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 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”.

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.

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.

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.

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.

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.

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”.

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.

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

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

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.

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

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 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.

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

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.

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.

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.

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

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 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:

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

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.

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

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.

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).

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.

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.

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 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 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 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 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 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.

Related to recommendation 16, the Working Group recommends that the likelihood and consequences be systematically assessed by appropriate agencies that would include Geoscience Australia, the Bureau of Meteorology, CSIRO and the Department of Agriculture, Fisheries and Forestry among others.

The Working Group recommends that in addition to existing disease control and pandemic management plans, States/Territories should consider developing a pandemic emergency management plan that considers the impact of pandemic disease broadly, encompasses all government and private sector agencies

The Working Group recommends that a review of the operation of the Commonwealth Mutual Recognition Act 1992 be conducted and that agreed national protocols be developed to manage the integration of

The working group recommends that a similar project to the Review of Australia's Ability to Respond to and Recover from Catastrophic Disasters be established to consider the longer term consequences of catastrophic disasters and their resulting recovery implications.

The Working Group recommends that State/Territory emergency management plans should explicitly take the need for rapid assessment of damaged physical infrastructure into account.

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