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1. Railway System in Hong Kong 2 Railway Network of HK  HR: 11 Lines, 84 Stations  LR: 12 Routes, 68 Stops  Total Route Length: 218km  5.1 Million.

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Presentation on theme: "1. Railway System in Hong Kong 2 Railway Network of HK  HR: 11 Lines, 84 Stations  LR: 12 Routes, 68 Stops  Total Route Length: 218km  5.1 Million."— Presentation transcript:

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2 Railway System in Hong Kong 2 Railway Network of HK  HR: 11 Lines, 84 Stations  LR: 12 Routes, 68 Stops  Total Route Length: 218km  5.1 Million pax / weekday

3 Oversight on Safe Railway Operations 3 Investigation of railway incidents Ensuring the adoption of appropriate safety practices by the railway corporations; Assessing and approving new railways and major modifications Assessing and following up the railway corporations' improvement measures

4 What is Human Factors? “… the environmental, organisational, and job factors, and human and individual characteristics which influence behaviour at work in a way which can affect health and safety.” (Health & Safety Executive, UK) 4

5 RecommendationHF Analysis accordingly to Risk Rating Risk Assessment Risk-based Model 4 Phases Classification of Incidents Risk Rating Likelihood Consequence CausationCausation Equipment Failure Human Factors External Factors DeficiencyDeficiency Skill Rule Knowledge RemediesRemedies Continuous Monitoring Plan-Do-Check-Act

6 Classification of Human Factor Incidents 6

7 Trends of Human Factors Incidents 7

8 8 Risk Assessment by Risk Matrix

9 9 OR1Unacceptable and shall be eliminated OR2Undesirable and shall be reduced by practicable control measures OR3Tolerable but shall be further reduced if possible OR4Negligible Risk Assessment by Risk Matrix

10 Analysis of High Overall Risk Incidents Human Deficiency Skill Rule Knowledge Performance Shaping Factors Task design, interface design, competence management, procedures, person, environment HF Analysis

11 11 Human Factors Incidents

12 12 Case 1: 21 January 2010, East Rail Line Failure of Data Transmission Network

13 Failure of Data Transmission Network at East Rail Line 13

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16 Case 1: 21 January 2010, East Rail Line Failure of Data Transmission Network 16

17 Failure of Data Transmission Network at East Rail Line 17

18 Case 1: 21 January 2010, East Rail Line Failure of Data Transmission Network 18

19 Remedial Measures Assigning designated staff to closely monitor audits and communicate with third-party expert Avoid peak hours audits Prohibit uploading of new software patches to the online operating systems during traffic hours 19 Case 1: 21 January 2010, East Rail Line Failure of Data Transmission Network

20 20 EAL Train Captain Pressing Door By-Pass Button without OCC Authorisation Case 2: 8 January 2012 East Rail Line Train Doors Opened when Train Stopped Short of Platform Rear End

21 Case 2: 8 January 2012, East Rail Line Train Captain Opened Doors of Train Stopping Short of Platform Rear End What’s wrong? Train captain did not identify the train stopping position There is a procedural bar for door opening Emergency activation by pressing door by-pass switch needs OCC authorisation Train captain did not seek OCC authorisation Potential safety threat of passenger falling to track at height

22 Switch relocation Reminder label Reinforcing the correct procedure for operating door by-pass switch Installing stopping mark atstopping mark each platform end Identifying train stopping position Improvement Measures Case 2: 8 January 2012, East Rail Line Train Captain Opened Doors of Train Stopping Short of Platform Rear End

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24 With Courtesy of MTR Corporation Limited Case 2: 8 January 2012, East Rail Line Train Captain Opened Doors of Train Stopping Short of Platform Rear End

25 25 Case 3: 21 October 2010, Tsuen Wan Line Breakage of Overhead Line Contact Wire

26 26 Case 3: 21 October 2010, Tsuen Wan Line Breakage of Overhead Line Contact Wire

27 Equipment Failure - Traction motor - Train-bourne circuit breaker Human Errors - Communication between OCC and Train Captain - Mistake in reporting the pantograph status to the Traffic Controller  Consecutive electric short-circuit faults  Overhead line contact wire overheated and burnt out Snowball Effect Human Errors - Procedure of the recovery of traction power by Power System Controller - Repeated attempts to reclose the traction DC circuit breaker before asking the platform supervisor to check the pantograph status on site

28 Agreed Mitigation Measures Install a visual indicator in the driving cab as an visual aid for the train captain to confirm the position of the pantographs Review and revise the operation control procedure for closing traction supply circuit breakers to provide clear steps for operators to follow Replace train- borne circuit breakers with new ones of higher current rupture capacity Case 3: 21 October 2010, Tsuen Wan Line Breakage of Overhead Line Contact Wire

29 13 JAN 2011 East Rail Line Breakage of rail as a result of crack propagating from an insulated rail joint bolt hole. Case 4: Rail Breakage Incidents at East Rail Line and Tsuen Wan Line

30 10 FEB 2011 Tsuen Wan Line Aluminothermic weld defect causing rail breakage Case 4: Rail Breakage Incidents at East Rail Line and Tsuen Wan Line

31 Track Maintenance Dating back from 13 January 2011 … Track maintenance staff had temporarily applied a bolt of smaller diameter Stress concentration at bolt and bolt hole Dating back from 10 February 2011 … Visual inspection every 3 days Track maintenance staff carried out NDT once every 2 weeks Could not detect any crack Case 4: Rail Breakage Incidents at East Rail Line and Tsuen Wan Line (2011)

32 RecommendationsRecommendations Adoption of ISO 9712 Independent examination certification of NDT personnel Improvement Measures RecommendationsRecommendations Adoption of EN14730 Site aluminothermic weld procedure Qualification of welding personnel

33 Conclusion Coping with human factors incidents – a job for both regulator and operator No recurrence of railway incident caused by the similar human errors Identifying high-risk scenarios and deploy resources accordingly for necessary improvements Targeted safeguard measures for reducing the HF risks to a level as low as reasonably practicable

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