1 / 34

23 rd International Railway Safety Conference Managing Human Factors in Hong Kong through

23 rd International Railway Safety Conference Managing Human Factors in Hong Kong through a Risk-based Approach Presented by Paul H.B. SEN Railways Branch Electrical & Mechanical Services Department Government of the Hong Kong SAR. Railway Network of HK. HR: 11 Lines, 84 Stations

shayla
Download Presentation

23 rd International Railway Safety Conference Managing Human Factors in Hong Kong through

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. 23rd International Railway Safety Conference Managing Human Factors in Hong Kong through a Risk-based Approach Presented by Paul H.B. SEN Railways Branch Electrical & Mechanical Services Department Government of the Hong Kong SAR

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

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

  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)

  5. Risk-based Model 4 Phases Deficiency Remedies Risk Rating Causation 1 2 3 4 Continuous Monitoring Plan-Do-Check-Act Skill Rule Knowledge Likelihood Consequence Equipment Failure Human Factors External Factors Classification of Incidents Risk Assessment HF Analysis accordingly to Risk Rating Recommendation

  6. Classification of Human Factor Incidents

  7. Trends of Human Factors Incidents

  8. Risk Assessment by Risk Matrix

  9. Risk Assessment by Risk Matrix

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

  11. Human Factors Incidents

  12. Case 1: 21 January 2010, East Rail LineFailure of Data Transmission Network

  13. Failure of Data Transmission Network at East Rail Line

  14. Case 1: 21 January 2010, East Rail LineFailure of Data Transmission Network

  15. Failure of Data Transmission Network at East Rail Line

  16. Case 1: 21 January 2010, East Rail LineFailure of Data Transmission Network

  17. Case 1: 21 January 2010, East Rail LineFailure of Data Transmission Network 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

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

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

  20. Case 2: 8January 2012, East Rail LineTrain Captain Opened Doors of Train Stopping Short of Platform Rear End • Reinforcing the • correct procedure for • operating door by-pass • switch • Identifying train stopping position K R Procedure Vigilance Improvement Measures D S Aid MMI • Installing • stopping mark at • each platform • end • Switch relocation • Reminder label

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

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

  23. Case 3: 21 October 2010, Tsuen Wan LineBreakage of Overhead Line Contact Wire

  24. Case 3: 21 October 2010, Tsuen Wan LineBreakage of Overhead Line Contact Wire Human Errors - Communication between OCC and Train Captain - Mistake in reporting the pantograph status to the Traffic Controller Equipment Failure - Traction motor - Train-bourne circuit breaker Snowball Effect • Consecutive electric short-circuit faults • Overhead line contact wire overheated and burnt out • 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

  25. Case 3: 21 October 2010, Tsuen Wan LineBreakage of Overhead Line Contact Wire 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 Replace train-borne circuit breakers with new ones of higher current rupture capacity Review and revise the operation control procedure for closing traction supply circuit breakers to provide clear steps for operators to follow

  26. Case 4: Rail Breakage Incidents at East Rail Line and Tsuen Wan Line 2011 Restricted Manual Mode Train Operation at 20 kph East Rail Line Breakage of rail as a result of crack propagating from an insulated rail joint bolt hole. JAN 13

  27. Case 4: Rail Breakage Incidents at East Rail Line and Tsuen Wan Line 2011 Restricted Manual Mode Train Operation at 20 kph Tsuen Wan Line Aluminothermic weld defect causing rail breakage FEB 10

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

  29. Case 4: Rail Breakage Incidents at East Rail Line and Tsuen Wan Line (2011) Recommendations Adoption of EN14730 • Site aluminothermic • weld procedure • Qualification of • welding personnel • Standards • Standards Improvement Measures Recommendations Adoption of ISO 9712 • Independent • examination • certification of NDT • personnel

  30. 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

  31. Thank You

More Related