Nelson Ng General Manager – Safety & Quality MTR Corporation October 2013

1. IRSC 2013Strengthening the Risk Controls of High Risk Scenarios through Operations System Safety Assurance (OSSA) Nelson Ng General Manager – Safety & Quality MTR Corporation October 2013

2. Railway Incidents France Derailment on 12-Jul Swiss Train Crash 29-Jul Spain Derailment on 24-Jul MTR Corporation MTR Corporation 10/14/2014 Page 2

3. MTR Corporation MTR Corporation 10/14/2014 Page 3

4. Are we still confident that all our risk controls are adequate and effective? Can we defend our systems and controls in front of the media and the court ? Railway Incidents France Derailment on 12-Jul Swiss Train Crash 29-Jul Spain Derailment on 24-Jul MTR Corporation MTR Corporation 10/14/2014 Page 4

5. A new system for assuring risk controls are adequate & robust Operations System Safety Assurance (OSSA) MTR Corporation

6. Business Overview of MTR We carry 5 million passengers every weekday in Hong Kong with 99.9% train punctuality MTR Corporation

7. Business Overview of MTR Heavy Rail 12routes 68 stops 36 KM length Light Rail Bus 11 lines 84 stations 182 KM length 17routes MTR Corporation

8. MTR in Hong Kong Weekday rush hours in Hong Kong… MTR Corporation MTR Corporation MTR Corporation 10/14/2014 10/14/2014 Page 8 Page 8

9. Corporate Safety Management Model A new process under “Risk Management” & “System Assurance” to drive continuous improvement MTR Corporation

10. Managing Risks Proactively Zero Fatality Accident Major Injuries Minor Injuries Risk 2500 risks in Risk Register ASRISK (plus many project phase risks) Human errors Organisational failures and Near misses Process failures Equipment failures Unknown risks • Not easily seen • Unexpected cause or consequence • Ineffective execution of risk controls MTR Corporation

11. To understand why existing control measures couldn’t safeguard these risks ? Risk Management Challenges MTR Corporation

12. Building & Maintaining Fit-for-purpose Assets Reducing Risks toALARP Update and review Identify & Evaluate Risks RISK CONTROL New Railway Lines Implement Controls Maintenance Interfacing Works Asset Modification Handover to Operations Design Register Risk ASSET LIFECYCLE Propose controls Challenge - Risk Controls proposed by different parties at different times Commissioning Construction MTR System Assurance Framework Project Phase Day-1 Operation Operating Operations Phase Asset Replacement MTR Corporation

13. Reference hazard log sent to contractor for review System Assurance (SA) Team to conduct risk assessments on specific issues, as raised by designers, construction team, or Operations Contractor to review the hazard log at various project phases • Contractor to: • - review the reference hazard log • conduct hazard identification • exercises e.g. HAZOP, PHA, etc. Contractor to prepare the contract specific hazard log Contract Specific Hazard Log Diverse risk sources and ownership Risk IdentificationProcess for new projects Consultants Contractors Sub-contractors Operating Railway MTR Corporation

14. Are we giving adequate attention to those R3/R4 risks with high consequences ? Regular Review of Risks by Risk Owners & Safety Committees MTR Corporation

15. Are the risk controls adequate and robust ? Regular Review of Major Risk Scenarios Train Derailment Human Factors Rolling Stock Failures Infrastructure Failures Signalling Failure S682 – SPAD during RM driving (R3) S5244 – Derailment due to wheelset failure (R2) Precursor: Non ATP or RM Working Precursor: SPAD SCI Axle SCI Wheel HighConsequence Risks HighFrequency Risks 12 Major Risk Scenarios Stringent maintenance control on Safety Critical Items (SCI) Precursor Trends MTR Corporation

16. Are the risk controls still fit-for-purpose to prevent human error ? Risk Management Challenges • Higher chance of having a high consequence incident due to a technical and/or human failure Controls to eliminate/mitigate gap Fall through platform gap Public Announcements Station Assistant Controls to warn passengers of gap Controls to detect passengers in gap Platform Supervisor CCTV MTR Corporation

17. OSSA (Operations System Safety Assurance) • Frequency of • Equipment failure • Consequence • Event • frequency per • year • (A) • (B) • (C) • (D) • 0.26 • 0.11 • 0.93 • 4.54E-02 • Y • Minimal • 4.54E-02 • 1.34E-02 • From FTA • 1.44E-02 • Y • Minimal • 1.34E-02 • Y • Train Collision • 1.03E-03 • N • 1.03E-03 Do we have a good tool to do a complete health check on the risk controls? • N • 1.30E-01 • Minimal • 1.15E-01 • N • 1.15E-01 Quest for Sharpening the Saw Systematic Review of SCI FTA ETA QRA System Diagram Operational Flow Diagram Risk Model (Scenarios) PHA HAZOP HAZOP MTR Corporation

18. Operations System Safety Assurance (OSSA) Operational risk controls are adequate & robust to prevent major railway incident O Seek new ideas and systematic improvement through benchmarking and brainstorming S Safety “Health Check” to review all risk causes and consequences and prioritise actions for weaker controls S MTR Corporation

19. Operations System Safety Assurance (OSSA) – Methodology • Successfully • Completed 3 studies ! • Platform Train Interface • Derailment • Escalator MTR Corporation

20. OSSA – Review of Risk Controls by Scenario Major Risk Scenario • Review adequacy and robustness of key controls under each scenario PTI Trapped and dragged Hit by train Trapped between PSD / train Fall through platform gap Identify Critical Controls and Management Process MTR Corporation

21. Platform Supervisor OSSA – Prioritise Risk Controls • Use trafficlight to show strengths & weaknesses Controls to eliminate/mitigate gap Controls to warn passengers of gap Fall through platform gap Public Announcements Station Assistant Station Assistant Controls to detect passengers in gap MTR Corporation

22. OSSA – Systematic Health Check on Risk Controls • Challenging the controls from four perspectives Provide additional assurance that risk controls are effective in reducing risks to ALARP MTR Corporation

23. Bowtie structure helps analyse the risk controls preventing the occurrence of an event and mitigating the consequences arising OSSA – Holistic Cause & Consequence Review MTR Corporation

24. OSSA – Validating Risk Control Effectiveness Risk Control Categories Effectiveness / performance measure Provide safety device Incident frequency trends (some normalised), for some controls – look at average severity Functioning of equipment (no human involved) T&C stage: test records, Operations stage: test records, daily incident record, failure trends Functioning of equipment (with staff involvement) See “Staff Competence” and “Functioning of Equipment” and “Provide operating procedure” and “Follow operating procedure” Maintain equipment Failure trends, Asset Condition Survey, maintenance records, SCI audit, contractor audit Technical specification Complies with specification. T&C record Provide and follow operating procedure Incident trends, passenger complaints, activity audit, compliance check results (e.g. LR speed checks) Staff competence Training record, briefing record, manager, D&A test results, contractor audit Passenger signs / announcements / warnings Not required MTR Corporation

25. Focus workshop on best practices in different railway companies and the justifications of not applying in MTR OSSA – Focus Workshop / Benchmarking MTR Corporation

26. Out-of-the box Thinking Process involving Corporate Relations, Finance, New Graduate Engineers, HR teams OSSA – Blue Sky Workshop MTR Corporation

27. Innovative and dedicated efforts to explore new technologies by our engineers OSSA - Provoking Innovative and New Ideas • Inflatable Platform Gap Fillers trial • Platform Edge LED / rubber gap filler Video MTR Corporation

28. Explore appropriate technologies to mitigate risk while minimising disturbance to train services OSSA - Provoking Innovative and New Ideas • Detect • Trial of under platform intrusion detection device (pressure mat from Japan) • Trial of platform intrusion detection device (two-layered) MTR Corporation

29. Enhancing the human factors aspects of risk controls which highly rely on human performance OSSA - Enhancing Human Factors Performance • Additional Platform Emergency Plunger (PEP) for high risk and curved platforms • Platform Supervisor CCTV and Monitors Upgrade and Trial MTR Corporation

30. OSSA - Integrating Safety Management Processes • Enhance the interface between Asset Condition Survey results (AMS) and risk review process (SMS) MTR Corporation

31. Learning Points – Critical Success Factors • Holistic and pragmatic approach • Right People and Right Thinking Process • Focus group to collect and verify risk information • ‘Blue Sky’ workshop with Non-technical colleagues • External subject matter experts MTR Corporation

32. Recap - Creating Values through OSSA Operational risk controls are adequate & robust to prevent serious incidents O As Prepared As Possible Seek new ideas and systematic improvement S S Safety “Health Check” providing assurance at all levels A MTR Corporation

33. Thank you Have a safe journey MTR Corporation