`Unreasonable risks' in railway infrastructure
The report on railway safety published yesterday opens with this executive summary:
International Risk Management Services (IRMS), in association with its partner consultants, were commissioned in 1998 by the Department of Public Enterprise (the Department) to conduct a railway safety study of the Iarnrod Eireann (IE) network.
The study was completed in October 1998 and a report "A Review of Railway Safety in Ireland" issued.
Approximately 12 months after issue of this report, IRMS and its partner consultants have been commissioned by the Department to carry out a review of progress being made by IE and the Government against the recommendations contained in the original report.
This report contains the results, conclusions and recommendations arising from the review.
The objectives of the implementation review study were to carry out a review of:
the programme and actions contained in IE's railway safety programme against the recommendations contained in the IRMS previous report;
IE's actual implementation of the study recommendations.
As previously, the complete IE railway system, including the DART suburban system and freight traffic, was included in the scope of the study. Since this was primarily an audit study, a sample set of locations was prepared by the consultants and discussed with IE for site visits to inspect aspects of the infrastructure and rolling stock. This took account of previously identified unreasonable risks and those items of the infrastructure which required immediate attention.
The review has considered the following topics:
the safety adequacy of infrastructure and rolling stock;
developments in IE's safety management systems;
the risk model developed for the initial railway safety study was updated to reflect changes in the condition of the infrastructure;
consideration of changes to Railway Safety Regulation, addressing both a review of the roles and responsibilities of the Railway Inspecting Officer and consideration of relevant EU Directives Implementation.
Overall, the review has found that a great deal has been done by IE over the last 12 months to reduce risk on the railway and many encouraging initiatives have been started. However, much further work remains to be undertaken and/or completed across a range of key areas.
With respect to IE's railway safety programme, the identified funding is broadly in line with that recommended in IRMS's initial report and tasks and actions within the programme have generally been correctly identified.
However, it is noted that the funding allocated to Signalling and Telecommunications does not allow for some essential signalling renewals or the increased expenditure associated with the delays to the implementation of the mini-CTC system. Monies allocated to Permanent Way appear to be in excess of those required to make the railway safe. It is also noted that some of the previously identified unreasonable risks reported within the programme as completed were in fact not fully actioned.
With regards to the safety adequacy of the infrastructure, it was found that significant progress had been made by IE in a number of areas, but it was noted that very few of the previously reported unreasonable risks can be unambiguously reported as fully resolved. In addition, a number of further unreasonable risks were identified during the site visits. All of these risks require to be addressed and mitigated immediately. Following the original study, IE were strongly recommended to prepare and conduct their own programme of site visits to identify faults and failures in the infrastructure. It is evident from the continuing number of unreasonable risks identified that this is yet to occur.
With regards to engineering systems, standards, procedures and instructions are currently being prepared by all departments. However, it was evident that with the exception of Signalling and Telecommunications that the documentation was not always appropriate to the function of the relevant department or the railway.
These problems have been exaggerated by the large volume of work and the ambitious time-scales for their production. There is also no evidence to date of a risk-based approach to planning and works activities and expenditure. There is a pressing need for IE to establish an in-hour capability to develop and co-ordinate IE's risk management activities. These deficiencies must be rectified as a matter of priority.
It was also noted that with one exception, five-year plans were not available. These will be required to justify, plan, finance and prioritise the long-term work of the railway. The control and management of contractors and third parties is being progressed by the production of a company standard which is awaiting issue. Given the large amount of work being carried out by the railway, this issue requires urgent resolution and implementation.
With regards to human resources issues, it is evident that there continues to be a lack of resources, particularly relating to skilled staff in the engineering and electrical disciplines. This has resulted in some staff having to work very long hours. In many areas consultants are being used to provide the necessary input of manpower and skills. Where this is being undertaken, it is important that IE put sufficient managerial resources in place to manage the work.
A large amount of training is in progress or planned for the near future. However, improvements are required to ensure that it meets appropriate organisational and personal training objectives.
It is also important to note that the continuing poor industrial relations within IE is a major stumbling block to further safety improvement and must be addressed as a major priority issue. There is also significant evidence that the tremendous amount of activity on safety is in danger of creating a resistance to the required changes.
IRMS consider that there is a real danger of IE trying to do too much, too quickly and not consolidating upon safety improvements in a methodical and robust manner. This issue is exacerbated by the absence of a dedicated project manager to strengthen the co-ordination and prioritisation of the safety programme.
With regards to railway regulation issues, the Department of Public Enterprise has taken a number of steps towards meeting the recommendation of the first report. The professional strength of the railway inspectorate has been increased, although not yet its administrative strength.
Better liaison with the HSA has commenced and the Minister has announced a wide-ranging package of reforms in railway safety regulation which are currently being developed for implementation. It was also found that the Department is adequately represented in Europe so far as railway policy matters are concerned and has adopted into Irish law the two European directives referred to in the previous IRMS report.
In summary, much has been done to improve safety on the railway and there is significant awareness of the changes in safety culture required to achieve a safe railway for staff, passengers and the public. However, there are a number of critical areas to be addressed by IE if continuing and sustainable improvements in safety are to be achieved. These include:
IE to close out all identified unreasonable risks and to prepare and implement an audit programme to identify faults and failures across the infrastructure;
development of a well-managed risk management programme to prioritise future expenditure, supported by appropriate risk-modelling techniques;
ensuring the proper management of the activities of all third parties working on the railway;
recruitment of staff with the necessary skills and expertise;
resolution of outstanding Industrial Relations concerns;
ensuring the effectiveness of each initiative by ensuring they are undertaken in a structured, methodical fashion. This in turn requires the future work programme to be prioritised to ensure that IE do not try to do too much, too quickly.
This audit has clearly revealed that, in addition to those identified in the first report, many additional unreasonable risks continue to exist on the railway infrastructure.
This in turn provides strong evidence that it is highly likely that each future audit conducted on behalf of the Department will continue to identify new unreasonable risks unless additional management controls are implemented by IE. These controls need to comprise a system by which IE undertake their own rolling programme of audits to identify such deficiencies, combined with a risk-based process to prioritise future investment programmes.
Once such systems are in place, it will then be possible for future audits conducted on behalf of the Department to focus on the adequacy and effective operation of management controls rather than a detailed investigation of infrastructure conditions.