INQ121
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: |
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: |
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. |