lessons management and after action review Recommendation 78

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

INQ121 REC121-3743 E - Agency Organisation 29 - Operational Health and Safety Recommendation 95

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

INQ121 REC121-3744 E - Agency Organisation 16 - Training and behaviour Recommendation 96

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

INQ121 REC121-3746 E - Agency Organisation 16 - Training and behaviour Recommendation 97

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

INQ121 REC121-3763 E - Agency Organisation 32 - Doctrine, standards, and reform Recommendation 114

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

INQ121 REC121-3764 E - Agency Organisation 29 - Operational Health and Safety Recommendation 115

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.

INQ121 REC121-3765 A - Responsibility 25 - Inquiry, audit, lessons management and after action review Recommendation 116

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.

INQ121 REC121-3766 E - Agency Organisation 12 - EM agency and authority Recommendation 117

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.

INQ121 REC121-3767 A - Responsibility 24 - Govt responsibility Recommendation 118

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

INQ121 REC121-3768 A - Responsibility 25 - Inquiry, audit, lessons management and after action review Recommendation 119

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.

INQ121 REC121-3769 E - Agency Organisation 32 - Doctrine, standards, and reform Recommendation 120

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

INQ121 REC121-3770 E - Agency Organisation 32 - Doctrine, standards, and reform Recommendation 121

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

INQ121 REC121-3771 E - Agency Organisation 32 - Doctrine, standards, and reform Recommendation 122

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;

INQ121 REC121-3772 E - Agency Organisation 32 - Doctrine, standards, and reform Recommendation 123

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

INQ121 REC121-3773 E - Agency Organisation 32 - Doctrine, standards, and reform Recommendation 124

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.

INQ121 REC121-3774 A - Responsibility 38 - Agency/Department Reporting Recommendation 125

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

INQ121 REC121-3775 A - Responsibility 38 - Agency/Department Reporting Recommendation 126

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

INQ121 REC121-3762 E - Agency Organisation 32 - Doctrine, standards, and reform Recommendation 113

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

INQ121 REC121-3761 E - Agency Organisation 32 - Doctrine, standards, and reform Recommendation 112

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

INQ121 REC121-3760 E - Agency Organisation 32 - Doctrine, standards, and reform Recommendation 111

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

INQ121 REC121-3747 E - Agency Organisation 29 - Operational Health and Safety Recommendation 98

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