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2010 by fdh56iuoui

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									                                            2010         0



                         REPORT
                     OF THE INQUIRY
    INTO THE ROADS AND TRAFFIC AUTHORITY’S RESPONSE TO
    AN ACCIDENT ON THE F3 FREEWAY NEAR JOLLS BRIDGE ON
                       12 APRIL 2010.




                                          K E MORONEY AO APM MA
                                               25 June 2010
                                                 


          1.             EXECUTIVE SUMMARY.
The Executive Summary is intended to provide a broad overview of the Report, the issues
identified in the Inquiry's review, and remedial action both taken and required to address issues
for the future.




 It has been one of the inevitable consequences of the invention of the motor
 vehicle that from time to time some drivers and riders will be involved in
 crashes. The outcome for those involved in these crashes, their families and
 indeed, the community, can vary and is dependent upon a range of factors,
 including circumstances, immediacy of medical assistance (when relevant),
 and, amongst other things, how those charged with response and recovery
 arrangements attend to their duties.

 Primacy of response has to be to those immediately involved in a motor
 vehicle crash and the community expects this to be so. The professionalism
 of the emergency services, both at the scene of the collision and in the
 aftermath of the collision, has been enhanced over many decades and
 Australia can be justly proud of those charged with the care and well-being of
 crash victims and their families.

 But, whilst there is an understandable attendance upon those involved in a
 motor vehicle crash, so, too, there has to be an appropriate level of care and
 response to those who are on the periphery of a crash scene, namely,
 motorists and others who may also be affected by the inevitable delays
 (including traffic disruption) that occur as a result of a motor vehicle crash.

 The responsibility for emergency response and assistance falls upon a number
 of New South Wales Government agencies. Primarily, these include the
 Ambulance Service of NSW, the NSW Fire Brigades and the NSW Police Force.
 Indeed, each of these agencies has a mandated role in prevention, response
 and recovery arrangements. Equally, and dependent upon the circumstances
 of a motor vehicle crash, a number of other agencies such as the NSW State
 Emergency Services and Rural Fire Service of NSW, may have a role to play.

 One of the most important agencies in how effective our response and
 recovery arrangements are facilitated, particularly from the point of view of
 road and traffic management, is the Roads and Traffic Authority (RTA) of New
 South Wales. The actions taken by the RTA and its officers are as essential,
 albeit complementary, to those taken by the emergency service agencies and
 are crucial to the restoration of (traffic) order and public confidence.




 K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010                            Page 1 
                                        

Indeed, the fundamental roles of the RTA include those of reassurance,
communications, and the effective and efficient management of our road and
traffic systems. Like the other agencies of Government, it has a clear and
mandated role to play.

There is no doubt it is the ability to meet organisational obligations that
reassures the community and allows a resumption of some normality, albeit,
for the case of the RTA, in our travelling lives.

As vital as it is to provide effective RESPONSE and RECOVERY arrangements
to any given situation, in particular, one affecting our road systems, it is
critical to meeting those objectives by ensuring that all agencies are focused
on the no less important aspects of PLANNING and PREPARATION. As the
Inquiry's review will show, these terms are co-dependent. They are not
mutually exclusive terms or a set of stand alone arrangements.

It follows then that planning, preparation, response and recovery
arrangements cannot, indeed, must not, be done in isolation of agency-based
responsibilities. Doubtless, there has to be an integrated, whole of
government approach and to do otherwise dooms any or all of these
arrangements to fail.

With these fundamental views in mind and with the specific Terms of
Reference established by the NSW Government, the Inquiry examined a
motor vehicle crash which occurred on the F3 Freeway near Jolls Bridge on 12
April 2010. It also examined the effectiveness of the planning, preparation,
response and recovery arrangements on that day, the integration of those
arrangements and whether or not they met a range of expectations, most
importantly, those of the community.

For comparative purposes the Inquiry examined a number of similar incidents
on the F3 Freeway in 2008 and 2009, to note and report on what emerged
from those events, and what actions had been taken by agencies of
Government arising from those crashes in the intervening period.

As important as it has been to examine the issues of the past and the
present, so, too, the Inquiry’s Report provides a focus for the future – a focus
that has to be built upon effective planning, preparation, response and
recovery arrangements on the one hand, and equally, meaningful, relevant
and timely communications, effective leadership, risk management and
consequence management, and community relations on the other.

The key to the approach outlined in the Inquiry’s Report turns not only on the
need for positive change and positive reinforcement, but, more importantly,
having the right organisational culture to achieve these things.




K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010              Page 2 
                                        

It is inevitable that further motor vehicle crashes will occur on the roads of
this State. That is not a defeatist view, rather, an acknowledgement that
human error remains a dominant feature in most crash statistics. That said,
the community and the Government are entitled to expect that responding
agencies will give their best to assist those who are injured or traumatised by
such events, and that they will recover and manage the consequential effects
of the crash as quickly and as efficiently as possible.

As a society we are entitled to expect that those engaged on our behalf to
plan and execute these actions are prepared and trained for these
eventualities and that there is an impetus for inter-agency co-operation.
Clearly, the rhetoric must match the reality. The community are entitled to
expect nothing less.

The Inquiry’s Report has identified a number of issues where systems,
accountability processes (including response and recovery arrangements),
and planning and implementation arrangements require stronger
reinforcement. As such, any approach - new or renewed - can only be to the
betterment of the wider community.

Notwithstanding its recommendations, the Inquiry remains firmly of the view
that there are two significant issues for the newly created NSW Government
agency, Transport NSW, and the RTA to address. These two important
issues, enhanced customer service and cultural reform, are the key to the
future direction of both agencies, and, equally important to a range of
integrated, deliverable road and transport management, and service delivery
arrangements for the people of NSW.




K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010             Page 3 
                                        


                2.       TABLE OF CONTENTS.

1     Executive Summary.                                         1-3

2     Table of Contents.                                         4-5

3     Recommendations.                                           6-12

4     Appointment of the Inquiry and Terms of Reference.         13

5     Introduction – Setting a Context.                          14

5.1   The Events of 29 January 2008.                             14-15

5.2   The Events of 30 January 2008.                             16-17

5.3   Deliberations and decisions arising out of the events of   17-20
      29 and 30 January 2008 – current status and related
      issues.

5.4   Memoranda of Understanding – a need for further            20-24
      articulation.

5.5   F3: Sydney-Newcastle Freeway Traffic Management            24-25
      Plans for Incidents.

5.6   The events of 21 April 2009 (and related issues)           26-28
      meeting the expectations of the community and
      Government of NSW.

6     The F3: Just another road or a unique road and the         29
      crash of 12 April 2010.

6.1   The F3 Freeway.                                            29-30

6.2   The events of 12 April 2010.                               30-34

6.3   The emergence of compounding issues.                       34-37

6.4   The role of the NSW Police Force.                          38-45

6.5   The role of the NSW Fire Brigades.                         46-54

6.6   The role of Scott’s Transport, Owner/Operator of the       55-58
      fuel tanker.

6.7   Carriage of fuel and dangerous goods on the State’s        58-61
      roads.

K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010      Page 4 
                                        

7     The Public Interest test.                                    62-67

7.1   Timely and accurate public information.                      67-68

7.2   The need for an effective media incident management          69-70
      strategy.

8     The Roads and Traffic Authority of NSW – an                  71-72
      organisational perspective.

8.1   The Transport Management Centre, Redfern – role and          72-77
      function.

8.2   Contra-flow – the principle and its application to traffic   78-79
      management.

8.3   The role of the RTA and the Transport Management             80-89
      Centre on 12 April 2010.

8.4   Response of the RTA post the incident of 12 April 2010.      89-91

8.5   Call for relevant documents.                                 91-92

8.6   Submission of the Chief Executive, RTA, - 24 May 2010.       93-96

8.7   The role, function and responsibility of the former          96-97
      Minister for Transport and Roads.

8.8   Responses of other public and private sector agencies        98
      to the Inquiry.

9     Future directions for effective traffic and transport        99
      management in NSW.

9.1   Transport, NSW.                                              99-106

9.2   The Roads and Traffic Authority of NSW – Meeting the         107-111
      challenges of tomorrow through a stronger customer
      service and cultural focus.

10    Conclusion.                                                  112-115

11    Index of Terms.                                              116

12    List of Agencies, Organisations and Individuals who          117-120
      assisted the Inquiry.

13    List of Attachments / Supporting Information.                121-122




K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010        Page 5 
                                        

          3.          RECOMMENDATIONS.


RECOMMENDATION 1 –

      That all outstanding action items identified in the “Rapid
      Response for New F3 Emergency Plan (2008)” be finalised as a
      matter of priority, and that a report be provided to the
      Director General, Transport NSW by the Chief Executive, RTA
      no later than 31 August 2010 as to the status of completion of
      all outstanding matters.


RECOMMENDATION 2 –

      That the Director General, Transport NSW, Commissioners of
      the NSW Police Force, NSW Fire Brigades, NSW Rural Fire
      Service, NSW State Emergency Services, and the Chief
      Executives of the Ambulance Service of NSW and RTA enter
      into a joint Memorandum of Understanding (MOU) which
      articulates the roles, functions and responsibilities of each of
      those agencies in responding to high profile road and traffic
      management issues.


RECOMMENDATION 3 –

      That any proposed joint MOU articulate the co-ordination and
      collaborative arrangements required across each of the
      agencies so as to provide a timely response to road
      management issues.


RECOMMENDATION 4 -

      That due to its role in regulating the transportation of
      hazardous goods on the road network consideration is given
      to having the Department of Environment, Climate Change
      and Water as a signatory to the proposed joint MOU.


RECOMMENDATION 5 –

      That the NSW Police Force will assume and lead the command,
      control and coordination arrangements of major motor vehicle



K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010     Page 6 
                                        

      incidents until overall resolution and hand-back to appropriate
      authorities.

RECOMMENDATION 6 -

      That the Joint Traffic Management Protocols for Priority
      Roads, May 2010, be amended to further articulate the NSW
      Police Force command and control arrangements    for   the
      resolution of significant motor vehicle crash incidents
      requiring a joint agency response.


RECOMMENDATION 7 –

      That consideration is given to reviewing the F3: Sydney-
      Newcastle Freeway Traffic Management Plan (2005), to
      ensure that it reflects contemporary best practice, policy
      decisions and operational priorities for the effective and
      timely management of road crash and related incidents.


RECOMMENDATION 8 –

      That the NSW Police Force consider commending the actions
      of Mr Corey Norris to the Royal Humane Society NSW, or St
      John Ambulance Australia (NSW Division) in recognition of his
      public spiritedness in rendering first aid to a driver injured in
      the motor vehicle crash on the F3 Freeway, near Jolls Bridge
      on 12 April 2010.


RECOMMENDATION 9 –

      That further consideration be given to providing for significant
      motor vehicles crashes to be included within the definition of
      'emergency' under the State Emergency and Rescue
      Management Act.


RECOMMENDATION 10 –

      That the Commissioner of Police give further consideration to
      the ongoing provision of Emergency Management and
      Incident    Command and Control Courses, including renewed
      training programs, for all Local Area Commanders / LEOCONs
      and Duty Officers as a matter of priority.



K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010      Page 7 
                                        

RECOMMENDATION 11 -

      That the Commissioner of Police give ongoing consideration to
      the provision of Incident Command and Control Courses for all
      Mobile Supervisors (irrespective of their class of duties)
      and Incident Site Controllers through the Education Services
      Command and the District Emergency Management Officer
      (DEMO) network.


RECOMMENDATION 12 –

      That the Commissioners of the NSW Police, Fire Brigades,
      Rural Fire Service, State Emergency Services, the Director
      General Transport NSW, and the Chief Executives of the
      Ambulance Service of NSW and RTA, give consideration to the
      development of an integrated Emergency Management and
      Incident Command and Control Course, incorporating the use
      of Hydra and Minerva facilities.


RECOMMENDATION 13 –

      That any programs developed and delivered by or on behalf of
      the NSW Police Force, either for internal delivery or across
      multiple agencies, be done so utilising (amongst others) the
      District Emergency Management Officer network.


RECOMMENDATION 14 –

      That all agencies impacted by the Inquiry and that have a
      range of core functional responsibilities within the emergency
      management and incident command and control framework,
      minimally undertake one joint table-top and one joint
      operational exercise per year. Such exercises should be
      independently assessed and adjudicated.


RECOMMENDATION 15 –

      That the State Emergency Management Committee give
      consideration to the oversight of development, delivery and
      implementation of Emergency Management and Incident
      Command and Control awareness training, across the key
      combat agencies and including the Transport NSW portfolio.



K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010    Page 8 
                                        


RECOMMENDATION 16 -

      That the NSW Police Force, NSW Fire Brigades and Transport
      NSW (in consultation with the Ambulance Service of NSW)
      undertake a thorough review of the policy, technical capability
      and operational effectiveness of the Inter-Cad Electronic
      Messaging System (ICEMS) to ensure that all inter-agency
      messages are the subject of review, analysis and timely
      dissemination to and within relevant emergency response
      agencies.


RECOMMENDATION 17 -

      That any such review takes account of the operational needs
      of the NSW State Emergency Services and the Rural Fire
      Service of NSW.


RECOMMENDATION 18 –

      That assessable training in ICEMS be regularly conducted
      across agencies to ensure contemporary knowledge of its
      application and use in day-to-day operations, and,
      importantly, emergency service response requirements.


RECOMMENDATION 19 -

      That the Director General, Transport NSW, chair an inter-
      agency Working Party to examine the registration, licensing
      and safety requirements of all vehicles engaged in the
      transportation and movement of dangerous goods (including
      fuels, chemicals and gases) on NSW roads.


RECOMMENDATION 20 -

      That the inter-agency Working Party convened by the Director
      General, Transport NSW, examine the requirement for a
      legislative framework and appropriate guidelines for the
      decanting of fuel from vehicles involved in motor vehicle
      crashes (or similar circumstances), and that such guidelines
      determine issues of standard operating procedures,
      appropriate clothing, equipment and training for personnel
      involved in such activity.


K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010    Page 9 
                                        


RECOMMENDATION 21 -

      That the Director General, Transport NSW consider inviting
      WorkCover NSW to join the Working Party.


RECOMMENDATION 22 –

      That Transport NSW enter into a formal Service Level
      Agreement with St John Ambulance Australia (NSW), NSW
      State Emergency Services, and other private sector or
      charitable organisations such as the Salvation Army, to
      provide welfare support services (including the distribution of
      water and light sustenance) to stranded motorists at times of
      inordinate and lengthy delays on the F3 Freeway.

RECOMMENDATION 23 –

      That the Director General, Transport NSW expedite
      discussions with the NSW Fire Brigades, Ambulance Service of
      NSW, NSW State Emergency Service and Rural Fire Service of
      NSW regarding the appointment of a senior, qualified Liaison
      Officer TMC, Redfern for each of these services.


RECOMMENDATION 24 –

      That the Chief Executive, RTA report minimally at 3 monthly
      intervals (or such timeframes as are agreed) to the Director
      General, Transport NSW, on the finalisation of all outstanding
      and approved recommendations identified in the ‘F3 Incident
      Management Improvement Program (May 2010)’ and the ‘RTA
      Report: F3 Incident 12 April 2010’.


RECOMMENDATION 25 –

      That the Transport Management Centre be removed from the
      organisational and functional control of the RTA.


RECOMMENDATION 26 –

      That the Transport Management Centre and the Transport Co-
      ordination Group be incorporated into a new entity entitled
      the 'Transport Information and Co-ordination Centre
      (TICC).

K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010    Page 10 
                                        



RECOMMENDATION 27 –

      That the functional responsibilities of the Transport
      Management Centre and the Transport Co-ordination Group
      be integrated to provide a seamless set of transport
      management arrangements across the whole of the transport
      network.


RECOMMENDATION 28 –

      That the operational management of the proposed Transport
      Information and Co-ordination Centre (TICC) be under the
      direction of one General Manager.


RECOMMENDATION 29 -

      That all existing personnel attached to both the TMC and the
      TCG be transferred to the new entity, the Transport
      Information and Co-Ordination Centre (TICC).


RECOMMENDATION 30 –

      That the General Manager, Transport Information and Co-
      Ordination Centre (TICC) report directly to the Director
      General, Transport NSW and be held accountable for the
      effective operations, management and administration of the
      Centre.


RECOMMENDATION 31 –

      That subject to the establishment of the Transport
      Information and Co-ordination Centre (TICC), the issues
      identified in the Director General, Transport NSW submission
      of 29 April 2010 to this Inquiry be the subject of development
      and adoption by Transport NSW.




K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010    Page 11 
                                        


RECOMMENDATION 32 –

      That within 12 months of the adoption of these
      recommendations, the Director General, Transport NSW,
      report to the Government on the effective management and
      operations of the Transport Information and Co-ordination
      Centre (TICC).


RECOMMENDATION 33 –

      That the Director General, Transport NSW, be admitted to full
      membership of the State Emergency Management Committee
      (SEMC).




K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010    Page 12 
                                        


          4. APPOINTMENT OF THE INQUIRY AND
                 TERMS OF REFERENCE.

On 14 April 2010, the NSW Premier the Hon. Kristina Keneally, MP announced
that an independent Inquiry would be conducted into the RTA's response to
the crash on the F3 Freeway at Jolls Bridge on 12 April 2010. It was also
determined that the former NSW Commissioner of Police, Mr Ken Moroney,
AO APM, would be appointed to conduct the Inquiry.

The main aim of the Inquiry was "...to identify what short-comings in
agency decision-making and communications contributed to the
delays on the F3 on 12 April 2010, and to ensure that the RTA and
other relevant agencies can put in place a more robust process for
responding to traffic incidents of a similar kind in the future".

Specific Terms of Reference were established for the Inquiry, namely:
(a)    What avenues are available to relevant agencies to ensure accurate
       and timely information can be made available to motorists and why
       were any avenues not used in this case;

(b)   What relevant information was made available to agencies over the
      course of this incident, including information provided by third parties
      affected by the incident, and what action was taken by the agencies in
      response to that information;

(c)   What inter-agency communication arrangements exist in relation to
      managing traffic accidents or breakdowns and how were these
      implemented in this case;

(d)   How could inter-agency communication arrangements in relating to
      managing significant traffic accidents be improved, including
      consideration of approaches taken in other Australian jurisdictions;

(e)   What operational policies and guidelines apply to managing significant
      traffic accidents, such as any guidelines relating to the implementation
      of traffic "contra-flow' arrangements, and how were these
      implemented in this case; and

(f)   How could operational policies and guidelines in relation to managing
      significant traffic accidents, or their implementation, be improved,
      including consideration of approaches taken in other Australian
      jurisdictions and whether additional flexibility for front line decision-
      makers is required.

It was on this basis that the Inquiry was conducted.

K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010            Page 13 
                                                      


      5.        INTRODUCTION – SETTING A CONTEXT.
      This Chapter provides a context to the motor vehicle crash on the F3 Freeway on 12 April 2010,
      by briefly examining a range of similar crashes on the same road with not dissimilar after-
      effects. It reviews response and recovery arrangements, road and traffic management issues
      and examines the commitment of the Government to issues emerging from those historical
      crashes (including their finalisation), and inter-agency co-operation and arrangements in 2010.



5.0.1          To better understand and appreciate the events which flowed from the
               crash on the F3 Freeway near Jolls Bridge on 12 April 2010, it is
               important to consider that incident against a background of not
               dissimilar incidents with comparable consequences, which have
               occurred on the F3 Freeway over, say, the past two years.

5.0.2          Whilst these historic motor vehicle crashes mentioned are by no means
               a definitive list, the Inquiry believes they provide a broad snapshot of a
               number of similar events on the F3 (with not dissimilar after effects),
               and seeks to put into context issues arising from these crashes and
               their relevance to the crash of 12 April 2010.

5.1            THE EVENTS OF 29 JANUARY 2008.

5.1.1          NSW Police report that at about 6.30am on Tuesday, 28 January 2008,
               a fully-laden semi-trailer was travelling south on the F3 Freeway and
               when about 1.5 kilometres south of the Windybanks Interchange, and
               travelling at a speed of about 100kph, the driver momentarily lost
               control of the vehicle and collided with a brick wall on the eastern side
               of the Freeway. After the initial impact, the vehicle travelled on for a
               distance of about 150 metres.

5.1.2          As a result of the impact between the semi-trailer and the brick wall,
               the prime-mover caught fire. A further consequence of this crash saw
               the whole vehicle engulfed in flame and its contents of waste paper
               destroyed. Most notably, part of the rock wall was blown out due to
               the impact of the crash and the intensity of the fire, and became
               unstable.

5.1.3          As a consequence of the crash, damage to the semi-trailer, its load and
               the instability of the rock wall, the F3 was closed and considerable
               delays resulted for all south-bound traffic for a period of seven (7)
               hours. Whilst diversions were put in place utilising the Old Pacific
               Highway, it is reported that traffic conditions did not return to normal
               until later in the evening.



        K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010                       Page 14 
                                                 

5.1.4         This event occurred at the end of a long weekend and at the end of
              the Christmas school vacation period. Consequently, a larger volume
              of traffic was on the Freeway at that time and was impacted by this
              event.

5.1.5         Not surprisingly there was considerable community, media and political
              comment at this time regarding the incident and the need, amongst
              other things, for better overall management of incidents of this type.




                         A photograph of the crash - Figure 1




                               Photograph courtesy on the NSW Fire Brigade




        K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010          Page 15 
                                                


5.2           THE EVENTS OF 30 JANUARY 2008.

5.2.1         NSW Police report that at about 2.00pm on Wednesday, 30 January
              2008, a total of five motor vehicles were involved in a crash whilst
              travelling north on the F3 Freeway, 1 kilometre north of Berowra. As a
              result of this crash nine (9) people were injured and conveyed to Royal
              North Shore and Gosford Hospitals by air and road ambulance.

5.2.2         Notably, and for the second time in as many days, this crash involved a
              semi-trailer and a table-top truck and trailer combination (deemed to
              be the at fault driver). As a consequence of the initial crash, the table-
              top truck then collided with the rock wall on the western side of the F3
              Freeway. The remaining vehicles in turn collided with the semi-trailer.

5.2.3         Records provided by the NSW Police Force note that the response by
              the emergency services was in part hindered due to the resultant build
              up of traffic and road works that were occurring at that time and in
              that area.

5.2.4         An overall consequence of this crash saw the F3 totally blocked and
              traffic had to be diverted from the Freeway to the Old Pacific Highway.
              It was also reported that the Freeway was blocked for a period of two
              (2) hours whilst the debris and vehicles were cleared from the scene.

5.2.5         As with the motor vehicle crash the previous day, there was
              considerable community, political and media comment regarding this
              crash, its impact on the F3 Freeway and motorists, and the
              requirement for a plan for deliberate action.

                         A photograph of the crash - Figure 2




                                                                          Photo courtesy
                                                                          of NSW Fire
                                                                          Brigades.




        K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010             Page 16 
                                                

5.2.6         Two important and inter-related issues arose from the last-mentioned
              crash.

5.2.7         Firstly, it is reported that the RTA declined to allow north bound
              vehicles affected by the crash, to travel to the south-bound side of the
              F3. This arrangement is known as contra-flow. The Report does not
              comment on why contra-flow was not introduced on this occasion, but
              does comment later on the principle of this important traffic
              management concept and its application to the events of 12 April
              2010. (Reference section 8.2).

5.2.8         Secondly, anecdotally it is reported that there were complaints from
              motorists that given high temperatures of that day, a number of adults
              and children were said to have suffered the effects of dehydration and
              heat stroke as a consequence of being delayed whilst emergency
              management response and recovery arrangements were carried out.

5.2.9         Clearly, what emerged from these two unrelated incidents on the F3
              Freeway was the requirement for a whole of government plan to be
              considered for the eventuality of a not dissimilar event occurring on
              any major arterial road, in particular, the F3 Freeway. Accordingly, the
              RTA was tasked with the development of an appropriate plan for the
              effective management of major incidents on the F3 Freeway.

5.2.10        It would seem to the Inquiry that key to the development and
              implementation of any Plan at that time, would be the requirement to
              take account of historical and similar events on the F3 Freeway and, as
              important, expressed community, political and media concerns for
              decisive action to be taken.

5.2.11        These things said, the Inquiry began from this point and worked to the
              adage that to move forward one has to stop and look back.

5.3           DELIBERATIONS AND DECISIONS ARISING OUT
              OF THE EVENTS OF 29 AND 30 JANUARY 2008 –
              CURRENT STATUS AND RELATED ISSUES
5.3.1         Arising out of a review of the events of 29 and 30 January 2008, the
              then NSW Premier, the Hon. Morris Iemma MP, announced on 16
              March 2008 the “Rapid Response for New F3 Emergency Plan
              (2008)” – (Attachment 1).

5.3.2         The centre-piece of the eight point Plan was the Government’s
              allocation of $28 million which provided, amongst other things –

                  •   Provision for diversion of traffic to the opposite side of the F3
                      during major incidents through a contra-flow arrangement;

        K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010            Page 17 
                                                  


                  •   The upgrade of seventeen (17) cross-over points and the
                      construction of two additional cross-over points to allow for the
                      smoother transition of traffic from one side of the F3 to the
                      other;

                  •   A major communications upgrade to provide sixteen (16) extra
                      electronic and changeable message signs on the F3 Freeway
                      and at major interchanges to get traffic moving faster;

                  •   An extra seven (7) traffic cameras to monitor the F3 and to
                      bring to twenty-nine (29) the number of live feeds to the
                      Transport Management Centre, Redfern, to allow Traffic
                      Controllers to react faster to incidents;

                  •   An extra two (2) web cameras to monitor the F3 traffic thereby
                      providing a total of five (5) live camera images covering the F3
                      on the RTA website and accessible to the public;

                  •   That in conjunction with the NSW State Emergency Services
                      (SES), the RTA would arrange supplies of bottled water to the
                      F3 that would be distributed quickly to stranded motorists in the
                      event of extended delays;

                  •   Provision for the RTA to   set up small depots at strategic points
                      along the F3 to house      traffic management equipment which
                      would allow a faster        response in the event of major
                      emergencies and delays;    and

                  •   A special emergency hot desk to be established by the RTA in its
                      Transport Management Centre, Redfern, dedicated to dealing
                      with incidents on the F3.

5.3.3         This inquiry notes that in committing to the eight point plan, the then
              Minister for Roads, the Hon. Eric Roozendaal, MLC said that the Plan
              was designed to “…(improve) our capability to respond to
              incidents on the F3 faster, and keep motorists informed about
              what’s happening”.

5.3.4         Further, the then Minister for Roads noted,“…the improvements
              will be concentrated on the section of the F3 between
              Wahroonga and Ourimbah, where traffic volumes are heaviest
              and most incidents occur”.

5.3.5         The agency charged with the development and implementation of the
              Government’s approved and announced 2008 eight point Plan was the
              RTA.


        K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010             Page 18 
                                                 

5.3.6         Given the history of motor vehicles crashes on the F3 and the
              consequent delays, and public, media and political comment that a
              number of those crashes caused, and given that impetus for action
              was further identified in the crashes of 29 and 30 January 2008; so
              then the implementation and ongoing evaluation of the Plan should
              have been seen as an important catalyst for the effective management
              of crashes and their aftermath. The Plan also identified and reinforced
              the critically important issue of effective traffic and road management
              arising from such incidents.

5.3.7         In addressing the issues arising from the motor vehicle crash of 12
              April 2010, the Inquiry turned its mind to each of the issues in the
              eight point Plan (2008) and the status of completion of the Plan. To
              this end, the RTA advised that as of May 2010, of the eight nominated
              requirements for total implementation of the Plan, two have been fully
              implemented, with six partially completed.

5.3.8         The six issues outstanding and awaiting finalisation (status highlighted
              in italics) include –

                  •   The major communications upgrade and installation of 16 extra
                      electronic and changeable message signs (9 installed and
                      operational and 6 awaiting power connection from Energy
                      Australia and 2 awaiting installation);

                  •   An extra seven traffic cameras to monitor the F3 (3 cameras
                      installed and operational; 3 installed and awaiting testing or
                      commissioning, and 1 awaiting construction);

                  •   An extra two web cameras to monitor the F3 (3 cameras
                      installed but awaiting commissioning in July-August 2010);

                  •   In conjunction with the NSW SES arrange supplies of bottled
                      water (water acquired and stored in 3 locations – 1.5 pallets at
                      each location. None distributed to date, including the crash of
                      12 April 2010).

                  •   RTA to establish small depots at strategic points to house traffic
                      management equipment (3 large facilities constructed and
                      operational; 4 smaller depots constructed and operational; 2
                      smaller garages under construction); and

                  •   Additional works to be undertaken to enhance incident
                      management capability on F3 corridor (1 of 2 Incident
                      Management Traffic signal sites installed and awaiting final
                      power; 12 of 27 electronic detour signage completed – others
                      under construction).

        K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010             Page 19 
                                                

5.3.9         The outstanding requirements of the 2008 Plan need to be finalised as
              a priority and a report provided to the Director General, Transport
              NSW by the Chief Executive, RTA, no later than 31 August 2010 as to
              the status of all outstanding matters.

              Therefore, the Inquiry recommends –

      RECOMMENDATION 1 –

      That all outstanding action items identified in the “Rapid Response for
      New F3 Emergency Plan (2008) “ be finalised as a matter of priority, and
      that a report be provided to the Director General, Transport NSW by the
      Chief Executive, RTA no later than 31 August 2010 as to the status of all
      outstanding matters.


5.3.10        It should also be noted that one of the key strategies arising out of the
              2008 Plan was an indication that contra-flow traffic management could
              and would be introduced on future occasions, when appropriate. This
              commitment may have inadvertently led to the expectation that
              contra-flow traffic management was an operational practice of first
              resort, and led to an assumption that it had an automatic application to
              all incidents and all situations. This is most definitely not the case.

5.4           MEMORANDA OF UNDERSTANDING – A NEED
              FOR FURTHER ARTICULATION.
5.4.1         Underpinning the “Rapid Response for New F3 Emergency Plan
              (2008)” – (Attachment 1), was an earlier direction by the then NSW
              Premier, the Hon. Bob Carr MP on 12 January 1999, that a formal
              agreement be reached between the RTA and NSW Police Force “…to
              delineate their respective responsibilities and ensure the
              optimum level of co-ordination and co-operation in relation to
              the management of incidents on major roads”.

5.4.2         Ironically, the Inquiry understands that the direction of the then NSW
              Premier arose from a serious motor vehicle truck crash on the F3 in
              1999, with the usual scenarios of lengthy delays and complaints.

5.4.3         Accordingly, a joint Memorandum of Understanding (MOU) between
              the two agencies was entered into in 1999; the most recent iteration of
              that MOU being on 13 October 2009 (Attachment 2).

5.4.4         The Inquiry notes that it is a fundamental tenet of the current (2009)
              MOU that “…overall, the RTA will assume the lead role in traffic
              management activities…resulting in a co-ordinated and


        K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010            Page 20 
                                                

              holistic approach to the management of effects of the event or
              incident”. There is nothing ambiguous about this tenet.

5.4.5         Similarly, there can be no doubt that on the basis of the current MOU,
              it was the RTA who, “…in accordance with its statutory
              obligations”, had primacy of responsibility for the effective
              management of the road system on 12 April 2010. This is not to say,
              however, that the RTA were or ought to be considered to be a combat
              or primary incident response agency in, say, the same manner as the
              Ambulance Service of NSW, NSW Fire Brigades or NSW Police Force –
              each of whom have clear statutory responsibilities in this regard.

5.4.6         Accordingly, the key requirements for service delivery by the RTA on
              12 April 2010, were always going to turn on the key and inter-related
              issues of the effective management of traffic and road
              networks.

5.4.7         This view is further reinforced when having regard to point 3.0 (within
              the current MOU), namely, “The Role of the Roads and Traffic
              Authority”.

5.4.8         An issue peripheral to the current MOU is the fact that the document is
              signed by representatives of the respective Legal Branches of the RTA
              and NSW Police Force. Given the recent carriage of the Transport
              Administration Amendment Act 2010, incorporating issues relevant to
              the future directions of the RTA (and related transport agencies), and
              the issues emerging out of the Inquiry's Report, there exists a
              requirement that the existing the MOU now be rewritten.

5.4.9         To this end, the Inquiry notes that the NSW Fire Brigades are also
              considering an update of their current MOU with the RTA. Likewise,
              the Ambulance Service of NSW has been contemplating entering a
              MOU with the RTA, but has not moved to formalise any arrangement in
              this regard. The Inquiry understands that there are no formal MOU
              arrangements with the Rural Fire Service of NSW or the NSW State
              Emergency Services.

5.4.10        In the same context, the Department of Environment, Climate Change
              and Water has a current MOU with the NSW Fire Brigades covering
              mutual assistance at hazardous materials incidents that threaten public
              health or the environment. Not surprisingly, this MOU covers the issue
              of public roads, albeit in the context of HAZMAT situations.

5.4.11        In all of the circumstances it would seem more relevant and preferable
              that there be one joint Memorandum of Understanding with Transport
              NSW (incorporating the RTA) and the abovementioned agencies. One
              MOU should articulate the roles, functions and responsibilities of the


        K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010          Page 21 
                                             

           signatory agencies and remove any ambiguity as to the delivery of a
           range of services in a co-ordinated, collaborative and cohesive manner.

5.4.12     As outlined, the agencies who are best placed to enter into a joint MOU
           with Transport NSW are the -
           • Ambulance Service of NSW;
           • NSW Fire Brigades;
           • NSW Department of Environment, Climate Change and Water;
           • NSW Police Force;
           • NSW RTA;
           • NSW Rural Fire Service; and
           • NSW State Emergency Services.

           (The Inquiry is of the view that having regard to the statutory
           responsibilities of the Department of Environment, Climate Change and
           Water in terms of the licensing and carriage of dangerous goods on
           the roads of New South Wales, consideration needs to be given to the
           inclusion of that Department in any proposed joint MOU).

           The Inquiry recommends -

   RECOMMENDATION 2 –

   That the Director General, Transport NSW, Commissioners of the NSW
   Police Force, NSW Fire Brigades, NSW Rural Fire Service, NSW State
   Emergency Services, and Chief Executives of the Ambulance Service of
   NSW and RTA, enter into a joint Memoranda of Understanding (MOU)
   which articulates the roles, functions and responsibilities of each of
   those agencies in responding to high profile road and traffic
   management issues.


   RECOMMENDATION 3 –

   That any proposed joint MOU articulate the co-ordination and
   collaborative arrangements required across each of the agencies so as
   to provide a timely response to road management issues.


   RECOMMENDATION 4 -

   That due to its role in regulating the transportation of hazardous goods
   on the road network consideration is given to having the Department
   of Environment, Climate Change and Water as a signatory to the
   proposed joint MOU.


     K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010          Page 22 
                                             

5.4.13     Finally, what needs to be articulated in any revised and joint MOU, is
           the clear and delineated role of each agency. It needs to be made
           clear and unambiguous - WHO IS IN CHARGE: WHO IS IN
           OVERALL COMMAND AND CONTROL? Whilst the combat agencies
           attend to their tasks, so then, given their existing statutory powers and
           responsibilities, the Inquiry believes this ought to be the NSW Police
           Force.

5.4.14     With this thought in mind, the Inquiry is of the view that in certain
           circumstances (such as that which occurred on the F3 Freeway on 12
           April 2010), and within the context of command and control
           arrangements, that the principles of emergency management - as
           provided in the State Emergency Rescue Management (SERM) Act and
           supporting State DISPLAN, are worthy of consideration.

5.4.15     The Inquiry's view is reinforced when having regard to the definition of
           ‘emergency’ within that Act, which provides (within the emergency
           framework) for the establishment of the State Emergency Operations
           Centre (SEOC) Sydney, and the utilisation of the various functional
           areas.

5.4.16     Albeit those situations like the F3 crash may be rare, the Inquiry
           proffers the view that the requirement for enhanced command and
           control arrangements can and ought to be considered within the
           emergency management context. The nature of the proposition ought
           not to be ruled out until it is ruled in.

5.4.17     Once examined, but determined that the SERM Act has no application
           to such circumstances, then the proposed joint MOU and the recently
           finalised “Traffic Management Protocol for Priority Roads” -
           (Attachment 13) (signed by all relevant Chief Executives in May
           2010), should be amended to define and strengthen command and
           control arrangements (point 5).

5.4.18     If the SERM Act and SEOC principles are deemed not to apply in such
           situations, it is open to the NSW Police Force to consider the utilisation
           of the Police Operations Centre (POC), Sydney.

           Therefore the Inquiry recommends –


   RECOMMENDATION 5 –

   That the NSW Police Force will assume and lead the command, control
   and coordination arrangements of major motor vehicle incidents until
   overall resolution and hand-back to appropriate authorities.



     K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010             Page 23 
                                                

   RECOMMENDATION 6 -

   That the Joint Traffic Management Protocols for Priority Roads, May
   2010, be amended to further articulate the command and control
   arrangements for the resolution of significant motor vehicle crash
   incidents requiring a joint agency response.

5.5           F3: SYDNEY-NEWCASTLE FREEWAY TRAFFIC
              MANAGEMENT PLANS FOR INCIDENTS.
5.5.1         A no less important and further relevant document, “F3 Sydney to
              Newcastle Freeway – Traffic Management Plans for Incidents”
              was developed and adopted by the RTA in December 2005. The
              Inquiry understands that this policy document remains in force today.
                     (Attachment 3).

5.5.2         The document clearly articulates a number of key strategies, namely –

                  1. The RTA Transport Management Centre (TMC) co-ordinates
                     the incident response and is responsible for collating and
                     disseminating information to all required areas.

                  2. The objective of the Plan is to minimise the delay to all road
                     users on the F3 Freeway as a result of an incident by
                     reinstating normal traffic flow conditions as quickly as
                     practical after an incident.

                  3. Key aspects to achieve the objective are quick response times
                     to incidents; effective traffic management plans; effective
                     communications with other agencies; co-operation with
                     incident response personnel, and to ensure that decisive
                     action is taken.

5.5.3         It is further noted that one of the key accountabilities of the Plan
              requires the RTA to assume command of the traffic management
              around an incident, or, as is more commonly known in emergency
              management terms, the outer perimeter. The inner perimeter is the
              domain of the relevant combat agency (in the case of the crash on 12
              April 2010, this was the NSW Fire Brigades).

5.5.4         Implementation to achieve the objectives and strategies of road and
              traffic management (as mentioned in the Plan), requires deliberative
              action on the part of the RTA Traffic Commander at the scene and in
              consultation with the Transport Management Centre (TMC), Redfern.



        K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010         Page 24 
                                                

5.5.5         Clearly, in any such arrangement – and beyond the purpose and intent
              of formal Memoranda of Understanding, Protocols, Plans and
              Agreements is the need for collaboration, co-operation and above all
              else, effective communications between the parties. The Inquiry is of
              the view that for reasons outlined elsewhere in this Report, these
              important characteristics, in particular, effective communications, were
              not always present on 12 April 2010. In fact, the absence of effective
              inter-agency communications at the scene proved to be a crucial factor
              on the day.

5.5.6         The Inquiry has noted the implementation of the latter-mentioned Plan
              (Attachment 3). In light of a range of incidents (crashes and bush
              fires) over, say, the past 2 years on or close to the F3 Freeway
              (including those highlighted in this Report), and given previous
              commitments arising from other reviews, the findings of this Inquiry,
              and recent legislative changes, the Plan should be revised where
              appropriate. The Plan now needs updating in terms of relevance and
              agreed responsibilities.

              Therefore the Inquiry recommends –


   RECOMMENDATION 7 –

   That consideration is given to reviewing the F3: Sydney-Newcastle
   Freeway Traffic Management Plan (2005), to ensure that it reflects
   contemporary best practice, policy decisions and operational priorities
   for the effective and timely management of road crash and related
   incidents.


5.5.7         Whilst it is opined that there is an argument for the redevelopment of
              the current Plan in light of more contemporary issues and recent policy
              decisions, the Inquiry proceeded to conduct its Review on the basis
              that any assessment of the effectiveness of agencies, in particular, the
              RTA, on 12 April 2010, could only be made against the requirements of
              existing policies and operational practices.

5.5.8         These policies include the current MOU (Police-RTA 2009) –
              (Attachment 2), the "F3 Sydney-Newcastle Freeway Traffic
              Management Plan for Incidents” (2005) – (Attachment 3), and
              the previous commitments of the NSW Government through the
              "Rapid Response for New F3 Emergency Plan 2008" –
              (Attachment 1). To this end, the Inquiry carefully considered each
              of these documents, their spirit and intent, and how the objectives
              outlined in these documents were met on the day in question.



        K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010           Page 25 
                                                 

5.6           THE EVENTS OF 21 APRIL 2009 (AND RELATED
              ISSUES) – MEETING THE EXPECTATIONS OF THE
              COMMUNITY AND THE GOVERNMENT OF NSW.

5.6.1         Before proceeding to the events of 12 April 2010, it is also important to
              reflect on another relatively recent significant motor vehicle crash on
              the F3.

5.6.2         NSW Police report that at about 11.35am on Tuesday, 21 April 2009, a
              prime mover and B-double combination was travelling north on the F3
              Freeway, 3km north of the Pacific Highway entry at Wahroonga. The
              vehicle was travelling in the second of three lanes and at the time light
              rain was falling.

5.6.3         It is understood that the vehicle negotiated a left-hand bend in the
              Freeway and in doing so entered lane 1 or the nearside lane. The
              vehicle then began to fishtail left to right which caused the prime
              mover to jack-knife to the right. The two trailers being towed by the
              prime mover continued forward and the nearside of the trailers
              impacted with the Armco railing. The vehicle then descended down
              the embankment for a distance of 50 metres.

5.6.4         As a result of this crash, the driver of the vehicle was fatally injured.

5.6.5         Due to the nature of the accident, the F3 Freeway was closed for a
              number of hours whilst arrangements were made to attend to the
              driver and recover his body. The Inquiry also noted that in the best
              interests of traffic management, the semi-trailer was not recovered
              until the following day.

5.6.6         On this occasion and following the accident (about 11.35am), there
              were lengthy traffic delays. These were effectively managed however
              by the decision to introduce contra-flow at 2.30pm and its eventual
              implementation at 4.18pm. The contra-flow ran over a distance of 2.5
              kilometres until 7.40pm when traffic flows resumed a normal pattern.

5.6.7         The great irony in the event of 21 April 2009 (when compared to the
              crash of the 12 April 2010) was the coincidence of crash time, namely,
              11.35am and 11.40am, respectively. The difference, however, was the
              timely introduction of contra-flow on the 21 April 2009 as opposed to
              the 12 April 2010.

5.6.8         The Inquiry can only speculate that given the response arrangements
              of the 21 April 2009, that there now already existed a working model
              that should have served as an operational beacon for similar response
              arrangements on the 12 April 2010.


        K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010               Page 26 
                                                   

                                         Figure 3.




                          Photographs courtesy of NSW Fire Brigades.

5.6.9         What each of the motor vehicle crashes cited in this Report have in
              common is the fact that beyond the commonality of the F3, there was
              (and always will be) a requirement for collaborative and decisive action
              to be taken by each of the responding agencies. The key to any or all
              successful outcomes has to be the equally important aspect of
              agency-wide effective, integrated and timely communications.

5.6.10        No other comparisons are made by the Inquiry in respect of the three
              motor vehicles crashes cited other than the common feature of their
              location and the involvement of heavy motor vehicles. There are,
              however, some key issues that bind these crashes to other motor
              vehicle crashes irrespective on which road they occurred.

5.6.11        Lamentably, most motor vehicle crashes are but a cross sample of the
              human frailty of some drivers, riders and pedestrians, and can occur on
              any road and at anytime. What emerges time and time again is the
              requirement for PLANNING, PREPARATION, RESPONSE AND
              RECOVERY to situations of this type by the relevant agencies of
              Government. The Inquiry cannot stress too highly that the key to
              meeting these requirements is collaboration, mutual understanding and
              effective communications. This is an issue which the Inquiry reiterates
              several times over.

5.6.12        The fundamental requirements to PLAN, PREPARE, RESPOND AND
              RECOVER are a constant and not a one-off or casual set of
              arrangements. Indeed, they are at the very heart of an integrated and
              functional set of arrangements that provides confidence and
              reassurance to those affected by particular circumstances of natural or
              man-made disaster.


        K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010           Page 27 
                                             

5.6.13     Having regard to the impact that the particular events of 29 and 30
           January 2008, and 21 April 2009 (and other motor vehicle crashes on
           the F3 over the past two and half years) have had both on those
           involved in these events and, equally, the travelling public, and when
           considering the commitment of the NSW Government of 16 March
           2008 and the resultant allocation of $28M (Attachment 1), the
           existence of the "F3 Sydney to Newcastle Traffic Management
           Plan" (2005) - (Attachment 3), and the "Rapid Response For
           New F3 Emergency Plan 2008" (Attachment 1) together with
           supporting policies, including formal MOUs, there was, and indeed
           remains, a reasonable expectation that lessons would be learnt and
           that key to the lessons of the past, was the existence of tested,
           functional arrangements.

5.6.14     Consequently, given past experiences and various policy and
           procedural arrangements that have been endorsed and implemented,
           the Government and the community were entitled to expect that the
           response to the crash on the F3 Freeway on 12 April 2010, would
           have invoked a more timely and integrated approach by the
           responding and responsible agencies. This issue then, is the real
           thrust of this Inquiry and its Report.

5.6.15     The expectations to which the Inquiry refers are not unreasonable and
           are predicated on the most important of criteria, namely, the public
           interest test. Put another way, organisational interest cannot over-ride
           public interest and the Inquiry's recommendations underpin this
           important principle.




     K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010           Page 28 
                                                      


                6. THE F3 - JUST ANOTHER ROAD OR A
                   UNIQUE ROAD, AND THE CRASH OF 12
                   APRIL 2010.
      This Chapter examines the events of the 12 April 2010 - the genesis of this Inquiry, and does
      so by commenting on the F3 Freeway from the perspective of what some describe as its
      uniqueness. The Chapter also examines the actual crash of that day and the roles of a range of
      agencies (including the emergency services) and how those agencies responded to the situation
      and implemented practical recovery arrangements.



6.1          THE F3 FREEWAY.
6.1.1          The F3 Freeway is 128 kilometres long and stretches from Wahroonga
               in the south to (near) Newcastle in the north. Its construction
               commenced in 1963 and variously over the past 47 years it has been
               extended and enhanced in various forms. The current Freeway was
               completed in 1998 and is part of the national highway scheme. As
               such, it is part of National Highway 1.

6.1.2          RTA records indicate that on a daily basis the F3 Freeway carries a
               total of approximately 75,000 vehicles of all makes and dimensions.
               Understandably, the number of cars, cycles, tourist coaches and
               caravans increases during school vacation periods or long-weekends
               thereby raising the potential for motor vehicle crashes.

6.1.3          Clearly, the F3 Freeway is of critical importance when having regard to
               the commercial, road freight, tourist and residential traffic that utilise
               this major arterial road on a daily basis.

6.1.4          Some describe the F3 Freeway as being unique. This uniqueness is
               not that it commences in a metropolitan environment and meanders
               through what might be described as unforgiving terrain (between
               Berowra and Somersby), or that it follows undulating farm land (north
               of Tuggerah). Indeed, these broad descriptors might equally apply to
               a number of major Highways or arterial roads.

6.1.5          What makes the F3 Freeway unique is the fact that unlike other major
               freeways, motorways (M5, M7, and, say, the F4 and F6) and arterial
               roads, there is not always the possibility of exiting the F3 once motor
               vehicles are on it. This certainly seems to be the case in the area
               between the Wahroonga entry and Calga in the north – a distance of
               about 100 kilometres.

6.1.6          This uniqueness is further amplified by the fact that for a reasonable
               distance the F3 Freeway runs along a ‘spine’ where dense foliage,

        K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010                       Page 29 
                                                

              rough terrain and the Hawkesbury River make it nigh on impossible to
              find an alternate route or exit point – features that are not as common
              to the other freeways, motorways and arterial roads mentioned.

6.1.7         The Inquiry's Report highlights a number of key features of the F3
              Freeway, in particular, the area of the crash on 12 April 2010. The
              maps attached to this report highlight some of the geographic and
              other features that qualify this public road for its unique status. These
              include - maps 1, 2, 3, 4 and 8.

6.1.8         At this point in its Report the Inquiry extends its appreciation for the
              co-operation and professionalism of Mr Tony Sleigh, Mr Rob Colless
              and Mr Sean Epe of the Emergency Information Co-Ordination Unit,
              Land and Property Management Authority for their assistance to this
              Inquiry, professionalism and the production of these and other maps.

6.1.9         It is the uniqueness of the F3 Freeway which further amplifies the need
              for the agencies of Government, in particular, the emergency service
              agencies and first responders (like the RTA) to have the capacity and
              ability to continually PLAN, PREPARE, RESPOND AND RECOVER to
              a range of circumstances including bush fires, motor vehicle crashes
              and the occasional road closure.

6.1.10        The Inquiry has been provided with of a number of Plans and related
              policies from a number of agencies. To varying degrees they contain
              elements of planning, preparation, response and recovery as they
              relate to the F3 Freeway. So it was then that on 12 April 2010, these
              Plans (and policies) would be tested against a set of real life
              operational outcomes. The questions that arise from this observation
              are whether or not these arrangements, plans and policies worked on
              the day, and if not, why not?

6.2           THE EVENTS OF 12 APRIL 2010.

6.2.1         Each of the aforementioned comments is designed to inform the
              reader of the Inquiry’s Report of the range of historical events, plans
              and policy decisions which were in place and preceded the crash at
              Jolls Bridge on 12 April 2010. It is against this background and the
              crash on that day, the issues and actions (which emanated from that
              incident) were assessed.

6.2.2         The NSW Police report that at about 11.40am on Monday, 12 April
              2010, a 16 tonne flatbed truck travelling north on the F3 Freeway near
              Jolls Bridge (in the nearside lane), collided heavily with the rear of a
              fully laden fuel carrier which was also travelling north and in the same
              lane. Due to the nature of the serious injuries to the driver of the
              flatbed truck, the exact cause of the crash is still unknown at this time.

        K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010             Page 30 
                                                 


6.2.3         The fuel tanker was carrying 57 tonnes of fuel consisting of 43,606
              litres of unleaded petrol and 8,004 litres of diesel. Notably, this fuel
              load was spread over two tankers with three and four compartments
              respectively.

6.2.4         As a consequence of this crash, the driver of the flatbed truck was
              trapped in his vehicle and sustained serious injuries to the head and
              chest, a compound fracture to the right arm, a fractured femur and
              suspected spinal injuries. The nature of those injuries was so serious
              that it took SCAT Doctors, Ambulance Paramedics and other rescue
              personnel, almost two hours to stabilise him at the scene and before
              eventually transporting him to Royal North Shore Hospital by air
              ambulance. The driver of the fuel tanker received a minor injury to his
              right wrist.

              Relevant photographs taken from the crash incident site are at
              Figures 4 to 8, inclusive.


                                        Figure 4




                                   Photographs courtesy of News Ltd.




        K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010           Page 31 
                                         

                                Figure 5




                                Figure 6




                            Photographs courtesy of News Ltd.




K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010     Page 32 
                                                  

                                         Figure 7




                                         Figure 8




                              Photographs courtesy of News Ltd.

6.2.5         It should be noted that soon after the initial impact between the
              vehicles, a number of passing motorists commendably went to the aid
              of the injured driver. The Inquiry understands that amongst those
              who responded was Mr Corey Norris who, it has been reported, acted
              in a caring manner.

6.2.6         Following the initial collision, the table-top truck commenced to roll
              backwards downhill for a distance of about 35 metres. The vehicle


        K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010         Page 33 
                                                

              came to rest on the western side of the Freeway against rocks and
              trees.

6.2.7         Undeterred, Mr Norris jumped onto the moving vehicle and rendered
              first aid to the injured driver, who, as mentioned, remained trapped in
              the wreckage of his vehicle and until the arrival of Ambulance Service
              personnel. Clearly, by his actions, Mr Norris acted in a selfless and
              commendable manner and should be suitably recognised for his public
              spiritedness. The Inquiry recommends that a report be provided by
              the NSW Police Force to either the Royal Humane Society NSW, or St
              John Ambulance Australia (NSW Division) for their consideration of
              suitable recognition being afforded to Mr Norris.

              Accordingly, it is recommended –


 RECOMMENDATION 8 –

 That the NSW Police Force consider commending the actions of Mr
 Corey Norris to the Royal Humane Society NSW, or St John Ambulance
 Australia (NSW Division) in recognition of his public spiritedness in
 rendering first aid to a driver injured in the motor vehicle crash on the
 F3 Freeway, near Jolls Bridge on 12 April 2010.


6.2.8         The Inquiry’s report now turns to the actions of individual agencies or
              organisations in the resolution of the initial crash response, the
              management of the scene, and the requirement for the normal
              resumption of traffic services.


6.3           THE EMERGENCE OF COMPOUNDING ISSUES
6.3.1         NSW Police advise that as a consequence of the crash and given the
              nature of the serious and life threatening injuries sustained by the
              driver of the table top truck, a decision was taken to close the F3
              Freeway northbound on the arrival of the Air Ambulance whilst he was
              being attended to by SCAT Doctors and Ambulance personnel.

6.3.2         This action was particularly necessary given the requirement to land
              the Ambulance Service helicopter on the roadway near to the crash
              site, and, for no less an important reason than the spread of the
              helicopter rotor blades – see photograph at Figure 9.




        K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010          Page 34 
                                                




Figure 9




                                          Photograph courtesy of News Ltd.

6.3.3         During the period prior to the arrival of the Air Ambulance (at about
              12.12pm) on the F3 Freeway, residual traffic (including heavy vehicles)
              travelled past the crash site in the offside lane, albeit at a much
              reduced speed. A number of emergency service vehicles occupied the
              centre northbound lane.

6.3.4         Not surprisingly, human nature being what it is, the pace of the
              passing traffic was impeded by what is more commonly referred to as
              ‘rubber-neckers’. Equally, and as already acknowledged, others
              stopped to see what genuine assistance they could offer. Overall, the
              actions of some drivers (and others factors) were to have a knock-on
              effect and compounded what was emerging as a difficult traffic
              management issue. Nevertheless, traffic proceeded past the crash site
              albeit at a slow speed.

6.3.5         Following the arrival of emergency service vehicles at the crash site,
              and the diversion by NSW Police of north-bound vehicles at the
              junction of the Old Pacific Highway at 11.52am, vehicle access past
              the crash site was restricted to heavy motor vehicles only.

6.3.6         This latter action had the concurrence of the principal combat agency,
              the NSW Fire Brigades and the on-site RTA Traffic Commander. It was
              thought to be a useful strategy given the potential for fuel vapours to
              escape from the damaged fuel tanker and sit low to the ground.

6.3.7         The F3 Freeway was eventually closed to all northbound vehicles on
              the southern side of the crash site at 12.12pm to allow the landing of
              the NSW Air Ambulance. The Freeway remained closed northbound


        K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010          Page 35 
                                                

              until the departure of the Air Ambulance at about 1.45pm – a period of
              just over 1.5 hours.

6.3.8         The Inquiry understands that during this time heavy vehicles were
              stacked in a corridor between the crash site and the Old Pacific
              Highway, pending reopening of the northbound lanes for their use. All
              other north-bound traffic was diverted from the three lanes of the F3
              Freeway into the single north-bound lane of the Old Pacific Highway
              near its junction at the Hawkesbury River Bridge. Maps 1 and 5 are
              illustrative of the route taken on the day with the Old Pacific Highway
              highlighted in yellow.

6.3.9         During this period, all southbound lanes of the F3 Freeway remained
              open but these were eventually closed during the conduct of the
              contra-flow arrangements from 8.48pm. South-bound traffic was
              diverted onto the Old Pacific Highway during this period.

6.3.10        Clearly, the action of diverting north-bound traffic onto the Old Pacific
              Highway during the emergency response and recovery arrangements,
              understandable as it was, was to have an immediate and ongoing
              impact on overall road and traffic management arrangements from the
              earliest period of the incident (at least 11.40am onwards with the
              arrival of the air ambulance and the initial closure of the F3 Freeway),
              until the implementation of contra-flow (at 8.48pm – a little over 8
              hours after the crash event).

6.3.11        Traffic management of this incident was also always going to be
              problematic given it was also school holidays, and some of the north-
              bound traffic was returning from events in Sydney.

6.3.12        As records indicate, the F3 Freeway was fully reopened and there was
              a normal resumption of traffic flows shortly after 12 midnight on 13
              April 2010 – a little more than 12 hours after the crash occurred.
              Plainly, from its earliest point a series of events were emerging
              whereby effective traffic management was going to be a key issue.
              There can be no doubt that on the basis of this last-mentioned point,
              timely decision making was going to be a key issue.

6.3.13        Past and similar experiences, particularly over the past 2 years alone,
              should have signalled that this was going to be an issue for continual
              assessment, and further, that recovery from the overall situation on 12
              April 2010 was not going to be immediately resolved. In other words,
              it should have been clear to all concerned that recovery from the
              situation was not going to be immediate nor accomplished within a
              short timeframe – notwithstanding the best efforts and commitments
              of all concerned.



        K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010            Page 36 
                                             

6.3.14     Plans, however well made, can never be a replacement for good
           judgement, life skills or effective decision making. Obviously, local
           knowledge is a key, too. Equally, plans and guidelines are only as
           good as those who understand them and how they work to assist the
           situation.

6.3.15     So, too, the effective implementation of any plans or guidelines turns
           on the equally important issue of strong and informed communications,
           inter-agency co-operation and a seamless roll-out, implementation,
           evaluation, and monitoring of those arrangements.

6.3.16     The Inquiry is of the view that visually a range of issues or intelligence
           had emerged (and was emerging) which required continued analysis
           and informed decision making. These issues or intelligence included:

           •   the location of the crash and the difficult and surrounding terrain;
           •   the nature of the serious injuries, and treatment and recovery
               options required for the injured driver (including the length of time
               taken to extricate him from his vehicle and subsequent transfer
               from the scene);
           •   the presence of a 50 plus tonne fully laden fuel tanker (51,610
               litres) which had sustained not inconsiderable damage to the rear
               of the tanker and it would seem, was structurally compromised;
           •   the fact that the damaged fuel tanker was not going to be easily
               moved from its location to another place;
           •   the unresolved issues regarding the arrival of the replacement
               tanker and the pump unit to decant the fuel from the damaged
               tanker; and
           •   the continual (and predictable) build-up of northbound traffic
               pending the commencement of the afternoon peak.

           Having planned and prepared for an incident of this type, and
           then responded to the event, what was crucial at this point
           was how the responding emergency service agencies
           recovered the situation and how the RTA managed the
           situation.

6.3.17     There can be no doubt that on the basis of all that had occurred and
           was occurring, clear and deliberative action and leadership was
           required. Essentially, time was of the essence not only for the injured
           driver and his treatment, but the general motoring public as well.

6.3.18     The Inquiry’s Report now turns to the actions of each of the
           responding agencies (including those of the RTA) to gauge how best
           they responded both on an individual basis and as a collective of
           responding agencies.



     K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010             Page 37 
                                                

6.4           THE ROLE OF THE NSW POLICE FORCE.
6.4.1         As the Inquiry has commented, in issues that require decisive action,
              so then command and control of such situations is crucial - who is in
              charge: who is making the key strategic decisions?

6.4.2         Similarly, within a structured set of command and control
              arrangements there is a requirement for complementary strategies of
              decision making, communications and leadership. Applying the SERM
              Act provisions, these functions would be those of a Site Controller, who
              is the most senior Police Officer at the site.

6.4.3         Notwithstanding these provisions, the Inquiry is of the view that whilst
              the responding agencies went about their respective tasks in a
              partnership arrangement, no one agency effectively assumed overall
              command, control, co-ordination or management of the incident site.

6.4.4         Circumstances requiring a multi-agency response cannot succeed if
              there is a duplication of command arrangements. As noted by the
              Inquiry, one agency must accept that responsibility and then work in
              support of the other agencies to resolve the overall situation. So it is
              then that the Inquiry's view is further supported when having regard to
              the requirements of the Police Act (1990) including the Oath of Office
              which provides, amongst other things, for the preservation of life and
              the protection of property.

6.4.5         It is not the role of the Police in such situations to direct the other
              combat agencies, particularly, in the case of their professional
              knowledge and skill. It is about bringing a cohesive and non-confusing
              set of arrangements into play that aids the resolution of a particular
              incident, in this case, the effective and timely response and recovery
              of the F3 Freeway. It seems, therefore, that Police were best placed to
              undertake this role on this day.

6.4.6         Turning to the issues of 12 April 2010, the Inquiry understands that
              the Police, Fire Brigade, Ambulance and RTA representatives attended
              the scene and operated from separate Incident Command vehicles.
              Whilst this allowed for discussion between those in the general area, it
              must be emphasised that an Incident Command vehicle is not
              and never was intended to be a joint-agency Command Post.
              The unintended consequence arising from what occurred was the
              apparent ambiguity as to who was actually in command of the
              overall control and management of the incident and the incident site.

6.4.7         To this end, the Inquiry believes that on this occasion as part of the
              timely resolution of issues, it would have been more effective had,
              amongst other things, an inter-agency Command Post been established
              near to the scene of the crash. If this had been the case the important
              aspects of co-ordination, communications, and management of a wide
              range of issues could have been better facilitated.

        K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010           Page 38 
                                                

6.4.8         Clearly, the role of the Command Post is not to tell the combat
              agencies how to undertake their specific or assigned roles. Rather, the
              inter agency Command Post exists to provide authority in the overall
              co-ordinated resolution of issues. It is the conduit between the
              decision makers (in another place) and those tasked with the
              implementation and carriage of their assigned roles and responsibilities
              in the field.

6.4.9         To support the Inquiry’s view regarding the role, function and
              responsibility of the Police in such situations, it is noted that the
              specific requirements of the (NSW Police Force) Duty Officer’s
              Handbook states, amongst other things, “Major Vehicle Crashes –
              Major or Minor Crashes – Arrival and Assessment – for major
              incidents establish a command post to co-ordinate activities at
              the scene” – (Attachment 4A) (pp2-3). This view is also supported
              by the issues outlined in the NSW Police Force document ‘Action Plan
              - Full or partial closure of F3 Freeway’ (Attachment 4B).
              (NOTE- This document has caveat and copyright restrictions)

6.4.10        To give further emphasis to the critical importance of command and
              control of such situations, the Inquiry believes that on 12 April 2010,
              the principles of the State Emergency Rescue and Management
              (SERM) Act 1989 (and supporting State DISPLAN) may have had
              relevance and a particular application.

              Most notable within that Act is the definition of an emergency which
              states that –

              “An emergency means an emergency due to an actual or imminent
              occurrence (such as fire, flood, storm, earthquake, explosion,
              terrorist act, accident or warlike action) which –

              a) endangers, or threatens to endanger, the safety or health
                 of persons or animals in the State; or
              b) destroys or damages, or threatens to destroy or damage,
                 property in the State, being an emergency which requires a
                 significant and co-ordinated response.

6.4.11        There may be a view that the provisions of the SERM Act had no
              application to the F3 Freeway incident of 12 April 2010. Whilst this
              may well be a topic for discussion amongst emergency management
              purists, the Inquiry is of the view that the situation on the F3 Freeway
              on 12 April 2010 was an emergency (however defined) in that it clearly
              required decisive leadership, clear inter-agency responses, effective
              communications, and based on past historical events, its impact on the
              specific and broader community, was going to be significant.



        K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010           Page 39 
                                              

6.4.12     Doubtless, the crash and its aftermath were always going to have
           significant community, political and media interest. Decisiveness was
           the key, not delay. As such, an inter-agency Command Post should
           have been established under the command and control of the NSW
           Police Force. It would, in all of the circumstances, have aided the
           situation and not hindered it.

6.4.13     Consequently, the Inquiry is of the view that had this important and
           strategic action been taken earlier (as it was taken later in the day),
           then a range of issues which later emerged at the site including
           fragmentation of approach, poor communications and a lack of
           management of some issues, may well not have emerged or emerged
           to the extent that they later appear to have done. This view is
           supported by the NSW Police Force documentation previously cited,
           and the accepted definition of emergency under the SERM Act.

6.4.14     The Inquiry is further strengthened in its view and notes that given the
           accepted definition of an emergency there is provision, amongst other
           things, that in a range of given situations issues requiring a higher
           level of resolution, may be lifted from a local level to a District level (or
           in special circumstances to State level). The F3 Freeway crash of 12
           April 2010 and its subsequent management was such a situation and
           closer consideration of this point would have assisted the earlier
           resolution of a range of issues.

6.4.15     The Inquiry is of the view that had an appropriate assessment been
           made by Police as to the overall tactical (short-term) and emerging
           strategic (long-term) issues surrounding the crash, that when having
           regard to both the principles and the provisions of the Act and
           supporting State DISPLAN, so then, the Local Emergency Operations
           Controller - LEOCON (who is also the Local Area Commander) would
           have been notified. Subsequently, it would have open to the LEOCON
           to have established a Local Emergency Operations Centre (LEOC) in
           support of field-based operations. Indeed, this should have been the
           first option.

6.4.16     In turn, the District Emergency Operations Controller - DEOCON (who
           is also the Region Commander) could have been similarly notified.
           Consequently, the State Emergency Operations Controller - SEOCON
           (who is the Deputy Commissioner, Field Operations) could have been
           notified as to the emerging issues relating to the crash (including the
           issues that had emerged and were emerging by the hour).

6.4.17     Importantly, had an assessment been made based on all of the known
           and emerging circumstances, the Inquiry believes that a decision
           may have been made (or at the very least considered) to open the
           State Emergency Operations Centre (SEOC) Sydney. Whilst it is not
           the role of SEOC to manage the on-site combat issues, it could have
     K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010               Page 40 
                                             

           facilitated and managed a wide range of no less important issues that
           ultimately attracted significant and negative community, political and
           media comment.

6.4.18     The SEOC is not an alternative to the Transport Management Centre
           (TMC) Redfern, or the Local Emergency Operation Centre (LEOC) or an
           inter-agency Command Post in the field. It is an important state-
           resource where the agencies of the state (and where relevant) federal
           governments are co-located with other agency partners. The SEOC
           acts as a key facilitator for action, resources, planning and
           communication. As mentioned the SEOC is there to complement the
           role of emergency service personnel in the field and the TMC, not be
           an alternate TMC, or LEOC or inter-agency Command Post.

6.4.19     The role of the SEOC is to ensure that there is a seamless approach to
           assisting the DEOC, the LEOC and inter-agency Command Post in the
           field, and with a view to the speedy resolution of a broad range of
           issues.

6.4.20     Having made these observational comments, the Inquiry sought to
           understand why earlier and more specific command and control
           arrangements were not applied on the day. At the local level, it was
           advised that the Local Area Commander, Brisbane Waters – who is also
           the LEOCON, was on annual leave at the time, but was being relieved
           in that position.

6.4.21     The Inquiry further understands that the Commander, Northern Region
           (Newcastle), who is also the DEOCON, was not fully informed of the
           seriousness of the situation and the ongoing nature of the emerging
           problem until late into the afternoon.

6.4.22     Clearly, more should have been done to regularly update the Region
           Commander of the nature of the crash and as important, the
           seriousness of the issues that were emanating from it. Had this level
           of communication occurred, the Inquiry believes that a range of more
           experienced-based decisions would have been realised.

6.4.23     To add to the situation, the Deputy Commissioner, Field
           Operations/SEOCON was on annual leave and the Inquiry understands
           his replacement was not fully informed of the emerging issues until
           later in the day. Therefore, there existed any number of circumstances
           including a lack of communication and key decision making that, in
           hindsight, should have been and could have been more effectively
           managed.

6.4.24     The principles of emergency management and their application to
           motor vehicle crashes do not have an everyday application. Equally, it
           cannot be dismissed as having no application in the resolution of a
     K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010         Page 41 
                                             

           wide range of complicated and not easily resolved issues such as were
           experienced on the F3 Freeway on 12 April 2010.

6.4.25     When considering the history of similar crashes on this same road,
           including a range of consequential effects, then the principles of
           emergency management and command and control have an
           application. They should have been considered as an operational
           option within response and recovery arrangements.

6.4.26     If in the debate that ensues regarding the Inquiry's view (that the
           principles of the SERM Act had an application to the response and
           recovery arrangements of 12 April 2010), it is concluded that this is not
           so; then there needs to be further discussion on this issue and, if
           appropriate, an amendment made to the SERM Act or State DISPLAN
           to include significant motor vehicle crashes within the definition of an
           emergency. Such an inclusion would give greater focus to traffic and
           transport coordination.

           Therefore, the Inquiry recommends -

    RECOMMENDATION 9 -

    That further consideration be given to providing for significant motor
    vehicles crashes being included within the definition of 'emergency'
    under the State Emergency and Rescue Management Act.



6.4.27     Whatever the outcome of those deliberations, an alternative to the
           SEOC provisions existed in the form of the Police Operations Centre
           (POC), Sydney. This state-of-the-art facility provides a range of cross-
           agency facilities in the conduct of major events – e.g. New Years Eve,
           significant public events and the like. By any reasonable definition, the
           F3 crash (and its aftermath) on 12 April 2010 was a significant event.

6.4.28     The possible utilisation of either the SEOC or the POC on these
           occasions ought not to be lightly dismissed. These things said, the
           Inquiry turned its mind to what other remedial action may be
           required.

6.4.29     Finally, there is a maxim that "you do not know what you do not
           know". Knowledge and experience are important and to the extent of
           at least considering the principles of emergency management and its
           protocols (as part of the overall decision making process for speedy
           resolution of issues), training and retraining has to be the key.

6.4.30     In this instance the inter-related issues of emergency management and
           incident management training are important for a range of reasons.
     K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010            Page 42 
                                             

           Some might view it in the context of counter terrorism preparedness,
           and that is appropriate. Thankfully though, instances of that type are
           infrequent in this country.

6.4.31     What is more frequent are instances of floods, bush fires, landslides
           and serious motor vehicle crashes (like that of 12 April 2010) that
           require a holistic response to a given set of circumstances. Doubtless
           in such situations, the NSW Police Force is the key and their leadership
           role is paramount.

6.4.32     Therefore, the Inquiry is of the view that the Commissioner of Police
           should consider the ongoing provision of Emergency Management and
           Incident Command and Control training (including renewed training) to
           all Local Area Commanders / LEOCONs and Duty Officers with such
           training to be provided as a matter of priority.

6.4.33     Equally, consideration should be given to ongoing Incident Command
           and Control Training for all mobile supervisors irrespective of their
           class of duties. This is important not only in the context of emergency
           management, but, how, in circumstances which gave rise to this
           Inquiry, emergency management and incident command and control
           protocols and processes have an application.

           Therefore, the Inquiry recommends –

   RECOMMENDATION 10 -

   That the Commissioner of Police give consideration to the ongoing
   provision of Emergency Management and Incident Command and
   Control Courses, including renewed training programs, for all Local Area
   Commanders / LEOCONs and Duty Officers as a matter of priority.



   RECOMMENDATION 11 -

   That the Commissioner of Police give ongoing consideration to the
   provision of Incident Command and Control Courses for all Mobile
   Supervisors (irrespective of their class of duties) and Incident Site
   Controllers through the Education Services Command and the District
   Emergency Management Officer (DEMO) network.

6.4.34     Further, the Inquiry is also of the view that the Commissioners of the
           NSW Police Force, NSW Fire Brigades, NSW Rural Fire Service, and
           NSW State Emergency Services, the Director General, Transport NSW
           and the Chief Executives of the Ambulance Service of NSW and the
           RTA, give consideration to integrated Emergency Management and
           Incident Command and Control training with the primary focus on risk
     K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010           Page 43 
                                             

           management,        consequence       management,       communications,
           collaboration and intra and inter agency co-operation.
           Therefore, the Inquiry recommends –


    RECOMMENDATION 12 –

    That the Commissioners of the NSW Police Force, Fire Brigades, Rural
    Fire Service, State Emergency Services, Director General Transport NSW
    and Chief Executives of the Ambulance Service of NSW and Roads and
    Traffic Authority, give consideration to the development of an
    integrated Emergency Management and Incident Command and Control
    Course, incorporating the use of Hydra and Minerva facilities.


6.4.35     Whilst formal training within the NSW Police Force is the responsibility
           of the Education Services Command (and their counterparts in other
           agencies), the Inquiry is strongly of the view that any programs
           developed either by the NSW Police Force (for internal consumption) or
           by a number of agencies (for cross-agency consumption) be done so
           utilising the considerable knowledge and expertise within the District
           Emergency Management Officer (DEMO) network. Indeed, the Inquiry
           is of the view that the DEMO Network should play a pivotal role in the
           development or redevelopment and delivery of appropriate education
           programs.

           Therefore, the Inquiry recommends –


   RECOMMENDATION 13 –

   That any programs developed and delivered by or on behalf of the NSW
   Police Force, either for internal delivery or across multiple agencies, be
   done so utilising (amongst others) the District Emergency Management
   Officer network.


6.4.36     It will need to be a fundamental requirement for any training in
           emergency management and incident command and control, that over
           and above issues relating to legislative requirements and operational
           procedures, that close and equal attention is given to –

           •   evidence-based decision making;
           •   lateral thinking;
           •   tactical – viz - strategic decision making;
           •   risk management – viz – consequence management;
           •   risk management – viz – risk avoidance;
           •   agency-specific responsibilities and inter-agency co-operation;

     K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010            Page 44 
                                              

           •   effective communications; and
           •   escalation of issues (as part of effective decision making).

6.4.37     It should also be a fundamental requirement that individual knowledge
           is regularly assessed. Therefore, it is recommended that minimally
           twice per year each of the abovementioned agencies exercise aspects
           of emergency management and incident command and control, and
           specifically as it relates to significant incidents on major and arterial
           roads. The proposed exercise regime should be one table-top exercise
           and one field-based exercise per year. Such exercises should, where
           possible, be adjudicated by independent assessors.

           Therefore, the Inquiry recommends –

  RECOMMENDATION 14 –

  That all agencies impacted by the Inquiry and who have a range of core
  functional responsibilities within the emergency management and
  incident command and control framework, minimally undertake one
  joint table-top and one joint operational exercise per year. Such
  exercises should be independently assessed and adjudicated.


6.4.38     Given their statutory responsibilities it is further recommended that the
           State Emergency Management Committee (SEMC), take the issue of
           emergency management training (including incident command and
           control) training as a matter of particular responsibility to ensure its
           implementation and introduction across their respective agencies.

           Therefore, the Inquiry recommends –


  RECOMMENDATION 15 –

  That the State Emergency Management Committee give consideration
  to the oversight of development, delivery and implementation of
  Emergency Management, and Incident Command and Control
  awareness training, across the key combat agencies and including the
  Transport NSW portfolio.




     K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010              Page 45 
                                                   

6.5           THE ROLE OF THE NSW FIRE BRIGADES.

6.5.1         In order to gain a further appreciation of the environment in which the
              response and recovery arrangements were managed on 12 April 2010,
              particularly from the point of view of hazard management by the NSW
              Fire Brigades, it should be noted from photographs taken at the scene,
              that the fuel tanker (consisting of a prime mover and two tankers)
              sustained extensive damage to the rear of the second tanker.

6.5.2         Indeed, Scott’s Transport has advised that the total cost of overall
              damage to their vehicle was in excess of $30,000.00. Details of the
              damage are assessed and more fully outlined at Attachment 5 and
              are worthy of note.

6.5.3         The nature of the overall damage would appear to underscore the
              observation that the fuel tanker was structurally compromised as a
              result of the crash. Subsequently, it was more likely than not that its
              movement whilst fully laden, was going to be problematic. Similarly, it
              was facing up hill and this was not going to be an issue quickly nor
              easily resolved.

6.5.4         The Inquiry is of the view that in the context of intelligence gathering
              and decision making, the damage that could be seen was valuable
              information and it should have been assessed for what it was, namely,
              a structurally compromised vehicle. Despite the best will in the world
              and the efforts of many, this vehicle was not going to be quickly nor
              easily moved.

              Amongst other things, damage to the tanker was occasioned to –




Figure 10




                           Photograph courtesy of Scott's Transport.
   DAMAGED LEFT (Passenger) REAR INNER WHEEL OF FUEL TANKER.

        K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010           Page 46 
                                            

                                  Figure 11




                    Photograph courtesy of Scott's Transport.

DAMAGED LEFT (Passenger) REAR INNER WHEEL OF FUEL TANKER.



                                  Figure 12




                    Photograph courtesy of Scott's Transport.
         OUTER SKIN OF DAMAGED FUEL TANKER.

 K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010    Page 47 
                                               

                                    Figure 13




                      Photograph courtesy of Scott's Transport.
  LEFT REAR WHEEL OF FUEL TANKER IN UPWARD LOCKED POSITION


                                    Figure 14.




                      Photographs courtesy of Scott's Transport.

BULLBAR OF TABLE TOP TRUCK LODGED INTO THE REAR OF THE FUEL
                             TANKER.


   K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010     Page 48 
                                                

              and,
              * rear tyres on the second tanker had commenced to bulge by 10cms.
              ( No photograph available)

6.5.5         For these reasons, and given the nature of the fuel load on board the
              tanker, it was deemed prudent by the Fire Brigade that they take
              deliberative action. It should be noted that in situations of this type,
              the NSW Fire Brigades are the designated combat agency.

6.5.6         In speaking to the Inquiry, representatives of the NSW Fire Brigades
              indicated that in their professional judgement that when having regard
              to the potential build-up of hydrocarbons vapours, that if an explosion
              were to occur due to a static discharge, or the inadvertent throwing of
              a cigarette or match from a passing vehicle, the result would have
              been catastrophic for those in the immediate surrounds.

6.5.7         Equally, an explosion may have resulted in a fireball travelling south
              down and across the northbound lanes of the F3 Freeway. No
              reasonable person could argue then that the caution taken in and
              around the damaged tanker, or the ultimate decision to decant in full
              both tankers of the unleaded petrol, was not an appropriate one.

6.5.8         The understandable priority of the Fire Brigade on this occasion was to
              ensure the safety and security of the fuel load, and that there was no
              immediate or pending danger to any person.

6.5.9         As a precautionary measure, the Fire Brigade established the first of
              two exclusion zones around the tanker at 12.26pm, and the other
              being prior to and during the decant process from just after 6.00pm.

6.5.10        Fire Brigade logs note that the Fire Brigade Incident Controller
              conferred with his senior colleagues who confirmed his decision in not
              moving the tanker. In all of the circumstances and given the
              experience and professional judgement of Fire Brigade officers at the
              scene, the Inquiry is of the view that these were prudent and
              appropriate actions.

6.5.11        In taking these deliberative actions there was always going to be a
              delay in the final resolution of the situation and reopening of the F3
              Freeway to normal conditions. Whilst there was understandable
              community concern and media interest regarding the extent of delays,
              one only has to contemplate that had a significant leakage or an
              explosion occurred, then the loss of life, injuries and damage to
              property (including the F3) and environmental damage would not have
              been a price that the community was willing to pay. The level of
              caution exhibited by the Fire Brigade officers was appropriate in all of
              the circumstances.


        K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010           Page 49 
                                               

6.5.12     The Inquiry’s view is further sustained when having regard to details
           outlined in the attached maps 1-16(rock walls which would hinder
           escape, and in the event of an explosion create a tunnel affect); map 8
           (difficult and hilly terrain and dense bushland); map 10 (power sites);
           map 12 (water and sewer mains and stormwater channels); map 13
           (potential spill extent); map 14 (potential fuel run-off flow paths); map
           15 (small hamlet near to the crash site), and map 16 (oyster and
           aquaculture leases). Clearly, there were human, environmental, and
           infrastructure considerations that had to be taken into account.

6.5.13     At this point, and given the potential volatility of the crash site, the
           Inquiry notes with gratitude the commitment and professionalism of all
           at the crash site and its environs. To that end, the Inquiry
           compliments members of the Ambulance Service of NSW (including
           SCAT Doctors), NSW Fire Brigade, NSW Police Force, the Roads and
           Traffic Authority, Scott's Transport and others who selflessly went
           about their duties at the scene of the crash. Clearly, they showed
           tenacity and resolve.

6.5.14     To further emphasise the Inquiry's support of the professionalism of
           the Fire Brigade officers who acted at the scene, the advice of the
           NSW Fire Brigades regarding two incidents in the United States, where
           fuel tankers exploded is noted. A graphic video of one of the
           explosions     in     Michigan     can      be     seen       at    -
           http://www.huntingtonpost.com/2009/07/16gasoline-tanker explodes.

           The two photographs below vividly demonstrate the point.
                                        Figure 15




                         Photographs courtesy of NSW Fire Brigades.



     K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010            Page 50 
                                                

                                         Figure 16




           Photographs courtesy of NSW Fire Brigades.

6.5.15     The Inquiry does not propose to reiterate the issue of emergency
           management and incident command and control training for members
           of the Ambulance Service of NSW and NSW Fire Brigades, but reaffirms
           its relevance as part of a holistic approach to this issue.

6.5.16     That said, the Inquiry believes it to be a fair comment that as part of
           their tactical and professional assessment of the situation, the NSW
           Fire Brigades should have made a wider strategic assessment of the
           overall situation (including the impact of the travelling public). Like the
           NSW Police Force, NSW Fire Brigades Command should have assessed
           the situation in the context of the principles of the SERM Act and
           State DISPLANS, and a recommendation made that consideration be
           given to open the State Emergency Operations Centre (SEOC).

6.5.17     Alternatively, it was open to the Brigade to suggest to the NSW Police
           Force that they consider opening the Police Operations Centre (POC),
           to better co-ordinate and manage what was a growing and complex
           set of recovery arrangements.

6.5.18     Further, and whilst the Inquiry is supportive of the professionalism of
           the NSW Fire Brigades at the scene of the crash relevant to the
           HAZMAT situation, it also notes there were issues of communication at
           the incident site between Fire Brigade and the Roads and Traffic
           Authority personnel. Put simply, communications on site might
           reasonably be described as being strained during critical periods.
           Frankly, that such a situation developed was not professional.

6.5.19     Doubtless, this breakdown in communications both at a personal and
           professional level did not enhance the important issues of overall
           effective collaboration.


     K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010             Page 51 
                                             

6.5.20     Equally, there can be no doubt that poor communications and
           misunderstandings (as well as other key factors later described)
           ultimately had an impact on the decisions of the RTA and the TMC in
           respect of the timing and introduction of contra-flow being much later
           than should have been the case.

6.5.21     NSW Fire Brigades advised the Inquiry that from their perspective the
           onsite situation took longer to resolve than had been first thought.
           These reasons included the -

           1. delay in the arrival of the replacement tanker;
           2. late arrival of the fuel pump unit to complete the decant process;
              and
           3. decision to decant the whole fuel tanker and not one compartment
              as had been first proposed due to a more detailed assessment of
              the damaged fuel tanker by Brigade personnel and Scott's
              representatives.

6.5.22     The key issue at this point is not that revised assessments were made
           regarding the fuel tanker, rather, they appear not to have been
           conveyed either in an effective or timely manner to other key decision
           makers, in particular, those at the TMC.

6.5.23     The Brigade also advised that at 3pm. when it was determined the
           issues were not going to be resolved quickly they provided information
           via to their Communications Control Centre, Newcastle. The Inquiry
           notes that this whilst this important information was discussed on site
           and further relayed internally within the NSW Fire Brigade, it was not
           entered into ICEMS, and as such able to be automatically brought to
           the attention of personnel in the TMC. TMC staff advised that they
           were unaware of the revised expected time or decision to decant the
           full fuel load until much later.

6.5.24     That notification sent by Fire Brigade personnel at 3.00pm, advised, in
           part, that decanting might now be expected to take many more hours
           to finalise. Notably, it was the same information provided to the NSW
           Fire Brigades Communications Control Centre that allowed the Media
           Unit, NSW Fire Brigades to state on radio (on a number of occasions)
           that delays could be expected and would be lengthy in their resolution.

6.5.25     The RTA and the TMC advise that they could not confirm this important
           information with the NSW Fire Brigades until about 6.30pm that night.

6.5.26     The Inquiry's Report digresses at this point to note that the RTA
           (through the TMC) state that on the basis of earlier advice, they
           maintained the belief that the incident was going to be resolved at or
           about 3.00 -3.30pm - the original time forecast for the resolution of the
           F3 incident and the possible reopening of the Freeway.
     K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010            Page 52 
                                             

6.5.27     This latter mentioned fact however seems at odds with the RTA TMC
           media adviser's comments when interviewed in a commercial radio
           news broadcast at 3.00pm on 12 April 2010.

6.5.28     Notably, the news commentator’s report on radio station 2GB at
           3.00pm on 12 April 2010 advised that lengthy delays were being
           experienced on the F3 Freeway, and it was expected to be closed for
           the evening peak hour. It would seem therefore, that there appears to
           have been different understandings within the TMC as to the evolving
           status of the traffic situation and its resolution. Media's understanding
           and the TMC's understanding of the resolution of the traffic
           management issues on the F3 appear somewhat askew.

6.5.29     The TMC hold to the view that critical information was not drawn to
           their attention in a timely manner. It may also be the case that it was
           not effectively conveyed to the TMC from the crash site due to
           communications issues in the field. Whatever the case, the absence of
           particular information regarding the need for a full decant of the fuel
           load significantly contributed to the TMC's decision not to introduce
           contra-flow arrangements earlier than it did, or, earlier than perhaps it
           should. This factor was to prove to be a significant issue as the day
           drew on.

6.5.30     Notwithstanding the factual position, it was at this juncture,
           that is, at about 3.00pm that the point of no return had been
           reached and every minute of delay in respect of the timely
           introduction of contra-flow further compounded the situation.

6.5.31     Before leaving the issue of technical communications and their
           application, the Inquiry notes that ICEMS is an important information
           tool used primarily by Police, Fire Brigade and the RTA (TMC). The
           NSW Fire Brigades advise that ICEMS links the computer-aided
           dispatch (CAD) systems of the different services by a
           telecommunications network that is fast, inexpensive, secure, simple to
           implement and provides a user-friendly means to enter and respond to
           messages. The result is a rapid and accurate transfer of emergency
           incident-related information between the Emergency Services and
           support agencies.

6.5.32     ICEMS was introduced between the NSW Police and the RTA in July
           2008, and between the NSW Fire Brigades, NSW Police Force and RTA
           in December 2009.

6.5.33     The Inquiry understands that a decision is pending regarding the use
           of ICEMS by the Ambulance Service of NSW, the Rural Fire Service of
           NSW and the NSW State Emergency Service. ICEMS forms the basis of
           inter-agency collaboration and job sharing and it is critical that both its
           application in day-to-day emergency response operations and its
     K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010             Page 53 
                                         

       effectiveness not be compromised. Before further proceeding with
       additional applications regarding ICEMS, additional qualitative work is
       necessary and in the best interests of effective inter-agency
       communications.


       Therefore, the Inquiry recommends -



RECOMMENDATION 16 -

That the NSW Police Force, NSW Fire Brigades and Transport NSW (in
consultation with the Ambulance Service of NSW) undertake a thorough
review of the policy, technical capability and operational effectiveness
of the Inter-cad Electronic Messaging System (ICEMS) to ensure that all
inter-agency messages are the subject of review, analysis and timely
dissemination to and within relevant emergency response agencies.




RECOMMENDATION 17 -

That any such review takes account of the operational needs of the NSW
State Emergency Services and the Rural Fire Service of NSW.



RECOMMENDATION 18 –

That assessable training in ICEMS be regularly conducted across
agencies to ensure contemporary knowledge of its application and use
to day-to-day operations, and, importantly, emergency service response
requirements.




 K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010          Page 54 
                                                

6.6           THE ROLE OF SCOTT’S TRANSPORT – OWNER /
              OPERATOR OF THE FUEL TANKER.
6.6.1         The Inquiry was advised that Mr Scott Tester, State Operations
              Manager, Scott's Transport, was informed of the crash by his driver.
              He noted this call at 11.37am.

6.6.2         As a consequence of this notification, Mr Tester immediately
              dispatched his Senior Technical Adviser and Driver Training Manager,
              to the scene of the F3 Freeway crash. Notably at this point, neither
              the all important fuel decanting pump unit or the compressor were
              taken to the scene.

6.6.3         Mr Tester advises that he initiated inquiries to locate a new driver to
              drive a replacement tanker to the scene so as to undertake the
              decanting process. The search for a replacement driver was made
              difficult by the fact that Scott's Transport drivers generally work a
              3.00am to 3.00pm shift and as most on-duty drivers were near the end
              of their shift, it was necessary to locate and recall a replacement driver
              from home.

6.6.4         The Inquiry was advised that once organised, the replacement driver
              and tanker departed Scott's Milperra depot at 12.45pm and arrived on
              site at about 3.00pm – 2.25 hours later, and 90 minutes later than it
              had been believed that the vehicle would be on site.

6.6.5         Eventually, the compressor arrived on site. However, it is unfortunate
              that the pump unit necessary to decant the fuel from the damaged
              tanker to the replacement tanker did not depart earlier with Scott's
              representatives. In fact, it was towed under a separate arrangement
              by another of Scott’s drivers who had also been recalled to duty.
              Overall, this fact was to compound the situation in terms of the
              ultimate arrival of the pump unit and the commencement and
              completion of the decanting process.

6.6.6         Again, in terms of overall critical decision making regarding the
              introduction of contra flow, this was to prove another piece of
              devalued intelligence.

6.6.7         It is noted that the pump unit eventually departed Scott’s depot at
              about 2.45pm and arrived on site at about 5.45pm – 3 hours later. The
              Inquiry was advised that the decanting process got underway shortly
              after 6.00pm The arrival of the pump unit at the latter-mentioned time
              was one of a number of unfolding events that impacted on the
              eventual implementation of contra-flow.



        K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010             Page 55 
                                                

6.6.8         Clearly, traffic en route from Milperra to the crash site was building and
              this fact did not assist the easy movement of either the replacement
              tanker or the pump unit. Indeed, the Inquiry was advised that the
              virtual progress of the pump unit (and its tow vehicle) had been
              thwarted when it travelled, in part, along the northbound breakdown
              lane of the F3 Freeway.

6.6.9         Some motorists, the Inquiry was advised, unaware of what the pump
              unit was, thought that the driver of the vehicle was another motorist
              simply seeking to take advantage of the breakdown lane and sneak
              past other stranded or slowing motorists. Regrettably, some motorists
              pulled into the breakdown lane and hindered the progress of the
              vehicle and pump unit.

6.6.10        The eventual arrival times of both the replacement tanker and the
              pump unit were well outside of what had been anticipated as their
              assumed arrival times, namely, about 1.30pm for the tanker with
              completion of the decanting process by about 3.00-3.30pm.
              Notwithstanding a range of related issues, this was never going to be
              the case.

6.6.11        The Inquiry believes that the issue of assumed arrival times had been
              based on a statement that Scott's Transport gave to the effect that
              they were "...on their way". Whilst there was truth in this statement, it
              appears to have meant different things to different people.

6.6.12        Whilst it would seem that time calculations were based on the distance
              from Milperra to the crash site; so then, the emergency services or the
              TMC were not initially aware of the delay in accessing replacement
              drivers for both the tanker and pump unit. Similarly, they would not
              have been aware of what ultimately proved to be the case, namely,
              that Scott’s initial on-site representative was not conveying the
              critically important pump unit with him.

6.6.13        Clearly, there should have been an ongoing validation and assessment
              of the information from Scott’s regarding their actual departure time
              and estimated arrival time at the crash site. This point is further
              emphasised when having regard to the fact that the time for their
              arrival (believed to be about 1.30pm) and the completion of the
              decanting process (about 3.00-3.30pm) had well and truly passed.

6.6.14        Questions should have been posed to Scott's Transport by the TMC on
              a continuous basis regarding the replacement tanker and pump unit
              and their anticipated time of arrival. This does not appear to have been
              done. As with a number of parallel issues at this time, this lack of
              ongoing validation and assessment (as to actual arrival times) was
              undervalued intelligence.


        K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010             Page 56 
                                             

6.6.15     As unfortunate as the situation described above was, it is clear that a
           number of key decisions regarding contra-flow should have been made
           no later than 2.00pm, and based on what was known. Indeed, the RTA
           Chief Executive’s diary notes provided to this Inquiry – Attachment
           19 - record that a decision regarding contra-flow would need to have
           been made by that time.

6.6.16     Similarly, critical intelligence that was evident and, it appears not fully
           considered, included evidence of ever increasing north-bound traffic
           numbers over an increasing distance, and the growing number of calls
           to talk-back radio from motorists stranded or slowed on the F3
           Freeway, do not appear to have been picked up or assessed.

6.6.17     Opportunities for informed and timely decision making at the scene
           and in the Transport Management Centre appear not to have occurred.
           Again, this aspect highlights the speculative view that the
           establishment of an inter-agency Command Post (with the support of
           the SEOC or the POC) may well have prevented a range of issues from
           arising or arising to the extent that they did.

6.6.18     The intelligence to which the Inquiry refers was evident in a number of
           known facts. These facts included the time taken for the replacement
           tanker to arrive on scene (2.25 hours) and the arrival of the pump unit
           (3 hours), were all clear indications that despite the best efforts of
           many, events were not unfolding as had been predicted. Clearly, the
           reverse was the situation.

6.6.19     As an example, when one looks at the time taken for Scott's
           representatives to arrive on site (and given the fact that they had all
           travelled from the one location), there was a clear indication that
           critical decisions regarding traffic management needed to be made
           sooner than later. This aspect alone appears to have been missed or
           not assessed for its informative value.

6.6.20     The Inquiry is of the view that Scott’s Transport took appropriate
           action as soon as the situation became known to them and attended
           the scene of the collision with a view to the well-being of their driver,
           the timely recovery of the fuel and the removal of the damaged tanker.

6.6.21     It is unfortunate that the pump unit did not accompany the Company’s
           first representative on scene. Indeed, it would have been ideal had it
           arrived with Scott's second on-site representative. There can be no
           other explanation other than it just did not happen. There was nothing
           malicious in this and it must be viewed in that light. Discussions with
           the General Manager, Bulk Tanker Division, Scott’s Transport, indicate
           that they have changed their Standard Operation Procedures to reflect
           more timely decisions in this regard. That approach is welcome.


     K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010             Page 57 
                                                

6.6.22        It is clear on this occasion that the delay experienced in the arrival of
              critical equipment to commence the decanting process, plus the
              distance over which the replacement tanker had to travel and the
              increasing traffic load, were all compounding factors in the overall
              resolution of the incident. Of these factors, and within the context of
              future incidents of this type, the issue of locating a replacement driver
              requires further discussion.

6.2.23        There needs to be debate on whether or not the replacement tanker
              should be sought from the company involved in the incident ( in this
              case Scott’s Transport) or, given a range of circumstances, that in the
              interests of all concerned and time, that a tanker be located from a
              closer source. This is an issue for further discussion by the RTA with
              the trucking industry, in particular, companies engaged in long-haul
              fuel cartage.

6.6.24        The Inquiry records its appreciation to the senior management of
              Scott’s Transport, Milperra, for their assistance to the Inquiry.

6.6.25        It is also relevant to note that in accordance with legal provisions,
              Scott’s Transport had in place a Transport Emergency Response Plan
              (TERP). That Plan and Scott’s report of the crash (which are additional
              legal provisions), are subject to further discussion and report between
              Scott’s Transport and the Department of Environment, Climate Change
              and Water, the oversighting agency in this regard. The TERP is
              provided at Attachment 6.

6.7           CARRIAGE OF FUEL AND DANGEROUS GOODS
              ON THE STATE’S ROADS.
6.7.1         A no less important issue emerges in the Inquiry's Report and it is
              appropriate that it be raised at this point.

6.7.2         Each day many thousands of vehicles carry a variety of fuels, gases
              and chemicals on the roads of NSW. These vehicles vary from those
              licensed and regulated by the RTA, and in mandated circumstances,
              those licensed to carry dangerous goods by the Department of the
              Environment, Climate Change and Water through their Specialised
              Regulation Branch.

6.7.3         Much has been done in recent years by both of the latter-mentioned
              agencies to ensure that registration and licensing requirements are met
              by companies and their drivers engaged in the transportation of
              dangerous goods on the road network. This work has been with the
              collaboration of the NSW Fire Brigades.



        K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010            Page 58 
                                                

6.7.4         Doubtless, there are a range of other vehicles (utilities and small table
              tops) using the State's roads which are not subject to the policing of
              the carriage of dangerous goods. Such goods may include chemicals
              and other substances that may be harmless in themselves, but with
              the possibility of being involved in a motor vehicle crash, they pose a
              potential hazard both to the safety and well-being of the drivers
              involved, the community and emergency service responders on the one
              hand, and on the other, to the environment.

6.7.5         The Inquiry notes the advice of the National Roads and Motorist's
              Association (NRMA) in its submission to this Inquiry that unlike
              European and United States experiences where volatile fuels are
              carried predominantly if not exclusively by rail, the Australian
              experience is that these hazardous materials are carried on the nation's
              roads. This issue is the subject of national debate. Again, Figures 15
              and 16, and the nominated web site illustrate the points made.

6.7.6         Notwithstanding the debate that is occurring and the level of current
              regulatory oversight, there exists the opportunity to continue to review
              how the safe carriage of fuels, gases and chemicals on the State's
              roads can be further enhanced. Such a review has the potential to
              bring a greater level of compliance and regulation not only by those
              within the industry, but as important, those who may sit outside of
              current oversight arrangements.

6.7.7         The obvious bodies to conduct such a review are those already
              engaged in the debate. It would be useful that the National Bulk
              Tankers Association and the Transport Industry Skills Centre be asked
              to contribute to these discussions. To this end, the Inquiry believes
              that the Director General, Transport NSW, is best placed to facilitate
              any proposed review, particularly, in this State.

              Therefore, the Inquiry recommends -

    RECOMMENDATION 19 -

    That the Director General, Transport NSW, chair an inter-agency
    Working Party to examine the registration, licensing and safety
    requirements of all vehicles engaged in the transportation and
    movement of dangerous goods (including fuels, chemicals and gases) on
    NSW roads.

6.7.8         It should be stressed in this Report that no blame for the crash on the
              F3 Freeway on 12 April 2010 is attributable to Scott's Transport or their
              driver. The Inquiry also understands that Scott's vehicle complied with
              the legal requirements (including its Transport Emergency Response
              Plan - Attachment 6) for the carriage of fuels.


        K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010            Page 59 
                                                

6.7.9         What also arose during the Inquiry's review were peripheral issues
              associated with the decanting of unleaded fuel from the damaged
              tanker.

6.7.10        For reasons outlined by the NSW Fire Brigades, close attention had to
              be given to all aspects of the decanting process. The Inquiry
              understands that this process involved the decanting of over 43,000
              litres of unleaded (and highly volatile) petrol through a 7cm or 3 inch
              spear located at the top of each compartment of the tanker, rather
              than through the normal outlet/inlet valve at the bottom of the tanker
              and which is understood to have been made inoperable by the crash.
              Notably, this fact alone explains the length of time taken to decant the
              whole of the tanker.

6.7.11        There can be no disputing the fact that in the lead up to the decanting
              process there were missed or misunderstood communications.
              Notwithstanding this fact every effort appears to have been made to
              decant the fuel from the damaged tanker in as timely a manner as
              possible, and within the requirements for the safe removal of
              hazardous materials. In saying this, the Inquiry notes the no less
              important issue that there appears to be no legislative standard
              regarding the decanting of fuel in these and like situations.

6.7.12        Accordingly, the Inquiry recommends that consideration be given by
              the abovementioned Working Party to the development of an
              appropriate standard for the decanting of fuel which includes, amongst
              other things, issues relevant to the governance of such arrangements,
              procedural guidelines for the effective decanting of fuel, appropriate
              equipment to be carried by the agent responsible for the decanting of
              the fuel, and the provision of relevant dress standards (including
              personal protective clothing). Equally, any such approach will need to
              take account of minimum standards of training.

6.7.13        Given their legislative responsibility for preventative work injuries,
              WorkCover NSW should also play an active role in any such review.

              Therefore, the Inquiry recommends that -
  RECOMMENDATION 20 -

  That the inter-agency Working Party convened by the Director General,
  Transport NSW, examine the requirement for a legislative framework
  and appropriate guidelines for the decanting of fuel from vehicles
  involved in motor vehicle crashes (or similar circumstances), and that
  such guidelines determine issues of standard operating procedures,
  appropriate clothing, equipment and training for personnel involved in
  such activity.


        K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010           Page 60 
                                         

RECOMMENDATION 21 -

That the Director General Transport NSW consider inviting WorkCover
NSW to join the Working Party.




 K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010    Page 61 
                                                    


 7.        THE PUBLIC INTEREST TEST.
 This Chapter examines the importance of meeting community expectations by addressing how
 agencies assess and meet the equally important and fundamental requirement of acting in the public
 interest.



7.0.1         Before turning to the role and actions of the RTA on 12 April
              2010, it is important to comment on two fundamental and inter-related
              requirements for public service, namely, meeting the community’s
              realistic expectations, and always acting in the public interest.

7.0.2         To varying degrees, one of the common issues that emerges in a
              review of motor vehicle crashes on the F3 Freeway over, say, the past
              decade (including those cited in this Report), is the common complaint
              of the inevitable delays caused to motorists on such occasions.

7.0.3         In fairness, meeting the community’s expectations has to be married
              against some equally complex issues. Indeed, as has also been noted,
              the uniqueness of the F3 Freeway compared to, say, other major
              roads, does, in part, compound the situation when dealing with the
              speedy resolution of traffic and road management issues.

7.0.4         Equally, for understandable reasons the very nature of some motor
              vehicle crashes will, on occasions, cause delays. Most fair-minded
              motorists and their passengers will understand that in some or all of
              these crashes an appropriate level of response is required from the
              emergency service organisations. These responses will be focused on
              attending and resolving a range of situations that ultimately go to
              saving lives and freeing the road for normal usage.

7.0.5         Indeed, in terms of the crash on 12 April 2010, there was an
              appropriate level of attention by SCAT Doctors and Paramedics to the
              injured driver of the table-top truck. The very nature of his injuries
              and the various treatment options required saw almost 2 hours elapse
              from the time of the crash until his eventual departure by air
              ambulance. During this time, the F3 Freeway was either closed or
              slowed, and traffic partly diverted via the Old Pacific Highway.

7.0.6         Similarly, and for reasons outlined in this Report, given the professional
              judgement and observations of the NSW Fire Brigades, there were
              compelling reasons to close the F3 Freeway as the issues leading up to
              and decanting of the fuel from the damaged tanker, were undertaken.




        K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010                    Page 62 
                                                

7.0.7         The actions of attending to the injured driver and the decanting of the
              fuel had one critical and important concept in mind – actions in the
              PUBLIC INTEREST.

7.0.8         It was in the interests of the injured driver that he receive professional
              help. Equally, it was in the best interests of the travelling public that
              they not be exposed to any danger through the potential for explosion
              and fire.

7.0.9         Indeed, members of the Fire Brigade told the Inquiry that had an
              explosion occurred, it may have caused a fireball and burning fuel to
              travel south down the north-bound lanes. Map 8 illustrates the
              topography of the crash site. The potential for loss of life both
              amongst the emergency service and RTA personnel on the scene, and
              motorists in the immediate area is a scenario too horrific to
              contemplate.

7.0.10        The Inquiry’s view is that in situations such as those experienced on
              the F3 Freeway on 12 April 2010, consideration of what was in the
              public interest, had to turn on what might be described as common
              well-being or general welfare. This approach is understandable. It is
              what the combat agencies do well.

7.0.11        In these situations the public's understanding revolves on their
              appreciation of what has happened and where; what is being done to
              resolve the situation; what level of intervention is required by which
              agencies; and if relevant, what is the nature and length of the delay
              that they face. These are not unreasonable questions to ask as they
              go to inform and allow those affected in such situations to make
              alternate arrangements and decisions, advise others of their situation
              and, if relevant, seek assistance.

7.0.12        This point is further illustrated in the Report of the Auditor General of
              NSW – "Managing Disruptions to CityRail Passenger Services (2005),"
              wherein he stated (at page 5) –

               “…providing clear, accurate and timely information is critical
              to ensure that passengers can choose the best alternatives to
              get to their destinations and minimise their inconvenience.
              Knowing what is happening may also prevent passengers from
              becoming too distressed”.

7.0.13        It is an equally important consideration that the flow of information to
              the public, in particular, those affected by such situations, needs to be
              timely and regular and not a one off that, say, the occasional traffic
              report or hourly news bulletin may offer via radio. Simply stated, the
              information flow has to be constant, it has to be informative and
              provide options. That is in the public interest.
        K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010             Page 63 
                                             


7.0.14     The Inquiry is of the view that the information flow to the travelling
           public on 12 April 2010 was not adequate, particularly, in its timing and
           detail. For some, it was too late in that they drove into the situation
           on the F3 Freeway and found themselves jammed or slowed by other
           traffic. They had no other option other than to sit it out.

7.0.15     A reasonable proposition exists that had many of those motorists been
           alerted to the situation earlier, they may well have been able to make
           a range of informed decisions, including alternate accommodation
           arrangements, travelling via train, or for some, diverting via the
           Wiseman's Ferry route. That would have been in the public
           interest.

7.0.16     That they were not adequately informed in a timely manner is not
           acceptable and is indicative of an absence of awareness of
           consequence management. This was not in the public interest.
           Indeed, the community’s reasonable expectations were not fulfilled on
           this occasion to the extent that they, the public, believed they were
           entitled to be advised.

7.0.17     This last point is further illustrated by the fact that agencies, in
           particular the TMC, knew of the situation and the issues that were
           evolving from its earliest point (about 11.40am), through to that point
           in time (and beyond) when the traditional traffic flow starts to build on
           the F3 Freeway from about 2.00pm.

7.0.18     Clearly, the information flow to the travelling public relating to the
           known or expected length of the delay on the F3 should have
           commenced earlier than it did and been regularly maintained. To do
           so would have been in the public interest, and, as mentioned,
           would have met the not unreasonable expectations of the community.

7.0.19     On 12 April 2010 the responsibility for effective, ongoing and
           meaningful communications with the public relating to roads
           and traffic management, rested with the Traffic Management
           Centre and the Corporate Communications Group of the RTA.

7.0.20     The Inquiry comes to the conclusion that it is better to over warn,
           which then allows for a range of travel and personal options; than have
           warnings that are infrequent, inadequate or not warn at all.

7.0.21     It is open to discussion that had appropriate assessments been made
           of the traffic and road management issues (based on known
           intelligence), an approach to the State Rail Authority for additional
           trains both on the evening of 12 April 2010, and for the return journey
           on 13 April 2010 (particularly for Central Coast and Newcastle
           travellers), would have been in the public interest.
     K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010            Page 64 
                                             

7.0.22     As with past experiences, the Inquiry believes that on 12 April 2010, a
           number of motorists found themselves land-locked and unable to
           progress their journey. Anecdotally there were reports that motorists
           and their passengers (including the elderly and children) found
           themselves without water or other sustenance.

7.0.23     From a health perspective it is fortunate that this crash did not occur in
           the warmer months when the internal temperatures of vehicles, in
           particular, those in a stationary position, would have been much higher
           and potentially, the consequences more serious.

7.0.24     It would also be a reasonable assumption that some travellers would
           also have been in need of medication (located in another place), or
           simply in need to travel further north to, say, pick up children. Equally,
           many of those affected by this situation would have been in need of
           toilet breaks, or whose vehicles were low on petrol or in a poor
           mechanical state.

7.0.25     Each of these scenarios would have been exacerbated by the length of
           time that motorists were delayed, and the length of the time that it
           took for them to progress their forward journey. Understandably, for
           some there may well have been issues of physical discomfort, and at
           the same time, issues of stress and anxiety for others. Clearly, none
           of these aspects were in the best interests of affected
           individuals.

7.0.26     The Inquiry kept returning to the issue of more effective
           communications and addresses this aspect through a number of
           recommendations in its Report. Equally, with the requirements for
           improved communications - as outlined in the"F3 Incident
           Management Improvement Program" (May 2010)- Attachment
           7, there exists an opportunity to not only learn from the issues of the
           past, but make some meaningful change. The realisation of the
           Program is in the public interest.

7.0.27     In terms of the partial ineffectiveness of communications with the
           motoring public, the Inquiry believes that there can be no plausible
           reason for what occurred on the 12 April 2010. This is further
           highlighted in the area of the provision of water or light sustenance to
           stranded motorists and passengers. Indeed, it was one of the key
           points in the Government’s eight-point Plan - Attachment 1,
           announced on 16 March 2008 and was the functional responsibility of
           the RTA to initiate.

7.0.28     Notably, it is this same 2008 Plan - Attachment 1, that would have
           seen the NSW State Emergency Services (SES) engaged to deliver and
           supply water. In fact, the SES was not contacted or engaged by the
           RTA. This was not in the public interest.
     K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010             Page 65 
                                             


7.0.29     It is with a touch of irony that the Inquiry notes that the provision of
           water to motorists in situations like that of 12 April 2010, is again
           identified as a key strategy in the "F3 Incident Management
           Improvement Program - Attachment 7". As agreeable as it is that
           this should be identified as a key action item for the future, it had been
           similarly identified in 2008.

7.0.30     The Inquiry’s observations again underscore the point that had
           decisions been made to consider the principles and the provisions of
           the State Emergency Rescue Management (SERM) Act, it may,
           amongst other things, have allowed the State Emergency
           Operations Centre (SEOC) to be opened. In turn, this would have
           allowed the establishment of the Public Information Functional Area
           Command (PIFAC), located within the SEOC to commence media and
           public communications, liaise with agencies like State Rail for additional
           trains and maintain them until cessation of arrangements. That this
           was not done was not in the public interest.

7.0.31     Equally, and had it occurred, it would have been open to the SEOC to
           facilitate the distribution of water and sustenance, whilst those
           engaged in the resolution of the crash and related matters got on with
           their various tasks. That would have been in the public interest.

7.0.32     As already noted, in lieu of the opening of the SEOC, it would have
           been appropriate to have opened the POC, Sydney.

7.0.33     On this occasion, there can be no dispute that the fundamental test of
           acting in the public interest failed when it came to the provision of
           timely information and integrated transport and road management
           arrangements. Clearly, there were opportunities lost.

7.0.34     Therefore, there can be no disagreement that one of the most
           important requirements of public service, namely, meeting the
           community’s reasonable expectations, was not realised to the extent
           that it should have on this occasion. This was not in the public
           interest.

7.0.35     To this end the Inquiry is of the view that the provision of services to
           the public can be enhanced when the co-operation of other agencies is
           sought and provided.

7.0.36     Within the community, assistance of key agencies like St John
           Ambulance NSW (first aid, provision of water and welfare support), the
           NSW State Emergency Services (water, sustenance and general aid),
           the NRMA (water, sustenance, mechanical aid to stranded motorists),
           or dependant on the circumstances, one the charitable organisations


     K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010             Page 66 
                                                

              such as the Salvation Army (water and sustenance or welfare) are able
              to provide appropriate levels of service.

7.0.37        Each of the agencies mentioned are key agencies whose fundamental
              charter includes work in support of the community. The Inquiry’s
              discussions with these agencies confirmed that they would be more
              than willing to become involved in providing not only relevant services,
              but be part of the speedier resolution of such situations. To have this
              level of engagement would have been in the public interest on
              this day.

7.0.38        Ironically, based on past experiences the Inquiry notes that had the
              SEOC or the POC, Sydney, been operating, many, if not all of the
              abovementioned agencies would have been present.

7.0.39        Therefore, the Inquiry recommends that Transport NSW enter into a
              formal Service Level Agreement with each of the nominated agencies
              regarding the provision of welfare services and call-out procedures in a
              range of defined situations. That is in the public interest.

              Therefore, the Inquiry recommends –

   RECOMMENDATION 22 –

   That Transport NSW enter into a formal Service Level Agreement with
   St John Ambulance Australia (NSW), NSW State Emergency Services,
   and other private sector or charitable organisations such as the
   Salvation Army, to provide welfare support services (including the
   distribution of water and light sustenance) to stranded motorists at
   times of inordinate and lengthy delays on the F3 Freeway.




7.1           TIMELY AND ACCURATE PUBLIC INFORMATION
7.1.1         The Inquiry has noted that much of the frustration and concern of
              motorists, the media and the community relating to the response and
              recovery management of the F3 incident relates to the issue of timely
              and accurate communication.

7.1.2         For its part the RTA has indicated that Variable Message signage was
              utilised extensively on major arterial roads to forewarn motorists
              travelling towards the F3, commencing at 11.42 am. shortly after the
              collision, with progressive updates throughout the day at 11.57 am.,
              12.16 pm., 12.24 pm.(citing expect delays), 17.50 pm., 17.58 pm.
              (advising F3 closed), 18.26 pm.( advising avoid area), and thereafter

        K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010           Page 67 
                                                

              during the remainder of the night when the contra-flow eventually
              commenced.

7.1.3         Similarly the RTA ‘s Incident Reporting Internet Service (IRIS) was
              operational and utilised to advise motorists prior to commencing their
              journey, and interactive voice recording messages were available to
              motorists who called to advise expected delays (12.10 pm.) and to
              expect significant delays (14.49 pm.).

7.1.4         Additionally, media advice on the status of the incident was provided to
              commercial radio by each of the various services (Fire Brigade, NSW
              Police and the RTA), with the RTA required to take greater involvement
              as the issue regarding the incident moved from extraction of the
              injured driver, safety and security of the incident crash site, to the
              expected delays to the traffic and thereafter the decision to not
              introduce contra-flow arrangements.

7.1.5         What remains questionable was the adequacy of communication and
              information services provided by the RTA to the motorists diverted
              onto the Old Pacific Highway and queued in the 20 km traffic backlog
              on the F3 in the afternoon peak, and the availability of the information
              relating to any expected or estimated time to travel on this alternate
              route during the diversion process.

7.1.6         Clearly there was significant confusion and unclear communication
              regarding the expected time for clearance of the crash site incident,
              not only on the ground, but also within the RTA TMC and with RTA
              senior management.

7.1.7         At 3.09 pm the RTA TMC spokesperson in a media interview on radio
              2GB indicated he “expected the F3 to be closed to traffic this evening
              due to the incident”. However, according to further RTA advice
              provided during the course of the Inquiry, a senior RTA executive is
              reported as indicating to the TMC at 3.30pm that it was still expected
              the freeway would be cleared by 5pm”.

7.1.8         Critically NSW Fire Brigade automatic message alert provided to all
              media at 17:27 pm. advised of the expected 4 to 6 hour delay in
              clearing the road. This message had been confirmed after advice from
              the on scene commander at 17:20 pm. that the fuel decanting process
              would take 4-6 hours once the truck arrived.

7.1.9         Live media interviews were being followed up on radio by
              Superintendant Ian Krimmer, NSW Fire Brigade media (2GB at 17:37,
              17:41 ABC), advising of the need to decant 43 000 litres of fuel, and
              with the expected delay of at least 4 to 6 hours. That same advice was
              provided to RTA media at 17:44 pm. regarding the decanting delays
              and the 4-6 hour timeframe.
        K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010           Page 68 
                                                

7.2           THE NEED FOR AN EFFECTIVE MEDIA INCIDENT
              MANAGEMENT STRATEGY
7.2.1         Every organisation has the potential to be scrutinised by the media and
              the public, and should be so prepared.

7.2.2         An organisation’s reputation or brand is one of its most important
              assets and in this regard the RTA represents one of the NSW
              Government’s most recognisable brands.

7.2.3         Whilst major traffic incidents similar to those which occurred on 12
              April 2010 cannot always be avoided, with appropriate preparation
              they can be managed. An operational crisis, well handled, doesn’t have
              to escalate to the point of becoming a public relations disaster.

7.2.4         Put simply, a media incident management strategy is generally
              prepared and used to ensure the public is informed about the incident,
              provide the community safety actions, and maintain public trust and
              confidence that the incident is being managed effectively.

7.2.5         Ideally this should address and build:
              • confidence by the community that agencies are effectively working
                 together in the response effort;
              • a positive understanding of the response, recovery and mitigation
                 programs in place;
              • appropriate access to information about the incident to all target
                 audiences; and
              • the maintenance of communication with those affected by the
                 incident.

7.2.6         The Inquiry has noted that on 12 April 2010 frustrated motorists were
              relaying advice on the impact of the delay direct to the afternoon
              media announcers via mobile phone reports from the scene of the
              traffic queue. This included the lack of adequate communication and
              information regarding the expected delay or circumstances relating to
              the accident.

7.2.7         The changes in news technology and demands of the public for instant
              information place significant pressure on the media to present timely
              information.

7.2.8         It would appear that the absence and inability of the RTA to control
              and provide adequate advice to the media (ie; preparedness for an
              incident of this nature) considerably fuelled the groundswell of
              negative community and media response to the efforts of both the RTA
              and emergency services agencies.


        K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010          Page 69 
                                                

7.2.9         Whilst much has been made of the media negativity / response to the
              Government’s and in particular RTA’s handling of the incident, advance
              media management preparation for incidents and crises of this nature
              by the RTA as the lead agency responsible for traffic management on
              the State’s road network, should have been actioned.

7.2.10        In particular, this would have afforded the opportunity to better keep
              the motorists informed of developments and in particular the positive
              efforts of emergency services at the scene, but it could also have
              mitigated the eventual the public relations disaster.

7.2.11        On the balance, it is the view of this Inquiry that this was a
              fundamental flaw in the RTA’s preparation for any major F3 incident for
              which there appears no valid reason, other than possibly oversight or
              capability.

7.2.12        Notwithstanding the latest renewed commitments by the RTA to
              enhance traveller information to provide enhanced readily accessible
              information to the travelling public involved in incidents, it is
              considered Transport NSW is better placed to lead, direct and ensure a
              future coordinated transport major incident media management
              strategy is developed and in place which addresses the needs of the
              travelling public.

7.2.13        In this event, the resources of the RTA media and communications unit
              should be utilised to support the direction of Transport NSW.




        K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010          Page 70 
                                                     


 8.       THE ROADS AND TRAFFIC AUTHORITY OF NSW –
          AN ORGANISATIONAL PERSPECTIVE.
 This Chapter seeks to examine the functional roles of the Roads and Traffic Authority and the Traffic
 Management Centre, Redfern. It also comments on one of the RTA’s major road incident
 management strategies, contra-flow. It examines the role of the RTA and the TMC on 12 April 2010,
 the application of the contra-flow policy, and the response to the crash by the Chief Executive and
 the RTA, both immediately after and in the post crash period. It also examines the role of the then
 Minister for Transport and Roads on the day.



8.0.1         The Inquiry has noted the NSW Parliament has recently approved the
              Transport Administration Amendment Act thereby creating the new
              Government department super agency, Transport, NSW. By the
              carriage of the Act, a number of public transport-related service
              agencies are now captured under one organisation (or super-agency)
              and under one accountable departmental head, the Director General,
              Transport NSW.

8.0.2         Notwithstanding the new legislative provisions, the Inquiry notes that
              on 12 April 2010, the RTA was a Government statutory authority of
              New South Wales. The RTA is constituted by virtue of the Transport
              Administration Act 1988. Primarily, that the Act provides for the
              management and function of the RTA       (and     other     nominated
              Authorities) and further provides for the administration of public
              transport in New South Wales. The RTA was formally established in
              1989.

8.0.3         A number of ‘complementary’ Acts also provide for the function,
              administration and enforcement of laws pertaining to the use of roads
              and motor vehicles in NSW.

8.0.4         At the time of the motor vehicle crash on the F3 Freeway on 12 April
              2010, the RTA was accountable to the Minister for Roads and
              Transport. The Inquiry also notes the more recent decision of the
              Government of 20 May 2010 to separate the Roads and Transport
              portfolios into two distinct Ministerial portfolios.

8.0.5         On 12 April 2010, the Minister had responsibility for setting the policy
              of the RTA (in accordance with the agreed directions of Government),
              and ensured fiscal responsibility and accountability of the agency.
              Day-to-day management and leadership of the RTA was vested in a
              Chief Executive (Mr Michael Bushby).

8.0.6         By any standards, the RTA is a large and diverse organisation. As at 30
              April 2010, it employed at total of approximately 8000 full time
              equivalent staff and in a range of diverse metropolitan and rural
        K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010                       Page 71 
                                                

              locations within NSW and it has a current annual roads budget in
              excess of $4 billion p.a.

8.0.7         Whilst the RTA provides a range of services it is most publically
              recognised for its licensing of over 5 million licence holders and the
              registration of over 5 million vehicles in this State. It also has
              responsibility for the effective management of the State’s road system.
              An organisational chart of the Authority is at Attachment 9.

8.0.8         The RTA is headed by a Chief Executive whose duties are described as
              having a number of core responsibilities, in particular, the general
              conduct and effective, efficient and economical management of the
              functions and activities of the (Authority). (Attachment 8).

8.1           THE TRANSPORT MANAGEMENT                                   CENTRE,
              REDFERN – ROLE AND FUNCTION.

8.1.1       As has been noted in the Inquiry's Report, two of the key performance
            requirements of the RTA’s functions, are the effective management of
            traffic and, as important, the road network throughout NSW.

8.1.2       Critical to meeting these requirements is the delivery of services through
            the RTA Transport Management Centre (TMC), which is located at
            Redfern. Co-located within the TMC is the Transport NSW Transport Co-
            ordination Group (TCG) whose functional responsibilities are later
            described.

8.1.3       The TMC is a state-of-the-art transport monitoring facility. The TCG also
            monitors other modes of rail, bus and water transport, with its primary
            focus being that of road management. The TMC monitors and manages
            the State’s 180,000 km road network 24 hours per day, 7 days per week.

8.1.4       The Inquiry was advised that the TMC provides three core services –

                  •   traffic management of incidents and events;
                  •   traffic information; and
                  •   network operations (including traffic signals, variable message
                      switching signs, movable median strips, pedestrian access and
                      bus priority systems).

8.1.5       Importantly, one of the key functions of the TMC “…is to provide
            accurate and timely information to motorists to ensure they can
            make the best travel decisions”. This point noted, the Inquiry is left
            to wonder how the issues raised at Chapter 7 (pp 62-67) of its Report,
            occurred. As history now records, it was the aspect of timely and


        K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010           Page 72 
                                                

            effective communications, which proved to be a crucial aspect of
            motorist’s dissatisfaction in the events of 12 April 2010.

8.1.6       In addition to meeting its core services, the TMC has a number of key
            performance responsibilities including –

              •   Events Management;
              •   Administration and Operational Support;
              •   Transport Operations;
              •   Emergency and Operations Planning;
              •   Systems (IT; Radio; Video; Engineering; Computers and Traffic
                  Networks – amongst others);
              •   Strategy and Performance;
              •   Transport Operations System;
              •   Network Operations, and
              •   Marketing and Communications.

8.1.7         The TMC is under the functional control of an experienced and
              qualified General Manager (who on 12 April 2010 was on annual leave
              and overseas).

8.1.8         A more detailed document on the role of the TMC is at Attachment
              10.

8.1.9         To complement the work and operational expertise of the TMC, there
              are a number of external Liaison Officers within Transport Operations
              who are drawn from the NSW Police Force and State Transit Authority.
              The Inquiry has noted the clear benefits of these Liaison Officer
              arrangements and believes that a case can and should be made for
              additional secondments to the Liaison Officer role, particularly, from
              other relevant state-based agencies. This aspect is covered elsewhere
              in this Report.

8.1.10        To further enhance the role of the TMC, the RTA has established a
              Road Safety and Traffic Management Centre (RSTMC), Hunter Region.
              The Centre is based at Newcastle and although a smaller operation
              than its Sydney-centric counterpart, it performs a range of
              complementary and similarly important functions.

8.1.11        Organisational charts for the TMC, Redfern and the RSTMC, Hunter
              Region, are at Attachments 11A and 11B.

8.1.12        As with every Government department, authority and instrumentality,
              the RTA, and specifically, the TMC, has a range of relevant policies,
              guidelines and operating procedures. To list them all, the Inquiry
              believes, would be extensive. It is, however, pertinent to this Inquiry
              (and its Terms of Reference) to note a number of key and related


        K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010          Page 73 
                                             

           policy papers that have relevance to the functional responsibilities of
           the RTA, and, importantly, the TMC. These include –


           1.     Use of RTA Traffic Management CCTV Cameras;

           2.     Use of Variable Speed Limit Signs;

           3.     Traffic Management of Unplanned Incidents;

           4.     Changes to Traffic Signal Settings;

           5.     Communicating Major Incident Information to Stakeholders;

           6.     The role of RTA Traffic Commanders in the Management of
                  Unplanned Incidents;

           7.     Regional Traffic Commander’s Structure and Conditions;

           8.     Legislative Support for Traffic Commander Operations;

           9.     Guideline for Driving Emergency Vehicles;

           10.    Traffic Emergency patrols in Traffic Management of Unplanned
                  Events;

           11.    Issuing RTA GRN Radios to Highway Patrol;

           12.    Communications for the Traffic Arrangement of Incidents;

           13.    Radio Communications with Traffic Emergency Patrols;

           14.    Disposal of Dangerous Goods on RTA Roads;

           15.    Displaying Manual Messages on VMS (Unplanned Incidents);

           16.    Traffic Management of Unplanned Incidents;

           17.    The Traffic Commander, Operations; and

           18.    Guidelines for determining a Major Disruption.


           Each of these policy statements is at Attachment 12.

8.1.13     Given the genesis of this Inquiry and having regard to its Terms of
           Reference, the Inquiry turned particularly to two additional policy
           documents, namely –
     K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010           Page 74 
                                             


           •   "F3 Sydney to Newcastle Freeway Traffic Management Plan
               for Incidents 2005 (Wahroonga to Beresfield)";
               (Attachment 3); and

           •   Policy and Procedure for Contra-Flow Traffic Management –
               F3 Freeway". (Attachment 14)

8.1.14     An additional document “F3 Freeway Incident Management
           Infrastructure Project”, dated 5 March 2010, is also instructive.
           (Attachment 15).

8.1.15     Given the critical role of the TMC (and the policy documents and
           guidelines that go to support its functional response arrangements),
           the Inquiry believes that each of the documents (Documents 1-18
           above, and Attachments 3, 14 and 15) should be viewed both as a
           ‘back-drop’ to the events that unfolded on 12 April 2010, and to the
           response requirements for the management of such incidents. It is
           therefore against these various policies (and related documents) that
           the Inquiry has sought to assess the performance of the RTA, in
           particular, the TMC on 12 April 2010.

8.1.16     As mentioned, it is not possible to consider the role of the TMC without
           considering the parallel role of the Transport Co-ordination Group
           (TCG) as it is co-located within the same complex as the TMC.

8.1.17     The composition of the Transport NSW TCG comprises representatives
           drawn from other transport providers (within the State framework).
           These include:

           •      State Rail Authority;

           •      Sydney Ferries;

           •      State Transit Authority; and

           •      the RTA.

8.1.18     The primary functions or responsibilities of the TCG include the
           provision of rapid response to incidents, to improve the daily
           movement of commuters, and the management of the morning and
           afternoon peak travel flows in the same way as special events are
           managed. The TCG is also responsible for providing streamlined
           communications to the travelling public.

8.1.19     Presently, whilst the TCG reports directly to Transport NSW, the
           General Manager, TMC reports to the RTA Director, Network
           Management, who in turn reports to the RTA Chief Executive.


     K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010           Page 75 
                                             

8.1.20     Over the course of this Inquiry it was unclear as to the role of the RTA
           Director, Network Management vis a vis the RTA Chief Executive in
           relation to the determination of contra-flow arrangements for the F3
           Freeway on the 12 April 2010. The General Manager, TMC, according
           to RTA Guidelines on Contra-flow management, is expected to liaise
           direct with the Chief Executive.

8.1.21     Notably, whilst the TCG is a separate functional body (located within
           the TMC), and is a complementary body to the TMC, it is a key
           provider in the overall effective management of transport in this State,
           as issues impacting on the rail, bus and ferry systems also have an
           impact on the road network and vice versa. There is a more than
           obvious need therefore for both of these critically important arms of
           transport and road management to work together in a cohesive and
           co-ordinated manner.

8.1.22     To assist in its day-to-day decision making regarding the effective
           management of the State’s road systems, the TMC is provided with a
           sophisticated network of CCTV cameras, on-road support staff in the
           form of RTA Traffic Commanders and in-the-field Response Teams.

8.1.23     To complement the role the TMC, TCG provides media coverage on a
           wide range of transport management (roads, trains, buses and ferry)
           issues for the information of the general public. Primarily, this is done
           through radio bulletins and news broadcasts.

8.1.24     In addition to those mentioned, other key staff provide a number of
           functional responsibilities, too. Amongst these are the external Liaison
           Officers mentioned above.

8.1.25     Presently, the NSW Police Force has two very experienced and well
           qualified senior Officers attached to the TMC. The personal and
           professional reputation of these Officers is high and they add
           considerable knowledge and expertise to the overall and effective
           management of road traffic.

8.1.26     So, too, the State Transit Authority has seconded Liaison Officers at
           the TMC and like their police counterparts they also enhance the
           day-to-day operations of the TMC and TCG.

8.1.27     These Liaison Officers perform a “can-do” role and facilitate much
           needed interaction with their parent organisations.

8.1.28     That said, the Inquiry is clearly of the view that additional Liaison
           Officers drawn from other agencies should be appointed to the TMC.
           Such appointments need not be on a fulltime basis, rather, when and
           as emergency or particular circumstances arise. This point is further
           emphasised given the immediate proximity of the Ambulance Service
     K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010            Page 76 
                                             

           to the TMC (next door), and the NSW Fire Brigade Academy nearby at
           Zetland. The Inquiry is of the view that such appointments would
           enhance the quality and speed of communications in and across
           agencies.

8.1.29     This issue has been identified by the relevant agencies and is an
           important element within the "F3 Incident Management
           Improvement Plan" - Attachment 7. The Inquiry recommends
           that discussions with the NSW Fire Brigades, Rural Fire Service of
           NSW, the NSW State Emergency Services and the Ambulance Service
           of NSW (with a view to the appointment of additional Liaison Officers
           to the TMC), be finalised as a priority.


           Therefore, the Inquiry recommends –


    RECOMMENDATION 23 –

    That the Director General, Transport NSW expedite discussions with the
    NSW Fire Brigades, Ambulance Service of NSW, NSW State Emergency
    Service and Rural Fire Service of NSW regarding the appointment of a
    senior, qualified Liaison Officer TMC, Redfern for each of these services.




     K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010        Page 77 
                                                


8.2           CONTRA-FLOW – THE PRINCIPLE AND ITS
              APPLICATION TO TRAFFIC MANAGEMENT.

8.2.1         Whilst the term and use of contra-flow has a formal meaning and
              application, there is a degree of misunderstanding as to its practical
              application. It is not as may be believed as simple as diverting vehicles
              from one side of the road to the other.

8.2.2         The RTA advise that “…Contra-flow traffic management generally
              refers to the use of the opposite carriageway of a dual carriageway
              road for the purpose of managing traffic impacted by a major blockage
              of the primary carriageway”. Its practical and simplest form of
              application can be seen on a daily basis on the Sydney Harbour Bridge
              and Southern Cross Drive (near the Airport tunnel), albeit, that
              compared to the F3 Freeway contra-flow requirements of 12 April
              2010, these locations are much shorter and far more manageable in
              their conduct.

8.2.3         The implementation of contra-flow is governed by, amongst other
              things, the existence of pre-approved Incident Response Plans, the
              existence of cross-over facilities on the affected roadway (which meet
              contra-flow arrangements), and the existence of minimum prevailing
              conditions, namely, high traffic volumes, major closures (of the
              roadway), and extended or protracted duration of any closures.

8.2.4         Before contra-flow is approved for implementation, alternative traffic
              management strategies are considered. These include suitable
              alternate routes (with adequate capacity to carry the traffic load); use
              of shoulder or breakdown lanes (if available and not being used by
              emergency service vehicles); and interchange on/off ramps.

8.2.5         For the sake of agreeable safety precautions, the RTA’s Policy
              Guidelines "Policy & Procedure for Contra-flow Traffic
              Management – F3 Freeway" – Attachment 14, specify that
              contra-flow operations generally should be restricted to a maximum
              length of 4 kms. This distance can be extended provided sufficient
              human and physical resources to manage the contra-flow are present
              and in place when introduced and activated.

8.2.6         For understandable safety reasons, speed limits during the conduct of
              contra-flow ideally are also restricted to 40 kph. This is both for the
              safety of drivers, the RTA personnel and Police Officers involved in its
              operation. The added dimension of darkness further highlights the
              need for safety.



        K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010            Page 78 
                                                

8.2.7         The decision to introduce contra-flow is one not taken lightly and due
              regard is given to the possibility of a secondary crash occurring on the
              roadway on which the contra-flow arrangements are running. In this
              regard a secondary crash would most likely have the impact of a total
              closure of the road in both the primary direction and in the contra-flow
              direction.

8.2.8         To assist in deliberations regarding the decision to implement and
              introduce contra-flow, a detailed check list is completed by the Duty
              Chief Traffic Operations Controller, TMC.

8.2.9         It was the Guidelines within the Policy and Procedure that governed
              whether or not contra-flow should be introduced on the F3 Freeway on
              12 April 2010, and the timing and implementation of those
              arrangements. That said, the Inquiry noted that on 12 April 2010 the
              ultimate approval to implement contra-flow was given by the Chief
              Executive, RTA at 6.30pm. The eventual implementation time of
              commencement was at 8.47pm that evening.

8.2.10        Finally, given the not inconsiderable debate about contra-flow and its
              application to particular circumstances, the Inquiry notes at point 7.8
              of the F3 Incident Management Improvement Program 2010 –
              Attachment 7, that it is intended that “…protocols (have been)
              introduced whereby the Duty Chief Traffic Operations
              Controller recommends to the General Manager, TMC the
              course of action (contra-flow or no contra-flow) to manage
              major or significant F3 incidents. This proposal appears
              appropriate and practical.

8.2.11        The document further indicates that "...(the) GM, TMC liaises with
              the CE and directs action to be taken in relation to contra-
              flow”.

8.2.12        The Inquiry particularly notes at point 7.8 (of that Program) that liaison
              is to be had direct with the Chief Executive. If the issue and
              recommendations in Chapter 9 (9.1.1-9.35) are not to be adopted, so
              then this aspect needs to be reconsidered and reference to such
              matters ought to rest with the Director, Network Management (to
              whom the General Manager currently reports) and who, dependent on
              the circumstances, is well placed to advise the Chief Executive.

8.2.13        The Inquiry does not down play the role that contra-flow has in traffic
              and road management issues, however, tactical considerations as to
              implementation and introduction of contra-flow ought to be made
              where they are best able to be made, namely, by the General
              Manager, Transport Management Centre. The Chief Executive has a
              range of other strategic issues on which to focus.


        K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010             Page 79 
                                                 

8.3           THE ROLE OF THE RTA AND THE TRANSPORT
              MANAGEMENT CENTRE ON 12 APRIL 2010.
8.3.1         When considering the events of 12 April 2010, a number of parallel
              operating decisions need to be considered, including, those taken by
              the emergency services agencies and Scott's Transport. The Inquiry
              has highlighted these issues at chapters 5-8 of this report.

8.3.2         Equally, the decisions of the Roads and Traffic Authority (RTA) on 12
              April 2010, have to be viewed against a background of inter-related
              policy positions and historical events (1999-2009) as well.

8.3.3         It is for the same reasons that the decisions taken or not taken on that
              day must be viewed within a framework of timely decision making by
              the RTA, both through its senior corporate managers and the actions
              of senior operational personnel at the Transport Management Centre
              (TMC), Redfern.

8.3.4         The Inquiry reaffirms the view that by any accepted legal and
              procedural definition, the RTA has functional and managerial
              responsibility for the public roads of this State. Clearly, this was the
              case on 12 April 2010.

8.3.5         To assist in the discharge of its legal and functional responsibilities, the
              RTA is supported by a number of key State agencies including the NSW
              Police Force, NSW Fire Brigades and the Ambulance Service of NSW.
              In addition, in times of particular disaster or crisis, the functional roles
              and responsibilities of other key agencies such as the NSW State
              Emergency Services and Rural Fire Service of NSW, are also crucial to
              the speedy resolution of issues impacting on the road and transport
              systems.

8.3.6         To assess events of 12 April 2010 it was important to the Inquiry’s
              review that it be informed both by interviews and documentation.

8.3.7         The Inquiry has considered the “RTA Report – F3 Incident 12 April
              2010” - Attachment 16. Whilst this document is not authored or
              signed it is understood to have been prepared by officers of the RTA,
              including the Chief Executive, and formed the basis of the submission
              of the Chief Executive, Mr Bushby to Government on 13 April 2010.

              This document can be viewed in two parts.

              Firstly, it provides a synopsis of events of 12 April 2010 (albeit from
              the RTA’s perspective). Secondly, the document contains a number of
              observational comments and recommendations for the future
              management of similar incidents (pp5-8).

        K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010              Page 80 
                                                


8.3.8         Whilst some of the recommendations raised in the Report are outside
              of the Terms of Reference of this Inquiry, they remain nevertheless
              matters for the RTA to further consider and provide position papers
              and recommendations to Government through its newly created
              ‘parent’ agency, Transport NSW.

8.3.9         The latter-mentioned recommendations include proposed major
              infrastructure and structural projects, and serviceability and availability
              of transport services, most notably, ferry services at Wisemans Ferry.
              Other recommendations within the RTA's document have been
              addressed within this Report or by the actions of agencies, in
              particular, Transport NSW and the RTA since the events of 12 April
              2010.

8.3.10        Turning to the synopsis of issues raised in Attachment 16, a range of
              operational issues relevant to 12 April 2010 are indicated. The Inquiry
              has added its comments in italics. The issues include –

                  a. Confirmation as to the time, date and place of the collision -
                     (consistent with the COPS Event);

                  b. The crash initially closed all three northbound lanes of the F3 -
                     (in fact NSW Police advise that only 2 of 3 lanes of the
                     F3 were closed from 11.52am until 12.12pm when the
                     helicopter arrived);

                  c. The NSW Fire Brigade advised the RTA that fuel from the
                     crashed tanker would need to be decanted before the site could
                     be cleared - (advice was provided as early as 12.08pm
                     and was on the basis of information then known);

                  d. Advice to the general public was provided by variable message
                     switching signs and radio regarding the crash by the RTA/TMC -
                     (this proposition assumes that such arrangements were
                     an adequate form of communications with the public
                     either by their physical presence [signs] or by their
                     content [radio]);

                  e. The RTA/TMC was initially advised that the decanting process
                     was estimated to take one hour and be completed by 3.30pm
                     and...no advice to the contrary was received at the TMC until
                     6.27pm - when the TMC was advised by the Fire Brigade that 4
                     hours would be necessary - (Poor communications in and
                     from the field, were reflected in the quality and
                     timeliness of advice to the TMC. In turn, this impacted
                     on key considerations for the implementation of contra-
                     flow. Equally, critical intelligence, which would have
        K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010             Page 81 
                                        

             gone to more effective decision making by the TMC,
             appears not to have been considered) ;

          f. As a consequence of the initial advice that decanting would be
             finished by 3.30pm, the need for contra-flow arrangements
             were discussed but eliminated by the RTA - (notwithstanding
             the view of the CE that contra-flow would need to be
             determined by 2pm to take account of the afternoon
             peak flow, the decision not to introduce contra-flow was
             based on the fact that the earlier implementation of
             contra-flow by the TMC did not fit within the approved
             RTA Guidelines and their checklist assessment. This
             approach represents a degree of rigidity in thinking.
             That said, from the RTA’s perspective, it is their view
             that had they been further alerted to the issues
             surrounding the timeframe for decanting the fuel load,
             they would have made the decision to implement
             contra-flow at about 3.30pm with its actual
             implementation at about 5.30pm);

          g. The decision to implement contra-flow was vested in the Duty
             Chief Traffic Operations Controller (DCTOC), TMC, and is only
             made following the completion of the relevant checklist and
             advice from professionals in the field - (these Guidelines,
             which are outlined in the "Policy for Procedures for
             Contra-flow Traffic Management - F3 Freeway", require
             the Duty CTOC "...to gauge senior management support
             for the implementation of contra-flow”. Notwithstanding
             this requirement, the decision to implement contra-flow
             was only made following the intervention by the Chief
             Executive almost 7 hours after the crash. There was an
             unacceptable delay in the decision making processes by
             the TMC, and this situation was a critical and
             compounding one);

          h. The first of Scott’s Transport vehicles on site did not have
             suitable fuel pumps on board - (clearly it would have been
             preferable had the pump unit arrived earlier than it did.
             The key issue here is the fact that whilst there was an
             expectation that the replacement tanker would
             complete its decanting task by 3.00pm - 3.30pm; in
             reality, the pump wasn't even on site by this time. From
             an intelligence perspective and a decision making
             perspective (regarding introduction of contra-flow), the
             Inquiry wonders how this critical fact was not further
             considered);



K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010        Page 82 
                                        

          i. The third of Scott’s vehicles arrived at 5.45pm to begin removal
             of fuel from the damaged tanker - (this was the pump unit
             for the decanting tanker and whose progress had been
             impeded by building traffic);

          j. NSW Fire Brigade advised the TMC that they had revised the
             time estimate to remove the fuel load to 4 to 6 hours (there is
             conjecture between the agencies as to the manner in
             which this information was conveyed, and when it was
             provided. The genesis of the decision to decant 7 or the
             8 fuel compartments came after more detailed
             inspection of the damaged tanker by Fire Brigade
             Officers and Scott's representatives);

          k. At 6.30pm “due to new advice” it was agreed that contra-flow
             arrangements would be put in place - (for everyone but the
             RTA this appears to have been old news. By this time
             important recovery opportunities, most notably the
             earlier introduction of contra-flow based on other
             intelligence sources, appears to have been not
             considered);

          l. After putting contra-flow arrangements in place, it was
             eventually introduced at 8.48pm - (about 9 hours after the
             first report of the crash, and about 5 hours after the
             mooted decanting process was to have been completed
             and the F3 Freeway opened);

          m. The contra-flow extended over almost 10 kilometres from
             Cowan in the South to Mount White in the north - (this proved
             to be the nation’s longest contra-flow and well outside
             of the RTA's Guidelines which have a maximum distance
             of 4 kilometres. South bound traffic had been diverted
             at Mt White and re-entered the F3 Freeway at Berowra.
             When implemented it was in darkness – an added
             feature of concern for all involved. It is also clear that
             had contra-flow been introduced earlier than it was,
             then its conduct would have been in periods of greater
             daylight);

          n. The TMC Media Officer (who is located within the TCG) advised
             metropolitan radio stations of the diversions and delays at about
             3pm - (past records on normal traffic flows (particularly
             during school holidays), and a history of not dissimilar
             incidents on the F3 Freeway that delays were going to
             be inevitable, should not have come as startling news.
             In fact, it was to be expected. Clearly, traffic was
             building from the time of the crash at 11.40am and this
K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010           Page 83 
                                             

                  build-up was further compounded when the F3 Freeway
                  was first closed from 12.12pm on the arrival of the Air
                  Ambulance, until its departure at about 1.40pm. There
                  was a growing bank of information and intelligence that
                  should have gone to more timely and effective decision
                  making within the TMC).

8.3.11     The advice of the RTA of 13 April 2010 seeks to record the fact that
           the timing of the decision to implement contra-flow (together with its
           actual implementation), was always dependent upon the advice of the
           emergency services, in particular, the NSW Fire Brigades. In principle,
           the Inquiry can understand the Authority's approach when having
           regard to the professional skill and knowledge of the Brigades.

8.3.12     Notwithstanding this point, there is conjecture between the RTA and
           the NSW Fire Brigades as to the timing, manner and referral of
           information to the TMC on 12 April 2010.            Fundamentally, the
           conjecture turns on this issue of the decanting process and specifically,
           when it was expected to have been completed (3.00-3.30pm) as
           opposed to when it was actually started (about 6.00pm). This point,
           the RTA believes, impacted their decision regarding the timing and
           introduction of the contra-flow arrangements.

8.3.13     Curiously, however, it seems incomprehensible that the TMC would
           have been unaware of the developing traffic problems. History,
           experience, traffic patterns, the fact that it was school holidays,
           communications from the field (however awkward they may have
           been), its system of CCTV and the immediacy of talk back radio reports
           would and should have been key factors in the decision to implement
           contra-flow earlier than when it occurred. The decision was the TMC’s
           to make and the essence of the issue was the timeliness of that
           decision.

8.3.14     To establish how this overall situation may have occurred, the Inquiry
           notes that shortly after the crash and following initial discussions with
           Scott’s Transport, assumptions were made about the departure and
           arrival of Scott’s replacement tanker and the pump unit (thought to be
           about 1.30pm).

8.3.15     It is now known that there were delays (based on legitimate reasons)
           in Scott’s Transport departure from their Milperra depot and arriving on
           site. It is no less important an issue to note that Scott’s Transport
           initial on-site advisers did not tow the all important fuel pump unit with
           them rather than, as was the case, having it arrive much later.
           Doubtless, this was also a compounding factor.

8.3.16     Equally, on the basis of first inspections of the damaged tanker, there
           existed the original intent by the Fire Brigade to decant one only
     K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010             Page 84 
                                             

           compartment of the damaged tanker (about 8,200 litres). The RTA
           received this initial advice. This position no doubt confirmed in the
           minds of some that the operation could be complete by 3pm –
           3.30pm.

8.3.17     As is now known, there were ongoing assessments both by the Fire
           Brigade and Scott’s representatives at the crash site that indicated that
           the damaged tanker was structurally compromised and that a
           decanting of the unleaded fuel would need to occur. This decision,
           made for a range of reasons, was to have a significant impact on the
           timely and overall resolution of the incident.

8.3.18     Clearly, there were discussions regarding the latter-mentioned position
           at the site. It is equally clear, that discussions regarding the position
           were not effectively communicated between some of the responding
           agencies or their representatives. This aspect might also be explained
           by the fact that there were four distinct command vehicles, as opposed
           to, say, one inter-agency Command Post.

8.3.19     Understandably, whilst there were ongoing field-based assessments of
           the overall site situation, there existed an equal need for continuing
           appraisal and validation of times, in particular, the actual arrival of the
           tanker and the pump unit and ever growing traffic management issues.

8.3.20     The Inquiry holds the view that this should have been done on a
           continual basis prior to the flagged arrival time, and, more so when the
           replacement tanker and pump unit were not on site by about 1.30pm
           and the intended decanting completed by the time of 3.00 – 3.30pm.
           As is already noted, the tanker arrived just before 3.00pm and the
           pump unit arrived at about 5.45pm with the actual decanting process
           starting after 6.00pm. There can be no doubt that critical decision
           making time, particularly as it related to the introduction of contra-
           flow, appears to have been mistimed.

8.3.21     These observations made, the Inquiry can only turn to the conclusion
           that there was a failure to manage the information, which led to a
           failure to manage the issues.

8.3.22     Parallel to the need for ongoing assessment and validation of what was
           occurring (assumed arrival – viz – non arrival of the tanker and pump
           by 1.30pm and completed decanting by 3.00-3.30pm) was the
           existence of critical information regarding related facts.

8.3.23     At the scene, initial decisions to decant one compartment of fuel were
           overtaken by further safety decisions to decant six of the seven
           compartments. Whilst made for sound reasons, the across-the-board
           communication of this decision appears mixed and poorly conveyed.


     K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010             Page 85 
                                             

8.3.24     Over and above what was occurring at the scene of the crash, other
           issues were a lot clearer and should have assisted in making a range of
           informed decisions, in particular, a more timely decision to implement
           contra-flow.

           Clearly, it was known to the RTA, in particular, the TMC that –

         a. the driver of the flat bed truck was seriously injured. Indeed, it took
            from 11.40am (the time of the crash) to about 1.40pm to extricate
            him from his damaged vehicle, stabilise him and remove him by air
            ambulance. Two hours had elapsed in this time alone. Traffic was
            beginning to build. Valuable intelligence.

         b. north-bound traffic was already commencing to build on the F3
            Freeway from the earliest time. Between the crash site and south to
            the Hawkesbury Interchange, the RTA’s advice was that between
            11.40am and 1.46pm traffic had queued for a distance of 3.1 kms.
            The RTA also advised that the traffic cleared in this section between
            2pm and 5.45pm. It then reverted to a 3.1 km queue between 6pm
            and 11pm. Valuable intelligence.

         c. south from the Hawkesbury Interchange (back to the commencement
            of the F3 Freeway), the traffic queue was 3 km (at 1.30pm), 4.5 kms
            (1.46pm), 10 kms (2.50pm), 13.5 kms (3.47pm), 20.1 kms (5pm), 18
            kms (7.30pm), 18 kms (8.48pm) and reduced gradually after contra-
            flow was implemented at 8.48pm to a nil queue at 11.55pm. Of
            itself, this was most telling intelligence and should have been
            part of an informed and more timely decision making
            process. Again, valuable intelligence. Figures 18 and 19 also
            illustrate this point (pp.117-118)

8.3.25     In addition, Police VKG advised the TMC via ICEMS at 3.30pm that
           traffic south of the Hawkesbury Interchange was already 4 kms long.
           This distance is at variance with the reported traffic queues of 10 kms
           at 2.50pm, and 13.5 klms at 3.47pm. That noted, it is fair to say that
           whatever the distance, there was clear and unambiguous intelligence
           that traffic was building and that its management was becoming
           problematic by the hour.

           These issues are highlighted at Attachment 17A.

8.3.26     Equally, Attachments 17B and 17C provide visual confirmation of
           ever increasing traffic build-up from 12.20pm - 40 minutes after the
           crash occurred, through to 8.48pm when contra-flow was introduced.

8.3.27     The Inquiry believes that notwithstanding the delays in the arrival of
           both the replacement tanker and pump unit, and whatever the level
           and quality of communications between those at the crash site and the
     K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010             Page 86 
                                             

           TMC were and should have been, it was always open to the Transport
           Management Centre to make its own assessment and act
           independently and more expeditiously in the best interests of
           motorists. To do so would have been in the public interest.

8.3.28     Albeit that the implementation of contra-flow had been considered on a
           number of occasions by the TMC much earlier in the day, its actual
           implementation was delayed based on the contra-flow guidelines and
           earlier assumptions and a belief that the F3 Freeway would be cleared
           sooner than later (3.00-3.30pm). This was not to be the case and in
           reality was unlikely to be the case.

8.3.29     Indeed, there almost seems to have been a position of waiting a little
           longer in the anticipation that the replacement tanker and pump unit
           would arrive at any moment and the decanting process completed.
           There also appears to have been the overriding view that given that
           contra-flow takes a minimum of 2 hours to implement, then there was
           room to wait given the presumed completion of the decanting process.
           Simply stated, there existed a view that the decanting process would
           be completed before contra-flow would be introduced. So it was then
           that the rigidity of the contra-flow guidelines negated effective and
           timely decision making on this occasion.

8.3.30     As has been highlighted in this Report, the intelligence value of the fact
           that it would also have been known to the RTA/TMC that this was a
           school holiday period, so then, larger than normal traffic volumes
           might be expected on the F3 Freeway.               This point is further
           emphasised given the RTA’s intelligence holdings regarding normal
           peak flows northbound on the F3 Freeway. (Attachment 18).

           The Inquiry is drawn to the conclusion that given -

           a. a range of historical events (previous delays caused by motor
              vehicle crashes on the F3 and resultant traffic delays; normal traffic
              flows on the F3 and known peak periods);

           b. the fact that it was school holidays and larger volumes of traffic
              might reasonably have been expected on the F3 at that time;

           c. the visible build up in traffic conditions along the F3 Freeway from
              11.40am onwards;

           d. that as the diversion arrangements progressed, the Old Pacific
              Highway was near to saturation point with traffic;

           e. the development and adoption of various contingency plans for
              emergency and timely response to situations on the F3 Freeway
              (based on past and not dissimilar situations);
     K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010             Page 87 
                                             

           f. the events as they were unfolding from 11.40am on 12 April 2010
              and the build-up of traffic (in particular, the period from midday to
              5.00pm); and

           g. that information was emanating from radio and talkback programs,
              so it was then that greater attention should have been given by the
              RTA, in particular, the TMC, to the evolving situation and its
              speedier resolution.

8.3.31     The Inquiry is led to the view that the decision to implement contra-
           flow should have been made earlier than it was (6.30pm) and its
           eventual implementation (8.47pm). Each minute that the decision
           to implement contra-flow was delayed, compounded the
           problem.

8.3.32     The Inquiry believes that for the reasons outlined above and based on
           the experience of TMC personnel, it would have been of greater benefit
           to all concerned had contra-flow been implemented (not simply
           considered) by no later than 4.00pm on 12 April 2010. As such, this
           would have been in line with the Chief Executive’s initial advice to his
           staff at the TMC that its implementation would need to be determined
           by 2.00pm.

8.3.33     The Transport Management Centre plays a critical role in the
           movement of all people across the various transport modes, most
           notably, in road management. It needs to understand and appreciate
           the issues that gave rise to this Inquiry, and as important, where it
           needs to reassess its service delivery.

8.3.34     Before moving from the points that have been made on the role of the
           TMC on 12 April 2010, it is again worthy to note that beyond the
           importance of timely decision making at all levels, is the underlying
           requirement for informed and inclusive communications. Such an
           approach underpins critical and evidence-based decisions.

8.3.35     As has been clearly expressed in this Report communications in the
           field, across agencies, and to the TMC should have been provided in a
           more professional manner. That they were not does not reflect on the
           professionalism of individuals nor the agencies they represent.

8.3.36     One can well understand that as issues progressed over the first 6 to 7
           hours of the post-incident recovery arrangements, that different but
           related pressures were being exerted upon the on-site personnel. So
           then, it appears that personal and professional communications
           suffered, principally between the NSW Fire Brigades and the RTA. As a
           result it might be reasonably assumed that critical issues important to
           overall decision making and recovery arrangements may well have
           been affected, too.
     K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010           Page 88 
                                                

8.3.37        The Inquiry does not seek to canvas the rights and wrongs of
              particular points of view, suffice to say that due regard should have
              been afforded to the professional and qualified advice of the lead
              combat agency, in this case, the NSW Fire Brigades in the response
              and recovery arrangements at the F3 Freeway on 12 April 2010. This
              was a HAZMAT situation and required a professional and considered
              response.

8.3.38        At the same time, instances of the type that occurred on 12 April 2010
              place pressures on organisations like the RTA and the TMC as they
              seek to respond to political, media and community concerns by
              opening roads sooner than later, and so it is that they have a job to do
              as well.

8.3.39        It is for this reason that the Inquiry believe that agencies like the RTA
              and the emergency services would benefit from further mutual
              training, which, in turn builds a professional body of knowledge as to
              what are the functional and legal responsibilities of other agencies. It is
              about building on knowledge that moves from a tactical response to
              incidents by individual agencies, to the wider strategic response
              required by all agencies. Such training exercises are more about
              holistic responses by the agencies of government and not, say,
              individual agency responses.

8.4           RESPONSE OF THE ROADS AND TRAFFIC
              AUTHORITY POST THE INCIDENT OF 12 APRIL
              2010.

8.4.1         Following the F3 crash of 12 April 2010, the then Minister for Transport
              and Roads the Hon. David Campbell, MP called for a report from the
              RTA as to the circumstances surrounding the crash and the agency’s
              response to that incident.       That document, “RTA Report: F3
              Incident 12 April 2010” (Attachment 16), was provided by the
              Chief Executive to the Minister on 13 April 2010.

8.4.2         The Report is unsigned and is not attributed to one author. The
              Inquiry understands, however, that it was a collaborative effort by the
              RTA, albeit, formally provided by the Chief Executive, Mr Bushby. The
              Report outlines an incident summary and seeks to place an
              organisational (RTA) context as to what occurred on 12 April 2010.

8.4.3         Notably, the RTA Report provided a number of recommendations
              “…for improved practices and other actions that should be
              undertaken in the management of future incidents in order to
              minimise delays to the travelling public”. These recommendations
              are built around the four key areas of process, infrastructure, co-


        K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010             Page 89 
                                                

              ordination across Government and customer focus – each laudable and
              agreeable points.

8.4.4         The Report of 12 April 2010 also contains an incident timeline recorded
              at the Transport Management Centre, Redfern, from 11.40am on 12
              April through to 1.02am on 13 April 2010, inclusive.

8.4.5         The Inquiry noted that the Report opines (p3) that from the RTA’s
              perspective that “…had the NSW Fire Brigade advice re timing
              been received earlier a decision to implement (contra-flow)
              could have been made at approximately 3.30pm with the
              contra flow operational by around 5.30 pm to 6 pm”. As has
              been noted by the Inquiry there is a degree of contention regarding
              advice to the TMC on this critically important issue. That said, it
              always remained open to the TMC to consider and implement contra-
              flow in accordance with its own professional judgement, the contra-
              flow guidelines, and based upon the range of information sources
              available rather than the unclear advice coming from the incident site.

8.4.6         The Report also notes (at p5) “…operations to secure and clear
              the crash site took much longer than first estimated. This was
              caused by a combination of technical and equipment problems
              exacerbated by the traffic conditions”.

8.4.7         The Inquiry is of the view that the approach outlined at page 3 of the
              RTA’s response seeks to apportion blame, whilst that outlined at page
              5 seeks to offer a part explanation of what occurred. Doubtless, poor
              communications were an explanation, however, they could never be
              considered to be the excuse for the events of 12 April 2010,
              particularly, in the post-crash environment.

8.4.8         The Report, as has been noted, was provided to the Government
              (through the Minister) on 13 April 2010. It is correct to say that
              following receipt of the RTA Report, it (the Report) was found to be
              inadequate.

8.4.9         In considering the term ‘inadequate’ the Inquiry turns to what usage
              the common man would make of that term. That common usage
              might include (a) insufficient for the purpose for which it was
              commissioned, or (b) it did not meet the expectations of government
              or the community in terms of its content, or (c) lacking in overall detail
              or explanation.

8.4.10        Whatever usage the Government had for the term, it was their view
              that the RTA’s Report of 13 April 2010, was inadequate.

8.4.11        The Inquiry believes it is important to note that at no point in its
              Report of 13 April 2010 does the RTA accept responsibility for its part
        K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010             Page 90 
                                                

              in the events that flowed from the F3 crash, or the delay in the
              resumption of normal road usage on the F3 more than 12 hours later.
              This, the Inquiry believes, is not what the community is entitled to
              expect.

8.4.12        As the lead Agency in road and traffic management arrangements on
              12 April 2010, it would have been appropriate for the RTA to have
              acknowledged a level of responsibility. That this was not done is
              unfortunate, for had it done so, the Inquiry believes that this would
              have reflected a higher degree of organisational maturity.

8.4.13        Whilst the recommendations outlined in the 13 April 2010 report have
              merit and remain worthy of further consideration, they are, in part, an
              acknowledgement that a range of systems, processes, policies and
              practices (including previously approved Plans) were not considered
              on the day, or if considered, were not adequately understood or
              applied to the issues that emerged on 12 April 2010.

8.4.14        On the basis of the stated inadequacy of the Report of the 13 April
              2010, the Government commissioned an Inquiry with relevant Terms of
              Reference, on 14 April 2010.

8.5           CALL FOR RELEVANT DOCUMENTS.
8.5.1         Following a call for documents (within the Terms of Reference and
              pursuant to Section 159A, Public Sector Management Act), the Inquiry
              was provided with a number of source documents by the RTA. These
              included seven (7) lever arch folders of information and maps. These
              documents related both to the events of 12 April 2010 and a number
              of other pertinent documents (including commercial-in-confidence
              documents) as well.

8.5.2         The documents provided by the RTA also articulate a number of
              historical events relevant to the F3 Freeway, its current management
              and, importantly, a continuing program for incident management on
              the F3 Freeway.

8.5.3         These documents have helped frame the Inquiry’s approach both in
              the context of a number of historical and related events, and, as
              important, progress on the overall future management of incidents on
              the F3 Freeway.

8.5.4         On a positive note, since the Inquiry was announced, a number of
              agencies, most notably the RTA, have sought to address the issues in
              light of the events of 12 April 2010 and not waited until the finalisation
              of the Inquiry’s Report and its recommendations. The Inquiry supports
              this practical and pro-active approach.

        K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010             Page 91 
                                                


8.5.5         The Inquiry notes that the RTA has now developed the “F3 Incident
              Management Improvement Program” – (Attachment 7). The
              Program articulates a range of actions that have been finalised or are
              in progress. The Inquiry endorses the action items outlined therein.

8.5.6         At the same time, the Inquiry believes that the Program could be
              strengthened by having agreed timeframes for the completion of each
              action item and the name or position of an identified officer within the
              RTA who has primary carriage and responsibility for each item. That
              view does not require a formal recommendation by the Inquiry and is a
              matter for administrative arrangements.

8.5.7         Similarly, as with the issues identified by way of recommendation in
              the report of the RTA on 13 April 2010 – “RTA Report: F3 Incident
              12 April 2010” (Attachment 16), the Inquiry also commends this
              document to the Director General, Transport NSW and the Chief
              Executive, RTA, for further development and implementation of the
              recommendations, and report to Government. As with the
              Improvement Program, timeframes need also to be set for the
              realisation of agreed outcomes.

8.5.8         That said, there is a ‘danger’ that the recommendations or proposals
              within these documents will simply be swallowed up along with a
              plethora of other RTA documents relevant to the effective
              management of the road network, in particular, the F3 Freeway. It
              must remain a key responsibility of the Chief Executive, RTA, to
              regularly report to the Director General, Transport NSW, on the issues
              identified in past and present documents to ensure their timely delivery
              or until such time as other agreed or enhanced strategies, or outcomes
              take their place.

              Therefore the Inquiry recommends –


 RECOMMENDATION 24 –

 That the Chief Executive, RTA report minimally at 3 monthly intervals
 (or such timeframes as are agreed) to the Director General, Transport
 NSW, on the finalisation of all outstanding and approved
 recommendations identified in the ‘F3 Incident Management
 Improvement Program (May 2010)’ and the ‘RTA Report: F3 Incident 12
 April 2010’.




        K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010           Page 92 
                                                

8.6           SUBMISSION OF THE CHIEF EXECUTIVE, RTA -
              24 MAY 2010

8.6.1         Following its formal commencement, the Inquiry has spoken to a
              number of senior executives in both public and private sector agencies
              including, in particular, the RTA Chief Executive, Mr Michael Bushby on
              a number of occasions.

8.6.2         On 26 May 2010, the Inquiry again met with Mr Bushby. Prior to that
              meeting, Mr Bushby provided a detailed submission dated 24 May 2010
              as to his knowledge of the issues relevant to 12 and 13 April 2010.
              That Report contains an additional copy of the RTA’s response of 13
              April 2010. (Attachment 19).

8.6.3         In his submission of 24 May 2010, Mr Bushby articulates both a
              synopsis of the events and details comments as he noted the issues
              relevant to the abovementioned dates.

8.6.4         These comments can be viewed in three particular areas, namely, an
              overview of the event of the crash on the F3 on 12 April 2010,
              background issues peripheral to that crash, and actions subsequent to
              the crash event.

8.6.5         In his most recent report, Mr Bushby has invited the Inquiry to make a
              range of findings relevant to the crash and the management of the
              incident (items 1-9, pp3-4). In addition, he has also invited the Inquiry
              to sustain two particular conclusions relevant to his personal
              involvement in events of 12 and 13 April 2010 (items 10-11, p4).

8.6.6         Relying on notes, phone calls and recollections, Mr Bushby articulated
              the events of 12 April 2010 from his first knowledge of the crash at
              11.56am, until his final actions relevant to the crash and post-crash
              issues of that day at 11.20pm (pp47-48). Indeed, he further notes
              that his work continued on past this point with phone calls and
              meetings between midnight and 11pm on 13 April 2010 (pp49-52).
              Furthermore there were additional discussions on 14 April 2010
              between 5.21am and 9.15am (p53).

8.6.7         Turning firstly to the recommendations of 24 May 2010, Mr Bushby
              proposes nine (9) recommendations (pp9-30).

8.6.8         Of these recommendations, recommendation 1 is a matter that the
              Inquiry believes is outside of its Terms of Reference. As such, it is a
              matter for discussion between the Federal and State Governments and
              their respective agencies) and needs to be determined against other
              Government priorities and budgetary allocations. That said, the
              recommendation ought not to be lightly dismissed.

        K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010            Page 93 
                                                


8.6.9         A number of the remaining recommendations (albeit with some slight
              word changes) are already the subject of discussion within Transport
              NSW and the RTA, or across agencies and are, amongst other things,
              identified in the “Traffic Management Protocols for Priority
              Roads” (Attachment 13) and the “F3 Incident Management
              Improvement Program” ( Attachment 7).

8.6.10        Notably, recommendation 4 in the Bushby Report – access to
              encrypted Police digital radios for RTA Traffic Commanders, has been
              the subject of discussion with the Commissioner of Police. The
              Commissioner has already given approval for the availability and use of
              such radios within the Transport Management Centre, Redfern, via the
              existing seconded NSW Police Liaison Officers attached to the Centre.
              The Inquiry is appreciative of the Commissioner’s immediate action in
              this regard.

8.6.11        It is appropriate that as further consideration is given to the
              recommendations arising in the Bushby Report of 24 May 2010, so
              then this Report needs to be viewed against recommendations arising
              out of the RTA’s Report of 12 April 2010. That said, there is some
              commonality to both sets of recommendations. That is not to say that
              either set of recommendations is without merit and they ought to be
              the subject of further discussion between the Director General,
              Transport NSW and the Chief Executive, RTA.

8.6.12        All in all, these recommendations (together with those of previous and
              similar reports) are designed to enhance operating and response
              arrangements on the F3 Freeway on the one hand, and at the same
              time, improve the travelling situation of motorists on the Freeway
              whether they are caught in incidents like that of 12 April 2010, or in
              their day-to-day use of that road.

8.6.13        Each of these comments made, the Inquiry also looked at Mr Bushby’s
              explanation of the events of 12 April 2010.

8.6.14        Without reiterating much of what has been reported regarding the
              crash incident, there are some important points that Mr Bushby has
              expressed and these might best be described as points of difference
              with the NSW Fire Brigades (p7 – Overview of the Incident).

8.6.15        These latter-mentioned points of difference turn on the time to
              undertake and complete the decanting process and the resultant time
              that the F3 Freeway might be expected to reopen for normal usage.
              The Inquiry is of the view that this will remain a point of contention
              between the agencies as to who said what to whom, and when, and
              the method by which that message was conveyed.


        K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010          Page 94 
                                             

8.6.16     The Inquiry also notes (p13 – Actions on the Day – Michael Bushby),
           that the Chief Executive became concerned (understandably) that at
           4.10pm “…the F3 was not yet opened…that the pump had still not
           arrived…(and) I decided I needed to go to the Transport Management
           Centre”.

8.6.17     Agreeable as it was for the Chief Executive to travel to the Transport
           Management Centre, it was in a sense, too late. That is not a criticism
           of Mr Bushby per se, rather, the decision to introduce contra-flow
           should have been made much earlier than in fact it was and clearly,
           within the TMC. Indeed, the contra-flow guidelines allow for this to
           happen (Attachment 20).

8.6.18     This point is further sustained when having regard to Mr Bushby’s
           Blackberry Records Analysis (p47 of his Report) (Attachment 19)
           which states, “…12.29 pm…discussed the need for contra-flow
           and that a decision would need to be made by 2pm for the
           evening peak”. That view, the Inquiry further notes, was expressed
           to the TMC, and it always remained open to the TMC to make the
           decision.

8.6.19     The Inquiry is of the view that the decision to implement contra-flow
           should not have been reliant on the deliberative action of the Chief
           Executive, Mr Bushby at 6.27pm. Clearly, the decision to implement
           contra-flow could have been made earlier and it should have been
           made. Indeed, this observation is reaffirmed when having regard to
           the known facts. Again, the contra-flow guidelines reaffirm this view.

8.6.20     Clearly, the Inquiry’s Report is coming from a position of hindsight –
           always a useful position. That said there were a range of timely
           operational and tactical decisions that should have been taken and
           were not taken. These issues, as has been noted, were not helped by
           poor or misunderstood communications both in the field and between
           the field and the TMC, and the late arrival of the fuel pump unit.

8.6.21     Returning to Mr Bushby’s invitation to this Inquiry (point 11, p4 of his
           Report of 24 May 2010) that his “…report to Government on 13 April
           2010 was adequate in light of the information then known”, the Inquiry
           has expressed a view that the finding of inadequacy was that of the
           Government’s.

8.6.22     The Inquiry notes, however, that as is usually the case in matters of
           this type, there is usually a requirement to respond rapidly to the
           requests of Government (as they are indeed entitled to make such
           requests), and the voraciousness of community and media discussion.
           It can however be the case that in some situations (particularly when
           immediate responses are required) not all of the known facts can be
           marshalled and reported on as quickly as one might want.
     K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010           Page 95 
                                                


8.6.23        Whilst accuracy in reporting the facts is always required, it should also
              be the case that given the known and emerging facts, that an
              acknowledgement should have been made by the RTA that in all of the
              circumstances recovery arrangements could have been handled better.
              As already noted, the Inquiry, or the community for that matter, would
              never regard this as a statement of weakness, rather, a statement of
              organisational maturity.

8.6.24        The Inquiry believes that in the aftermath of the F3 crash of 12 April
              2010, the RTA and the TMC should have acknowledged that the road
              and traffic recovery arrangements should have been managed in a far
              more effective way.

8.6.25        Finally, the Inquiry notes with appreciation the candour of Mr Bushby
              and his demonstrated willingness to co-operate and inform the Inquiry.

8.7           THE ROLE, FUNCTION AND RESPONSIBILITY OF
              THE FORMER MINISTER FOR TRANSPORT AND
              ROADS
8.7.1         In the period following the crash of the 12 April 2010, and in the days
              following that event, significant comment was made regarding the role
              the then Minister for Transport and Roads should have played in the
              management of the recovery arrangements of that day. There was
              particular criticism that he ought to have taken a greater hands-on role
              by way of specific directions to the RTA. This view, the Inquiry
              believes, is mistaken.

8.7.2         Over a number of decades in this country there have been many
              findings provided by Parliamentary Inquiries, Judicial Reviews and
              other proceedings regarding the accountability of Ministers of the
              Crown, and, in some cases, the role, function and responsibilities of
              Chief Executive Officers.

8.7.3         The Inquiry does not propose to reiterate those historical findings in its
              Report suffice to say that history and convention record (and
              Parliament has opined) sufficient and informed debate on this issue.

8.7.4         In the discharge of his/her duties it is open to the Minister to issue
              lawful directions to the agency’s Chief Executive Officer. In doing so,
              the Minister is responsible for the implementation of Government policy
              (as it relates to the agency) and is responsible for the fiscal
              accountability of the agency.




        K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010             Page 96 
                                                

8.7.5         The day-to-day operations and management of the agency is the
              domain of the Chief Executive Officer. In turn, it is the responsibility of
              the CEO to hold officers of his/her agency responsible and accountable
              for meeting the mandated requirements of the agency, as well as
              meeting the priorities and policies set by Government.

8.7.6         In providing advice to the Minister, it is the responsibility of the agency
              (through its Chief Executive Officer) to ensure that the information
              provided is correct and is provided in a timely manner. This aspect is
              particularly the case when the responsible Minister is required to
              provide a response or answer a question in the Parliament. For the
              Minister to mislead the House is inappropriate and may have particular
              consequences for that Minister. History, too, records that this is so.

8.7.7         Turning to the events of 12 April 2010, in particular, the post-crash
              period, it was open to the Minister to ask questions of his Chief
              Executive, to seek clarification on information already provided by the
              Chief Executive and the RTA/TMC, and in doing so, make suggestions.
              It was not the responsibility of the Minister to direct the response and
              recovery arrangements impacting on the F3 Freeway on 12 April 2010.

8.7.8         Clearly, the Inquiry is of the view that the response and recovery
              arrangements, specifically as they related to road and traffic
              management of the F3 Freeway on 12 April 2010, were the
              responsibility of the RTA through the TMC, albeit, with the support of
              other key agencies.

8.7.9         The Inquiry has been advised that following text advice sent direct to
              the Minister at 4.39pm by the RTA Chief Executive, the Minister rang
              the Chief Executive at 5.51 pm to discuss what was occurring, and in
              particular, the significant traffic delays. The Inquiry was also advised
              that the Minister advised the Premier of the issues and the action being
              taken to resolve the matter.

8.7.10        In speaking to Mr Bushby and other officers, it was clear that over a
              period of hours the Minister asked many questions regarding both the
              event, and the road and traffic management response and recovery
              arrangements. There is anecdotal comment that he sought clarification
              on issues, in particular, regarding the more timely implementation of
              the contra-flow arrangements and the overall management of the
              incident. Clearly, it was open to the Minister to do so and the Inquiry
              believes that he operated within accepted Ministerial norms.




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8.8           RESPONSES OF OTHER PUBLIC AND PRIVATE
              SECTOR AGENCIES TO THE INQUIRY.
8.8.1         To gain an appreciation of the views of other public and private sector
              agencies, the Inquiry wrote to a number of relevant agencies and
              groups. These included the–

              •   Auditor General of NSW (Attachment 21);

              •   Department of Health NSW (Attachment 22);

              •   Department of Human Services (incorporating the Department of
                  Community Services) (Attachment 23);

              •   Emergency Management NSW (Attachment 24);

              •   Independent Transport Safety & Reliability Regulator (Attachment
                  25);

              •   National Roads and Motorists Association (Attachment 26);

              •   St John Ambulance Australia (NSW) (Attachment 27);

              •   WorkCover NSW (Attachment 28);

              •   Transport NSW (Attachment 29); and

              •   Department of Environment,          Climate   Change   and    Water
                  (Attachment 30).

8.8.2         Responses received from the agencies are included within the
              nominated attachments. To varying degrees, some if not most of
              these agencies, have a role to play as part of the management of a
              range of holistic options for response and recovery arrangements
              including those which occurred on 12 April 2010. These responses are
              referred to the Director General, Transport NSW for his consideration.

8.8.3         In addition, as has been indicated the Inquiry met with the (former)
              Minister for Transport and Roads, the Hon. David Campbell MP, and
              the Leader of the NSW Nationals, the Hon. Andrew Stoner MP. Both
              meetings were instructive and went to assist the Inquiry in the
              formulation of its various recommendations.

8.8.4         Similarly, the Inquiry met with a number of Commissioners, Directors
              General and Chief Executives mentioned herein as well as senior
              representatives of the NRMA, St John Ambulance Australia (NSW) and
              Scott’s Transport. All meetings were instructive and went to assist the
              Inquiry in the formulation of its views and recommendations. To that
              end, the Inquiry formally records it appreciation to those who have
              assisted its inquiries.

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        9. FUTURE DIRECTIONS FOR EFFECTIVE TRAFFIC AND
           TRANSPORT MANAGEMENT IN NEW SOUTH WALES.

  This Chapter looks to the period post the events of 12 April 2010 and the directions that Government
  Agencies have taken and propose to take in respect of more holistic approach to road and transport
  management. The chapter notes arrangements for enhanced transport service delivery, albeit,
  under a federated model of management. The Inquiry also poses recommendations to strengthen
  existing proposals through cultural change and an even greater customer orientation.




9.1           TRANSPORT NSW.

9.1.1         In concluding its report to the Government, the Inquiry has turned its
              mind to two critically important issues which both stand alone, yet, by
              their very nature, are inter-related. Importantly, the Inquiry’s thoughts
              turn to both the mandated statutory role of the newly created agency,
              Transport NSW, and to the RTA.

9.1.2         The Inquiry has noted that during the past month the NSW
              Government has proceeded to establish the new framework for the
              administration and governance of the delivery of NSW transport
              services and infrastructure by public transport agencies (including the
              RTA) under the general direction of the Director General of Transport
              NSW.

9.1.3         The existing transport services agencies affected by this proposal (and
              the subsequent carriage of the Transport Administration Amendment
              Act 2010) include RailCorp, State Transit Authority, Sydney Ferries and
              the RTA.

9.1.4         Specifically, the Transport Administration Amendment Act 2010
              provides for a strengthening of the role of Transport NSW, and
              includes the conferring of statutory powers and accountabilities with
              the Director General of Transport NSW including transport services
              coordination, incident management, and provision of transport
              information.

9.1.5         In this regard incident management includes specifically the
              management of incidents affecting the efficiency of the road and public
              transport networks, including the coordination of communications with
              and responses by relevant agencies. Transport information includes the
              provision of information about transport services and transport
              infrastructure to assist people to use those services or infrastructure.



        K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010                      Page 99 
                                                

9.1.6         In establishing the legislation the NSW Government explicitly
              acknowledged that the community expects the Government to deliver a
              transport system that is integrated and coordinated; which amongst
              other services manages incidents when they occur in an efficient and
              coordinated way; that has a single person in charge who is
              accountable for improved services.

9.1.7         Furthermore, it is noted that when moving the legislation in Parliament
              on 13 May 2010 the Minister for Transport and Roads outlined that
              under the new transport governance model the “…Director General
              (would have) an overarching accountability - incident
              management - through four key objectives (including)
              accountability of public sector agencies (and) - ENSURING A
              GREATER FOCUS ON THE CUSTOMER AND A MORE RESULTS
              DRIVEN CULTURE” [emphasis added].

9.1.8         In concluding his second reading speech, the Minister commented that
              ”…through better integration and co-ordination, greater
              accountability, more effective strategic planning, a greater
              focus on meeting key performance measures AS EXPECTED BY
              THE COMMUNITY" [emphasis added] would be achieved.

9.1.9         Germane to this integrated approach is the requirement “…that
              agencies work together to develop solutions that go beyond their core
              modes”.

9.1.10        This Inquiry strongly supports and endorses the above direction taken
              by the Government as being a significant opportunity to ensure that
              the public interest and expectations of the community are
              appropriately considered and addressed, should, if and when,
              significant traffic incidents similar to the April 2010 F3 accident occur
              in the future.

9.1.11        Having regard to the spirit and intent of the Act as outlined by the
              Minister, the Inquiry turned its attention to the more effective
              and practical management of day-to-day transport management issues
              across the State.

9.1.12        Similarly, it has sought to identify how best the critically important
              issues     of    co-ordination,  co-operation,   collaboration    and
              communications might be better integrated across all transport
              agencies (including the emergency services) and delivered in the
              manner not only prescribed by the Act, but as important, in the
              manner in which the general public and Government would expect
              them to be delivered.

9.1.13        So it was then that the Inquiry sought to identify a range of common
              denominators to a more efficient and effective set of transport
        K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010          Page 100 
                                             

           management arrangements. It seems to the Inquiry that the common
           denominators are - THE PUBLIC..MOVEMENT..CO-ORDINATION..
           and COMMUNICATIONS.

9.1.14     The challenge beyond this point is to give effect to these arrangements
           in a way that is both practical and seamless, and at the same time,
           provides a set of arrangements in which the public and the
           Government can have confidence.

9.1.15     This broad approach is supported in the submission of the Director
           General, Transport NSW, dated 29 April 2010 to the Inquiry which
           noted there was “… a requirement for the improved delivery of
           incident co-ordination and communication across the modes
           through expanding the role of the Transport Co-ordination
           Group (TCG)”. (Attachment 29).

9.1.16     Presently, the TCG operates out of the Transport Management Centre
           (TMC) Redfern. Its focus is predominantly in the key public transport
           modes of buses, rail and ferries and provides a range of information
           services including public transport updates (including issues relating to
           the road system). It operates and maintains an equally important
           media advisory line to radio programs and news rooms.

9.1.17     With the TMC, the TCG has an equally important role to play in events
           management and these events are usually associated with, say, New
           Year’s Eve, Australia Day, Anzac Day, significant public events such as
           the recent Jessica Watson arrival in Sydney Harbour and Sydney
           Foreshore, and similar events.

9.1.18     In his submission of 29 April 2010, the Director General, Transport
           NSW provided nine (9) key recommendations which he invites this
           Inquiry to consider. There is an attraction to those proposals and the
           Inquiry supports and concurs with the principles of what is proposed in
           each of the recommendations.

9.1.19     Clearly, when speaking to the Bill and new legislative arrangements for
           transport in NSW, the Minister on behalf of the Government placed not
           inconsiderable and agreeable emphasis on the importance of
           integration of strategic and tactical planning across agencies, in
           particular, the transport agencies, the need for effective
           communications and, importantly, the delivery of integrated response
           and recovery arrangements to critical incidents when and as they arise.

9.1.20     As with the comments outlined in the second reading speech to the
           Bill, the Minister's intentions and emphasis were clear -
           PUBLIC...MOVEMENT..CO-ORDINATION...COMMUNICATIONS.



     K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010          Page 101 
                                             

9.1.21     With these views in mind and drawing on the lessons learnt from the
           F3 Freeway incident of 12 April 2010, and having regard to a range of
           historical and not dissimilar incidents across the road network, the
           Inquiry lends itself to the view that the more effective management of
           the public transport and road systems (including the effective
           management of major incidents) will only be realised when there is a
           more holistic approach to agency-based responsibilities. These goals
           will only be reached with an equally disciplined focus on enhanced co-
           ordination, co-operation, collaboration and communications.

9.1.22     Therefore, when considering these four important characteristics, it
           seems to the Inquiry that there must be a greater emphasis on the
           holistic management of each of the transport functions or modes
           though a strategic and tactical approach to PEOPLE...THEIR
           MOVEMENT...CO-ORDINATION OF EFFORT...AND EFFECTIVE
           COMMUNICATIONS.

9.1.23     These things said, the Inquiry believes that what goes hand-in-hand
           with a greater emphasis on PEOPLE, THEIR MOVEMENT, CO-
           ORDINATION OF EFFORT, and EFFECTIVE COMMUNICATIONS, is the
           requirement for a strong mindset or cultural impetus to achieve the
           goals set by Transport NSW.

9.1.24     The Inquiry (at Chapter 10) has gone to some length to address the
           issue of the need for cultural reform within the RTA - cultural reform
           that gives a greater emphasis to the RTA‘s customers, namely, the
           road users of NSW. So, too, any organisation that exists for the
           primary purpose of the movement of people in a co-ordinated and
           seamless way, must have at its centre a culture that is people and
           customer service centric. Unless this is the case, history is bound to
           repeat itself.

9.1.25     The cultural integrity to which the Inquiry refers is crucial if the
           essential requirements for enhanced roads transport movement are to
           be realised. Similarly, the co-ordination relates not to one element of
           the transport mode, rather, the co-ordination of all aspects of transport
           to provide a far more effective set of transport management
           arrangements that keep people on the move.

9.1.26     Therefore, the Inquiry is strongly of the view that the existing
           organisational arrangements of having the Transport Management
           Centre (TMC) under the control of the RTA are no longer workable and
           to some extent, redundant. Whilst it is a model that has suited past
           road and traffic management arrangements, there is, the Inquiry
           believes, now a need for realignment of its governance and
           management structure that reflects the totality of today's public
           transport and roads system including buses, ferries and trains, and the
           integration of these systems.
     K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010          Page 102 
                                             


9.1.27     The Inquiry is of the view that the operational face of transport and
           road management - the existing TMC, is no longer suited to the RTA
           organisational model. The RTA provides, amongst other things,
           professional and qualified advice, planning, management and advisory
           services that go to the establishment, maintenance and construction of
           public roads and infrastructure, and vehicle and driver and rider
           certification. On the other hand, the Transport Management Centre
           (TMC) and the Transport Co-ordination Group       (TCG)   provide    a
           functional and real-time approach to transport and road management
           that needs to be strengthened in a way that    reflects the practical
           and operational aspects of their work.

9.1.28     The Inquiry is of the view that the existing TMC and TCG should be
           combined into one functional area under a General Manager. External
           road crews, who currently report to the TMC, need also to be included
           within the new structural arrangements.

9.1.29     Having regard to the previously noted specific statutory accountabilities
           for incident management and transport information now being formally
           vested in the Director General of Transport NSW it is recommended
           that the RTA Transport Management Centre (infrastructure, staff and
           resources) be removed from the accountability of the RTA, and placed
           under the direct reporting responsibility into the Director General
           Transport NSW.

9.1.30     To    reflect   the   importance     of   PEOPLE…MOVEMENT...CO-
           ORDINATION…COMMUNICATIONS, the name of the new entity
           should reflect what it is they are charged to do, namely, provide for
           the safe, co-ordinated and seamless movement of public transport
           passengers and road users. As well, issues impacting on the delivery
           of these services need to be communicated with the public in a timely
           and informed manner.

9.1.31     In this respect, it is recommended that the Transport Management
           Centre be renamed the Transport Information and Coordination Centre
           (TICC) in line with the recently integrated transport portfolio and new
           accountabilities of the Director General, Transport NSW.

9.1.32     In turn, and to reflect the accountabilty and importance of the role of
           the new entity, the General Manager, TICC should now report directly
           to the Director General, Transport NSW.

9.1.33     Whatever the title of the new entity, the Inquiry is strongly of the view
           that it must reflect change and provide a better service to NSW - a
           change that is reflective of cultural change and change that supports
           the commuting and travelling public.


     K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010          Page 103 
                                                  


9.1.34          By way of broad explanation, Figure 17 seeks to illustrate the
                concepts out-lined above.
                                        Figure 17


          TRANSPORT INFORMATION AND
              COORDINATION CENTRE




                                                                                    MANAGMENT
SYSTEMS




                        COMMUNICATION
  9.1.35        For the reasons outlined, and given a range of issues of the immediate
                and not too distant past, and when having regard to what the Inquiry
                regards as the spirit and intent of the Transport Administration
                Amendment Act 2010, and the requirement for greater public
                commuter and motorist support, the Inquiry makes the following
                recommendations -

          RECOMMENDATION 25 –

          That the Transport Management Centre be removed from the
          organisational and functional control of the RTA.



          K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010        Page 104 
                                        


RECOMMENDATION 26 –

That the Transport Management Centre and the Transport Co-ordination
Group be incorporated into a new entity entitled the 'Transport
Information and Co-ordination Centre (TICC).


RECOMMENDATION 27 –

That the functional responsibilities of the Transport Management Centre
and the Transport Co-ordination Group be integrated to provide a
seamless set of transport management arrangements across the whole
of the transport network.


RECOMMENDATION 28 –

That the operational management of the proposed Transport
Information and Co-ordination Centre (TICC) be under the direction of
one General Manager.


RECOMMENDATION 29 -

That all existing personnel attached to both the TMC and the TCG be
transferred to the new entity, the Transport Information and Co-
ordination Centre (TICC).


RECOMMENDATION 30 –

That the General Manager, Transport Information and Co-ordination
Centre (TICC) report directly to the Director General, Transport NSW
and be held accountable for the effective operations, management and
administration of the Centre.



RECOMMENDATION 31 –

That subject to the establishment of the Transport Information and
Co-ordination Centre (TICC), the issues identified in the Director
General’s submission of 29 April 2010 to this Inquiry be the subject of
development and adoption by Transport NSW.



K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010    Page 105 
                                              




   RECOMMENDATION 32 –

   That within 12 months of the adoption of these recommendations, the
   Director General, Transport NSW, report to the Government on the
   effective management and operations of the Transport Information and
   Co-ordination Centre (TICC).


9.1.36     Finally, any review of a range of man-made or natural disasters in this
           State, will invariably find that many of those disasters have had an
           impact on all aspects of our transport system, most notably, the roads
           system.

9.1.37     Traditionally, responses to those disasters have come from the
           appropriate combat agencies such as the Ambulance Service of NSW,
           NSW Fire Brigades, NSW Police Force, Rural Fire Service of NSW, NSW
           State Emergency Services, and other functional utility areas (water,
           electricity, human services etc). Whilst elements of transport
           management have been represented in their own right, they have not
           been represented as one group.

9.1.38     With the carriage of the Transport Administration Amendment Act
           2010, and the creation of Transport NSW, there exists an opportunity,
           particularly at a Chief Executive level, for this situation to be corrected.

9.1.39     It would seem that for a range of relevant reasons including inter-
           agency co-operation, enhanced communications and a broader and
           more inclusive policy framework, that the Director General, Transport
           NSW, should be included as a full member on the State Emergency
           Management Committee (SEMC). Such an inclusion, the Inquiry
           believes, will not only provide opportunities for co-operation and
           collaboration at agency CEO level, but across those agencies as well.

           Therefore, the Inquiry recommends –



    RECOMMENDATION 33 -

    That the Director General, Transport NSW, be admitted to full
    membership of the State Emergency Management Committee (SEMC).




     K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010             Page 106 
                                                

9.2           THE ROADS AND TRAFFIC AUTHORITY OF NSW –
              MEETING THE CHALLENGES OF TOMORROW
              THROUGH A STRONGER CUSTOMER SERVICE
              FOCUS.
9.2.1         There is no doubt that the RTA is an organisation of focused and
              committed professional and highly qualified officers. Its skills base is
              as diverse as the NSW road network that it seeks to service. It is also
              fair to say that the challenges it faces to provide and maintain a strong
              focus on the network of road and traffic management arrangements on
              a day-by-day basis, are numerous, complex and diverse.

9.2.2         It is equally reasonable to observe that there are many challenges for
              the RTA both now and into the future. Critical amongst these
              challenges will be its integration into the newly created agency,
              Transport NSW. Unlike the past, the RTA is now, and agreeably from
              the Inquiry's view, part of a more manageable and integrated transport
              management network.

9.2.3         The challenges that Transport NSW and the RTA face are built around
              the integration of transport and land use management, co-ordinating
              transport development across all modes, management of sophisticated
              network systems, capacity building and, ensuring high quality access
              and mobility in large urban and rural areas.

9.2.4         Key to the realisation of these objectives, including the better
              management of the road network, is the equally compelling
              requirement for complementary whole of Government strategies.

9.2.5         Whilst it is obvious that these strategies include an understandable
              focus on road incident management, including contra-flow, so it is then
              that the Inquiry has opined that there must be an even greater
              emphasis on those who matter most – the customers of the RTA and
              the road users of New South Wales.

9.2.6         The Inquiry does not conclude that the RTA does not have a
              customer service focus, rather, there needs to be a reassessment and
              a greater emphasis on this critically important area of community
              relations.

9.2.7         From the Government’s perspective it may be reasonably stated that
              the public face of the RTA, the State’s Motor Registries, have
              previously undergone a significant customer service focus. It is also
              fair to say that for most if not all road users, any encounter at a Motor
              Registry may be as infrequent as every few years (licence renewals)
              or, at best, every twelve months (registration renewals). The reality is
              that members of the public use the roads of NSW on a daily basis and
        K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010          Page 107 
                                                

              they are commentators on the effectiveness of the RTA. They can and
              should be a strong ally.

9.2.8         The most important challenge for the RTA in 2010 and beyond, is how
              it recognises and understands that its most important asset base is not
              only having the budget to complete major works and infrastructure,
              nor its capacity to plan, implement change or introduce new
              technology and other systems for enhanced road management.
              Clearly, the community (and its support) are its greatest asset base.
              Whilst the other elements of service delivery are crucial, they are of
              less importance when valuing the people that the RTA seeks to serve,
              namely, the community.

9.2.9         There can be no doubt that both directly and indirectly the community
              has sent a strong message to the RTA regarding their displeasure at
              what occurred on the F3 Freeway on 12 April 2010, in particular, the
              events following the crash and the recovery of the Freeway to normal
              usage. This was the community’s judgement to make and they have
              made it. The RTA and Transport NSW would be unwise to ignore that
              message.

9.2.10        The frustration and annoyance of the community relevant to 12 April
              2010, was further compounded by the fact that this was not the first
              time that an incident of this type, and to this extent, has occurred on
              the F3 Freeway. Given the policy, public and financial commitments of
              2008, the community's expectations for the speedy and timely
              resolution of traffic incidents on the F3 Freeway were not
              unreasonable.

9.2.11        Commitments were given and in the minds of some members of the
              community they were not met on 12 April 2010. This may not be an
              agreed view within the RTA; it is, however, the community’s view.
              Clearly, and for the reasons outlined, it is a brave organisation that
              does not now hear, interpret and act on the community’s messages in
              a positive way.

9.2.12        From a positive perspective, the Inquiry has noted the development
              and adoption of the “F3 Incident Management Improvement
              Program" – (Attachment 7). The Inquiry remains supportive this
              Plan of Action as an important set of initiatives that go to address not
              only the issues of the 12 April 2010, but, as important, a range of
              integrated measures that support the critical requirements for effective
              PLANNING, PREPARATION, RESPONSE and RECOVERY.

9.2.13        That said, of the 20 key strategies Customer Care and Education is
              ranked at number 3 (3.1 to 3.5). In fact, it ought to be re-ranked at
              number 1. True it is that a number of the other strategies have
              elements of customer service interwoven in their sentiments and goals,
        K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010          Page 108 
                                              

           but, emphasis has to be given to demonstrable customer service both
           in words, and in operational management and practice.

9.2.14     The Inquiry is aware that many public and private sector agencies have
           won awards for their customer service focus. Notably, two agencies,
           Centrelink and the NSW Police Force have been commended and
           awarded for their programs. These programs are not notional. In fact,
           external validation has recognised both their positive content and
           delivery in the community. They are but two that Transport NSW and
           the RTA, in particular, might consider.

9.2.15     Finally, when addressing the issue of enhanced customer service
           policies and practices, there remains the equally concomitant
           requirement for cultural change.

9.2.16     Complementary to any proposals for new or renewed customer service
           strategies across Transport NSW, and in particular, the RTA, is the
           equally compelling and critical importance of addressing organisational
           culture and cultural or transformational reform. Positive culture aids in
           the realisation of the organisation’s objectives, whilst negative culture
           can be both divisive and defeatist.

9.2.17     It is not the Inquiry’s intent to write a treatise on cultural or
           transformational reform suffice to say that whilst processes, systems,
           policies, rules and regulations are important in all aspects of business,
           so too there needs to be an appreciation and application of sensible
           business practices.

9.2.18     Some of these practices include, amongst others, risk taking as
           opposed to risk avoidance; risk management and consequence
           management; evidence-based decision making; accurate and timely
           information that aids effective decision making; lateral thinking that
           aids both tactical and strategic decision making; effective intra and
           inter-agency and customer service communications; and above all else,
           an acceptance and an application of accountability and responsibility.

9.2.19     Overall, it remains an inexplicable issue for this Inquiry that, despite all
           the resources available to the RTA, including the various internal media
           and corporate communications staff, it took a telephone call from no
           less than the Minister to the RTA Chief Executive shortly before 6pm.
           on 12 April 2010 before the RTA Chief Executive became made aware
           that the media and Fire Brigade were advising it was expected the fuel
           pumping (and hence F3 road closure) would take 4 to 6 hours.

9.2.20     Thereafter it took a further 30 minutes before this crucial piece of
           information could be confirmed by the RTA with the NSW Fire
           Brigades, before the RTA Chief Executive was prepared to approve the
           contra-flow.

     K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010             Page 109 
                                             


9.2.21     This was despite the fact that the traffic was already by that time
           queued over 20 kms south from the diversion point, and media had
           been reporting from as early as 3pm. the issues regarding expected
           delays to the afternoon peak traffic, with the Fire Brigade similarly
           again confirming the length of the expected decant of fuel as 4 to 6
           hours in the media from 17.30 pm.

9.2.22     From a cultural reform perspective each of these (and other)
           requirements must be driven from the top down and within the
           organisation. Equally, there has to be a cultural reform-customer
           service champion within the organisation who enjoys the demonstrable
           support of Government and the agency, and importantly, the
           community.

9.2.23     On more than a few occasions anecdotal comment was expressed to
           the Inquiry that the RTA is staffed by highly skilled professionals. The
           Inquiry agrees that this is so. However, it has also been said that the
           RTA is process-driven, rigid in its approach, is complex and
           bureaucratic in its nature, and overly rule bound.

9.2.24     Whatever the truth to these perceptions, they are matters that the
           RTA must come to terms with. The Inquiry believes that these
           perceptions must be addressed through a significant cultural and
           transformational change within the RTA. To do otherwise dooms it to
           fail again.

9.2.25     Key to cultural change and enhanced customer service is the need to
           listen to the community and its representative groups. Agencies like
           the NRMA (and others) have propositions gathered from their
           community inter-actions and community consultation. Transport NSW
           and the RTA could do no worse than to listen to the community
           through these representative groups.

9.2.26     The Inquiry does not suggest that the RTA does not already engage in
           a consultative process with the community, rather, that the current
           arrangements are in need of enhancement. Consultation arrangements
           in the future ought not to be a one-off, rather, but part of a more
           regular regime of community-based interactions.

9.2.27     Doubtless, any community-based debate and consultation will evoke
           different points of view on different issues and consensus may not
           always be possible. To not engage in the debate in the first instance is
           a grave misjudgement. Ultimately, it is the community and groups like
           the NRMA who seek to aid road and traffic management, and their
           knowledge and commitment ought not to be discounted.



     K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010          Page 110 
                                             

9.2.28     The Inquiry concludes on this point by indicating that the lessons
           identified and learnt arising from the motor vehicle crash on the F3
           Freeway on 12 April 2010, will not be addressed solely by a process-
           driven recovery or by more rules, or the production of more F3
           Freeway Plans. More is needed, and the more will only be achieved
           when there is a legitimate focus and commitment to renewal.
           Significant cultural reform within the RTA is the key to that renewal.

9.2.29     With the support of Government, the community and Transport NSW,
           the priority for reform in each of the areas identified must begin by
           addressing the parallel issues of culture and customer service. When
           this happens, the remaining challenges will be met.




     K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010        Page 111 
                                                  

  10.        CONCLUSION.
  This Chapter concludes the Inquiry's Report by focusing on the future of road and traffic
  management by providing not only a renewed focus on planning, preparation, response and
  recovery, and the implementation of recent plans and proposals, but by providing a way forward to
  those now tasked with the implementation of enhanced transport management arrangements.


10.0.1      On reading this Report, its findings and recommendations there may
            well be some who indicate that it is easy to come from a position of
            hindsight. Indeed, that is so. But before hindsight comes foresight
            and the ability to plan and prepare for future needs and all manner of
            contingencies. Hopefully, the Inquiry has provided the foresight that is
            required to address the issues identified in the its Report.

10.0.2      In completing its Report, the Inquiry has sought to apply fairness and
            balance. Equally, the Inquiry accepted the invitation to be frank in its
            Report. In doing so, the Inquiry has consulted widely and has been
            provided with comment and observations that, in turn, have gone to
            making shaping its overall recommendations.

10.0.3      When reflecting on the events of 12 April 2010, there were a range
            of contributing circumstances in the overall resolution of the crash
            incident. Some of these circumstances might fairly be described as
            fitting under the broad rubric of 'Murphy's Law'. These included -

            1.      The difficult terrain of the F3 Freeway near Jolls Bridge - the
                    crash site (maps 2, 3, 6, 8, 9 and 13);

            2.      The difficulty in finding alternate routes from the F3 Freeway
                    once committed to certain areas - inability to get off like other
                    major arterial roads, and accessing and using the challenging
                    Old Pacific Highway (maps 1- 16 inclusive);

            3.      School holidays and the larger than normal volume of traffic on
                    the F3 Freeway at this time of the year;

            4.      The later than expected arrival of the replacement tanker and
                    pump unit;

            5.      The need to decant 6 of the 7 compartments of the damaged
                    tanker (approx. 43,000 litres of unleaded petrol through a
                    7cm[3 inch] spear), and not the original 1 compartment (8,200
                    litres);

            6.      An absence (on annual leave) of experienced personnel in a
                    number of key agencies; and



     K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010                    Page 112 
                                             

           7.     The overall nature of the structural damage to the fuel tanker
                  thereby making it impossible to tow it from the scene without
                  full decanting.

10.0.4     Notwithstanding the coincidence of these things, there remained the
           fact that the overall response and recovery arrangements leading to
           the resumption of normal traffic conditions, did not happen in a timely
           manner or in the way that the community reasonably expected them to
           happen. Clearly, there were opportunities lost, and as the Report
           notes, some opportunities were not even considered.

10.0.5     Agreeably, a number of the key agencies, including Transport NSW and
           the RTA, have sought to understand what went wrong on the day.
           They have put forward the introduction of a range of new policies and
           procedures that, ideally, will prevent a repeat of the circumstances
           which arose on the F3 Freeway on 12 April 2010. Whilst that approach
           is appropriate, a sceptical community will say that they have heard this
           commitment before. So then, any recommitment to higher level
           service outputs needs to be demonstrable, achievable and measurable.

10.0.6     Notwithstanding any intention to develop new or renewed plans and
           policies, comes an even higher requirement to ensure they are
           understood, practiced and will, when required, be fully implemented.
           Thus, by a strong demonstration of commitment, so then its
           achievement and measurement will be realised.

10.0.7     No single new or revised plans is any more important than another,
           but, of all of the issues identified, effective communications remains
           the key. It is the lynch-pin that allows all of the other aspects of
           response and recovery arrangements (including road and traffic
           management) to occur.

10.0.8     The effective communications to which the Inquiry refers relates to
           inter and     intra-agency    relations, and,   equally,    effective
           communications with the community. It is the basis of these effective
           communications that allows informed decisions to be made by the
           emergency services and other responders on the one hand, and at the
           same time, by those who may be impacted by inordinate and lengthy
           days - as was the case on 12 April 2010.

10.0.9     There can be no doubt that whilst unintentional, there were poor
           communications with all manner of groups at both the scene of the
           crash, the key decision makers in Sydney, and, as important, those
           most impacted by this event (other than the injured driver), namely,
           the travelling public.

10.0.10    The Inquiry has noted the issue of uniqueness associated with
           elements of the F3 Freeway, particularly in the area of the crash site
     K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010         Page 113 
                                            

          (maps 1-16 inclusive), and the ability for natural or man-made
          disasters to occur on the Freeway at anytime. It is for these reasons
          that the continuing efforts of all of the relevant agencies need to be
          both marshalled, directed and unified. Fragmentation of effort has the
          potential to dissipate the recovery arrangements, not aid them.

10.0.11   It is true to say that the genesis of this Inquiry is found not in its
          Terms of Reference, rather, in the fact that crashes like that of 12
          April 2010 have occurred on the F3 Freeway in the past. In some of
          those previous crashes, the after effects have been comparable -
          serious injuries, significant property damage and lengthy traffic delays.
          Past lessons based on the more timely delivery of holistic recovery
          arrangements should have shaped the future.

10.0.12   Arising out of past crash events, response and recovery plans have
          been made, policies announced and public funds committed. So it is
          then, that it is the Inquiry's view that in determining the adequacy of
          the recovery arrangements on 12 April 2010, it is more the fact
          that the identified inadequacies relate more to what did not occur
          rather than that which did.

10.0.13   Past commitments, plans and public funds created an expectation,
          namely, that the agencies of government would be prepared, had
          planned and were able to respond in a timely manner, and in so doing,
          recover the situation as quickly as circumstances would allow. On 12
          April 2010 not all of these elements were aligned and there was the
          inevitable fragmentation of effort. That is not acceptable by any
          standard.

10.0.14   The community's principal and lead representative in effective road and
          traffic management is the RTA, and it is assist in this regard by the
          Transport Management Centre. On 12 April 2010 the community were
          let down and for that they, the community, are owed an apology. It
          must come in this instance from the RTA. Some sceptics may regard
          an apology as belated, but rather that than no apology at all.

10.0.15   The RTA is a learning organisation and it must learn from this incident
          and the events that eventuated from it. The Inquiry provides its
          encouragement and support to the Chief Executive and officers of the
          RTA, as they set about to realise the directions set both by Transport
          NSW and this Inquiry.

10.0.16   Along with the RTA (and the Transport Management Centre), there
          were other agencies involved in the response and recovery
          arrangements on 12 April 2010, and their roles and duties were also
          critical to those arrangements. They too, should review relevant
          operational response and training arrangements, and at the same time,
          they need to understand what occurred (or failed to occur) from their
    K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010          Page 114 
                                            

          agency's perspective and why. As important, they too need to learn
          and it is through informed learning that opportunities for enhanced
          operational performance exist.

10.0.17   Finally, the Inquiry notes and concurs with the view of Austroads that
          traffic crashes by their nature are abnormal and random events. The
          response by the agencies of government to those incidents requires a
          systematic, planned and co-ordinated set of arrangements that reduces
          the duration and impact of the crash incident and, ideally, gets traffic
          moving again and quickly as possible.

10.0.18   Austroads opines (and the Inquiry agrees) that on such occasions and
          where traffic volumes are high, their cumulative effect can be
          substantial. Some of the negative impacts include -

              •   increased response times by police, fire and other emergency
                  units;
              •   lost time and a reduction in productivity;
              •   increased cost of goods and services;
              •   increased fuel costs;
              •   reduced air quality and other adverse environmental issues;
              •   increased vehicle maintenance costs; and
              •   negative public image of public agencies in incident
                  management activities.

10.0.19   How each of these factors are managed, co-ordinated and delivered
          will be the continuing challenges for all of the relevant authorities. The
          key to meeting these challenges has to be collaboration and mutual
          appreciation of corresponding roles and functions. The community of
          New South Wales deserve nothing less.

10.0.20   The Inquiry commends its Report to the Government.




    K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010           Page 115 
                                            



        11.   INDEX OF TERMS.



CAD:             Computer Aided Dispatch.

DEOCON:          District Emergency Operations Controller, State Emergency and
                 Rescue and Management Act.

DEMO:            District Emergency Management Officer, State Rescue and
                 Emergency Management Act.

HAZMAT:          Hazardous Materials.

ICEMS:           Inter-Cad Electronic Messaging System.

LEOCON:          Local Emergency Operations Controller, State Emergency
                 Rescue and Management Act.

MOU:             Memorandum of Understanding.

POC:             Police Operations Centre, Sydney.

RTA:             Roads and Traffic Authority (of NSW).

SCAT:            Special Casualty Access Team.

SERM Act:        State Emergency and Rescue Management Act.

SEOCON:          State Emergency Operations Controller, State Emergency and
                 Rescue Management Act.

TCG:             Transport Co-ordination Group (Redfern).

TMC:             Transport Management Centre (Redfern).

VKG:             NSW Police Communications Centre (Call Sign).




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 12.    LIST OF AGENCIES, EXECUTIVES AND KEY STAFF CONSULTED
        DURING THE F3 INQUIRY


AMBULANCE SERVICE OF NSW.

Mr Greg Rochford, Chief Executive.
Mr George Smith, Director, Special Operations Unit.
Mr Michael Willis ASM, General Manager, Operations.
Ms Katherine Woods, Director, Media Unit.

AUDIT OFFICE OF NSW.

Mr Peter Achterstraat, Auditor General.

AUSTRALIAN INSTITUTE OF POLICE MANAGEMENT.

Dr Tom Rogers, Executive Director.

DEPARTMENT OF COMMUNITY SERVICES.

Ms Annette Gallard, Chief Executive Officer.

DEPARTMENT OF ENVIRONMENT, CLIMATE CHANGE AND WATER.

Ms Lisa Corbyn, Director General.
Mr Greg Sullivan, Deputy Director General.
Mr Craig Lamberton, Director, Specialised Regulation.

DEPARTMENT OF HUMAN SERVICES.

Ms Jennifer Mason, Director General.

EMERGENCY MANAGEMENT NSW.

Mr Stacey Tannos ESM, Director General and State Emergency Recovery Controller.
Mr Heinz Mueller, Director, Response and Recovery.

INDEPENDENT TRANSPORT AND SAFETY REGULATOR.

Mr Len Neist, Chief Executive Officer.

LAND AND PROPERTY MANAGEMENT AUTHORITY.

Mr Tony Sleigh, Director, Emergency Information Management Co-ordination Unit.
Mr Rob Colless, Manager, GIS and Operations, Emergency Information
Management Co-ordination Unit.
Mr Sean Epe, Emergency Information Management Co-ordination Unit.
     K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010      Page 117 
                                             

NSW DEPARTMENT OF PREMIER AND CABINET.

Mr Brendan O’Reilly, Director General.
Mr Chris Raper, Deputy Director General.
Mr Terry Archer, Director, Performance Improvement and Review.

NSW HEALTH.

Professor Deborah Picone AM, Director General.

NSW FIRE BRIGADES.

Commissioner Greg Mullins AFSM.
Deputy Commissioner John Benson AFSM, (Emergency Management).
Chief Superintendent John Denny AFSM, Office of the Commissioner.
Superintendent Ian Krimmer AFSM, Director, Media Unit.
Superintendent Greg Wild, Staff Officer, Office of the Deputy Commissioner.
Inspector Chris Forster, Incident Commander (12/4/10).
Inspector Kiernan Lambert, Station Officer, Parramatta.
Inspector Peter Nies, Station Officer, Newcastle.

NSW POLICE FORCE.

Commissioner Andrew Scipione APM.
Deputy Commissioner David Owens APM, Field Operations.
A/Deputy Commissioner Catherine Burn APM, Corporate Services.
Asst Commissioner John Hartley APM, Commander, Traffic Services.
Asst Commissioner Robert Waites APM, Commander, Communications Group.
Asst Commissioner Carlene York APM, Commander, Northern Region.
Supt Geoff McKechnie APM, Local Area Commander, Brisbane Waters.
Inspector George Bradbury, Brisbane Waters Local Area Command.
Inspector Kevin Daley, Public Affairs Branch.
Senior Sergeant Ben Millington, Office of the Deputy Commissioner.
Senior Sergeant James Prendergast APM, Liaison Officer to the TMC Redfern.
Sgt Chad George, Highway Patrol, Brisbane Waters Local Area Command.
Mr Strath Gordon, Director, Public Affairs Branch.

NSW STATE EMERGENCY SERVICES.

Commissioner Murray Keir AFSM.

NATIONAL ROADS AND MOTORISTS ASSOCIATION.

Mr Tony Stuart, Group Chief Executive Officer.
Mr Mark Wolstenholme, Senior Policy Advisor – Traffic and Roads.
Mr Gary Campbell, General Manager, Roadside Service Delivery.



     K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010         Page 118 
                                             

OFFICE OF THE (FORMER) MINISTER FOR TRANSPORT AND ROADS.

The Hon. David Campbell MP, (former) Minister for Transport and Roads and
Member of Keira.
Mr George Houssos, (former) Minister’s Chief of Staff.
Mr Ryan Liddell, (former) Media Advisor.

OFFICE OF THE LEADER OF THE NATIONAL PARTY.

The Hon. Andrew Stoner MP, Leader and Member for Macleay.

OFFICE OF THE NSW PREMIER.

Mr Walt Secord, Chief of Staff.
Ms Lisa McLean, Director of Communications.
Ms Cassandra Wilkinson, Policy Adviser, Transport.


ROADS AND TRAFFIC AUTHORITY OF NSW.

Mr Michael Bushby, Chief Executive.
Ms Ann King, Acting Chief Executive.
Mr Peter Collins, Director, Network Management.
Mr Phillip Akers, General Manager, Transport Management Centre, Redfern.
Ms Tracey Arthur, General Manager, Corporate Communications.
Mr Ken Boys, Media Adviser, Transport Co-Ordination Group, TMC.
Mr Tony Chalmers, Duty Chief Traffic Operations Controller.
Ms Shannon Mackay, Manager, Media Unit.
Mr Robert McCarthy, General Manager, Governance Branch.
Mr Craig Moran, Acting General Manager, TMC Redfern (12 April 2010).
Mr Abe Khoury, Chief Traffic Operations Controller, TMC Redfern.
Mr Colin Moore, Chief Traffic Operations Controller, TMC Redfern.
Mr Craig Walker, Traffic Operations Manager, Hunter Region
Mr Seaton Wilson, RTA Traffic Commander

SCOTT'S TRANSPORT, MILPERRA.

Mr Michael Edwards, General Manager, Bulk Tank Division.
Mr Scott Tester, State Operations Manager.
Mr Steven Hay, NSW Training Manager, Tanker Division.

ST JOHN AMBULANCE AUSTRALIA (NSW).

Hon. Peter Collins, AM QC RFD, Chair, Board of Directors.
Mr Sean Gavin, Chief Executive Officer.




     K.E. Moroney AO, APM ‐ Inquiry into F3 Crash, 12 April 2010       Page 119 
                                             


TRANSPORT NSW.

Mr Les Wielinga, Director General.


VICTORIA POLICE.

Deputy Commissioner Ken Lay APM, (Traffic Operations).


VICROADS.

Mr Gary Liddle, Chief Executive Officer.


WORKCOVER AUTHORITY OF NSW.

Ms Lisa Hunt, Chief Executive Officer.




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13.   LIST OF ATTACHMENTS / SUPPORTING INFORMATION
Attachments
1     -    Rapid Response for New F3 Emergency Plan, March 2008
2     -    NSW Police – RTA MOU, Traffic Management of Events
           and Incidents, October 2009
3     -    F3 Sydney to Newcastle Freeway – Traffic Management Plan
           for Incidents, RTA, December 2005
4A    -    Motor Vehicle Crashes – Major or Minor Crashes – Arrival and
           Assessment – NSW Police Force Duty Officers Handbook
4B    -    Full or Partial Closure of the F3 Freeway, NSW Police, April
           2010
5     -    Damage to Truck Assessment, Scott’s Transport, April 2010
6     -    Transport Emergency Response Plan, Scott’s Transport,
           September. 2009
7     -    F3 Incident Management Improvement Program, May 2010
8     -    RTA Chief Executive Duty Statement, RTA, July 2009
9     -    RTA Organisational Chart, April 2010
10    -    Role of the Transport Management Centre, RTA
11A -      Organisational chart for the Transport Management Centre,
           Redfern, April 2010
11B -      Organisational chart for the Road Safety and Traffic
           Management Centre (RSTMC), Hunter Region
12    -    Listing of additional RTA F3 policy statements (18)
13    -    Traffic Management Protocols for Priority Roads between RTA
           and Emergency Services, May 2010
14    -    Policy and Procedure for Contra-Flow Traffic Management –
           F3 Freeway, RTA, March 2009
15    -    F3 Freeway Incident Management Infrastructure Project, RTA,
           March 2010
16    -    RTA Report – F3 Incident 12 April 2010 (prepared for Minister
            for Transport and Roads, 13 April 2010)
17A -      RTA F3 Traffic Flow patterns
17B -      Map of F3 northbound traffic, time x length of queue, pre-contra-
           flow period, 12 April 2010
17C -      Map of F3 northbound traffic, time x length of queue, post-
           contra-flow period, 12 April 2010
18    -    RTA Traffic Flow on F3 Freeway
19    -    RTA Chief Executive Submission to Inquiry, 24 May 2010
20    -    RTA Contra-flow Guidelines
21    -    Response of Auditor General to Inquiry, 30 April 2010
22    -    Response of Health NSW to Inquiry, 3 May 2010
23    -    Response of Department of Human Services to Inquiry, 4 May
           2010
24    -    Response of Emergency Management NSW to Inquiry, 4 May
           2010
25    -    Response of Independent Transport Safety and Reliability
           Regulator to Inquiry, 30 April 2010
26    -    Response of National Roads and Motorists Association to
           Inquiry, 6 May 2010

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List of Attachments (continued)

27    -        Response of St John Ambulance Australia (NSW) to Inquiry, 5
               May 2010
28    -        Response of WorkCover NSW to Inquiry, 7 May 2010
29    -        Response of Transport NSW to Inquiry, 29 April 2010
30    -        Responses of Department of Environment, Climate Change and
               Water to Inquiry, 4 May 2010 / 2 June 2010

Maps ( 1-16)


Photographs / Other Figures
1       F3 Crash of 29 January 2008
2       F3 Crash of 30 January 2008
3       F3 Crash of 21 April 2009
4       F3 Crash of 12 April 2010
5       F3 Crash of 12 April 2010
6       F3 Crash of 12 April 2010
7       F3 Crash of 12 April 2010
8       F3 Crash of 12 April 2010
9       F3 Crash of 12 April 2010
10      F3 Crash of 12 April 2010 (Damage to Fuel Tanker)
11      F3 Crash of 12 April 2010 (Damage to Fuel Tanker)
12      F3 Crash of 12 April 2010 (Damage to Fuel Tanker)
13      F3 Crash of 12 April 2010 (Damage to Fuel Tanker)
14      F3 Crash of 12 April 2010 (Damage to Fuel Tanker)
15      Truck Crash Explosion, Michigan
16      Truck Crash Explosion, Michigan
17      Concept Diagram of Proposed TICC
18      Traffic build up – 12.20pm – 5.00pm on 12 April 2010
19      Traffic build up 8.48 pm – 11.55 pm (contra-flow running) on 12
        April 2010




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