iesm 2013 Integrated System Assurance Approach for Railway Design, Construction and Operations

Transcription

1 iesm 2013 Integrated System Assurance Approach for Railway Design, Construction and Operations Nelson Ng General Manager Safety & Quality MTR Corporation 11 April 2013

2 Business Overview of MTR We carry 4.9 million passengers every weekday in Hong Kong Page 2

3 Heavy Rail 11 lines 84 stations 182 KM length Light Rail 12 routes 68 stops 36 KM length Bus 17routes Business Overview of MTR Page 3

4 Our rush hours MTR Corporation 4/17/2013 Page 4

5 Business Overview of MTR Guangzhou-Shenzhen-Hong Kong Express Rail Link Kwun Tong Line Extension Shatin to Central Link West Island Line South Island Line (East) Page 5

6 Our Vision We aim to be a leading multi-national company that connects and grows communities with caring service Beijing Metro Line 4 Shenzhen Metro Longhua Line Hangzhou Metro Line 1 LOROL MTR Stockholm Metro Trains Melbourne Page 6

7 Safety Management Framework Corporate Safety Governance Framework 2013/4/17 Page 7

8 Our Safety performance is amongst the very best in the world 2 Safety Aspirations 40 Safety Total Fatalities / Billion Passenger Journeys To be amongst the very best in safety performance globally Better To be the safest mode of public transport in every place where we operate As - Asian Metros Eu - European Metros As MTR As SA SA* Eu Eu Eu Eu Eu NA Eu NA NA - North American Metros SA - South American Metros Source : CoMET Data Only metros with data are listed (* 2009 result) Page 8

9 Hong Kong Safety & Health Regulations Mass Transit Railway Ordinance Cap. 556 and Operating Agreement Factory & Industrial Undertakings Ordinance (occupational safety & health) No local prescriptive railway safety standards Adopt UK and other international safety and risk management principles and good practices ALARP Principle As Low As Reasonably Practicable R1 R2 R3 High Risk R4 Size of risk Low Risk Driving for Continuous Improvement 9 Page 9

10 Corporate Safety Management Model Risk Management & System Assurance are fundamental elements of our SMS to drive continuous improvement MTR Corporation 4/17/2013 Page 10

11 MTR System Assurance Framework Project Phase Day-1 Operation New Railway Lines Interfacing Works Building & Maintaining Fit-for-purpose Assets Handover to Operations Design ASSET LIFECYCLE Operating Commissioning Construction Operations Phase Maintenance Asset Modification Reducing Risks to ALARP Update and review Implement Controls RISK CONTROL Identify & Evaluate Risks Register Risk Asset Replacement Propose controls Page 11

12 MTR System Assurance Process Organization Key Processes Project Phase Day-1 Operation Operational Phase New Railway Lines Interfacing Works Operating Maintenance Asset Modification Asset Replacement Project System Assurance Risk Control Operations System Assurance System Assurance Plan & Specification SA / RAMS Analysis (HAZOP, PHA, FMECA, FTA, ETA, QRA, DSA, CCF, SIL, MRA, DSC, Human Factors, PHL) Independent Safety Assessment Risk Identification & Control (ASRISK) Risk Identification (R1 to R4) Risk Review CBA Integrated SA HAZOP RCM PHL Risk Assessment V&V, Audits EMC, Software Maintenance Control of SCI Operational Control of SCO Risk Control Performance Precursor Monitoring Operations System Assurance Value Assessment V1 to V4 Independent Safety Assessment Design Control (SCS) Hazard close out & Transfer Design Control SCS System Reliability Modelling System Safety Report RAM Demo., DRACAS Risk Scenarios Review Operations System Safety Assurance (OSSA) Technical Safety Assurance Software & Integrity Assurance Enterprise Risk Management (ERM) Page 12

13 Corporate-wide Risk Knowledgebase Over 3,000 Risk Records, ~60 Precusors and ~600 Safety Critical items (SCI) Used by Operations, New Projects and C&R Works Page 13

14 Project System Assurance Framework (Life Cycle) Particular Specifications Contract Award Design Completion System Validation Revenue Service Definition / Specification Tendering Design Construction / Installation T & C Trial Running Operation / Maintenance Requirement analysis and specification Project Hazard Log Safety Analysis (if needed) Validation and Verification System Safety Report Operations Hazard Log Page 14

15 Risk Identification (Project Phase) Reference hazard log sent to contractor for review 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. System Assurance (SA) Team to conduct risk assessments on specific issues, as raised by designers, construction team, or Operations Contractor to prepare the contract specific hazard log Contract Specific Hazard Log Page 15

16 Risk Identification (Project Phase) Bottom-up Approach Top-down Approach High Level Hazard Records Project Specific Issues Interface with operating railway Software cut-in Unattended Train Operation Page 16

17 Risk Identification (Project Phase) Top Events (Major Hazards) Collision Derailment Fire External Factors Others. MTR Corporation 4/17/2013 Page 17

18 A1. Suspension system failure A2. Bogie structure failure A3. Broken axle A4. Underframe equipment drops onto track xxx equipment failure A5. Wheel failure (e.g. excessive wear beyond limit) A6. Braking system fails to reduce train speed B1. ATP Wrong Side Failure cause train overspeeding B2. Wrong Side Failure of speed indication B3. ATP failure to detect correct point position B4. Point moves when train berthing above the point Trains Signalling C1. Defective switch or crossing C2. Undetected broken rail C3. Broken clips or mounting failure C4. Track twist C5. Incorret track profile C6. Materials left or object fallen from OLE on track C7. Equipment installation (including OLE, TECS, trackside auxiliary,...etc.) inside tunnel infringe KE Tracks Derailment Others Station E1. Advertising panel detached from wall E2. PSD detached E3. Equipment installation at platform infringe KE D1. Signalling Passing at Danger under RM mode D2. Tunnel structure failure (e.g. concrete spalling from ceiling) D3. Differential settlement of WIL stations MTR Corporation 4/17/2013 Page 18

19 Interfacing Works Risk Management Works at SHW Uptrack Temporary Refuge Siding Sheung Wan Admiralty Works at SHW Downtrack New Temporary Refuge Siding Page 19

20 Project System Assurance System Safety Report New Railway Project System Safety Report New Railway Project System Safety Report Section 1 Introduction Section 2 System Description Section 3 Safety Management System Section 4 Operations Assessment Section 5 Hazard Identification & Control Section 6 Deterministic Safety Assessment Section 7 Conclusions Appendices Overview of the operational safety of the new railway system prior to handover to Operations Outline the operational safety management tasks undertaken at project phase and planned downstream for future operations Provide a summary of the key operational safety issues, that complement the risks to be transferred to Operating Railway Page 20

21 Operations System Assurance 5 million people a day 99.9 % train reliability Any changes could have an effect on its people, organisation, procedure and equipment and overall system performance Equipment/ Environment Procedure People Organisation Page 21

22 Technical Safety Assurance Framework Integrated System Assurance Framework Software Assurance Framework Integrity Assurance Framework New Business Safety Assurance Framework Operations Assurance Process Assure assets are able to perform to the required Reliability, Availability, Maintainability and Safety requirements Management and Engineering Assurance Tasks Risk Management, Independent Check, QRA, FMECA, RAM analysis, Interface requirement, Reliability Centered Maintenance, Cost Benefit Analysis, software V-model, technical audit Page 22

23 Technical Safety Assurance To assure a safe railway operation Tasks for assuring safety of O&M activities and modification of asset involving Safety Critical System Tasks for seeking continuous safety improvement Independent Check Incident Review Technical Investigation Fit-To-Test and Fit-To-Run Certification Quantitative Risk Assessment Safety Alert from other Railways Review on International Standard Operating Railway Benchmarkin g Technical Safety Assurance Page 23

24 Integrated System Assurance To assure seamless transition with the introduction of new assets and modifications of existing assets Life cycle SA - from concept stage through to handover and future O&M Prj. Stage Concept/ Funding Tender/ Design Const. T&C DLP Project Risk Appraisal Formulation of SA Program Plan Implementation of SA tasks in SA Program Plan Handover Tailoring SA activities based on risk of individual project Page 24

25 Software Assurance To assure critical software changes are properly done for Safety / Service Critical Systems, e.g. Signalling / AFC Page 25

26 No. of >=2 mins delays per month Integrity Assurance To assure assets are fit for the purpose after years of service Technical Audits System Reliability Monitoring Asset Condition Surveys 60 URL -- No. of 2 min Delays vs Probability of Escalating to 5-min Delays 50 Worse 40 KTL (2011Q2-2012Q1) Better ISL (2011Q2-2012Q1) TWL (2011Q2-2012Q1) KTL (2012Q2) TWL (2012Q2) TKL (2011Q2-2012Q1) 500:1 PAR 10 TKL (2012Q2) ISL (2012Q2) 1000:1 PAR 1500:1 PAR Probability of Escalating to 5-min Delay Page 26

27 Managing Safety Critical Systems and Tasks Design Control Maintenance Control Operational Control Safety Critical Systems (SCS) Safety Critical Item (SCI) Safety Critical Operations (SCO) e.g. Train Wheel & Axle, Emergency Brake and Door System, Signalling ATP / interlocking system e.g. Train underframe equipment, door control unit, Escalator safety switches, Platform Screen Door detection relays (600 items) e.g. Door Isolation, Train Manual Mode operation, Manual operations of points, operation of tunnel emergency ventilation Competent design staff Design and functions verified and validated Independent design checks Technical audit Maintenance by certified staff Safety Independent Check Full maintenance records Period audits Incoming goods inspection control Operations by qualified staff Safety Independent Check Full log book/ records of actions and system affected Periodic review/audits Page 27

28 PHA HAZOP Systematic Review of SCI Evolution of Safety Toolkits FTA ETA QRA System Diagram Operational Flow Diagram Risk Model (Scenarios) OSSA (Operations System Safety Assessment) HAZOP Consequence frequency Event per year Frequency of Equipment failure (A) (B) (C) (D) E-02 Y Minimal 4.54E E E-02 Y Minimal 1.34E-02 From FTA Y N Train Collision 1.03E E-03 N 1.30E-01 Minimal 1.15E-01 N 1.15E-01 Train stalled in a Tunnel PAX on PAX inform incident Tcap of incident train thru PAD Tcap TC1 Acknowledge incident & inform TC Acknowledge incident Observe fire symptoms (CCTV) & assess situation N Saloon on fire? Y Try to put out the fire Inform pax to use fire extinguisher Fire extinguishable? Make PA to inform & calm down pax Communicate with TC Hold other trains at stn in affected sections Report incident & summon assistance Y Follow Non-emergency Detrainment Procedure N Decide detrainment option # All call to other trains/stns end side CC Acknowledge incident Declares major incident Summons FSD & emergency services PAX on other trains Tcap of other trains PAX ask for help thru PAD Acknowledge incident & inform TC Multiple TC2 Acknowledge incident Page 28

29 Risk Tree and Safety Critical Items/Precursor Trend Major Risk Scenarios Risk Tree Derailment Object on / near track Track Failure Staff Behaviour Train Failure Bogie Signalling Coupler Brake Pantograph Derailment due to XX rail (Rx) Derailment due to XX unloading (Rx) Derailment due to damage of coil sxxs (Ry) Derailment due to structural damage of bogie frame (Rx) Root Cause High Frequency Risks ASRISK High Consequence Risks Coil Spring (Safety Critical Item) Page 29

30 Operations System Safety Assessment (OSSA) A new tool to review Major Risk Scenario High consequence scenarios Trapped and dragged Identify Critical controls The management processes for critical controls Fall through platform gap Design Existing processes Hit by train PTI Train moves with PSD open PTI Maintenance Existing process Trapped between PSD / train Operations Existing processes Fall through platform gap adequacy and robustness of key control measures for high consequence scenarios Review existing, rejected and potential controls Use traffic light to focus on strengths & weaknesses Overview of Strengths and weaknesses Provide an increased level of assurance that risk controls are reducing risk ALARP Page 30

31 Integrating Human Factors with SMS Incident Review / Safety Process Accident Reports (Staff / Contractor) Human Factors Process Incident / Investigation Reports Human Factors Issue Register Equipment/ Environment People People Hazard & Near Miss Reporting Change Management Job Hazards Behavioural Safety Observation (BAPP) Human Factors Reports PSF Root Cause Recommendations Risk Register (ASRISK) Human Factor Studies Design Ergonomics Workload Human Performance Issues & Control Measures Procedure Equipment & Environment Organisation Process Human Factors Wheel (Error Traps Analysis) MTR Corporation 4/17/2013 Page 31

32 Integrating all Risks under Enterprise Risk Management (ERM) Framework Top 10 The Board (Annually) Executive Committee (6 monthly) + hot spots Top 30 Legal/ Regulatory Enterprise Risks E1, E2, E3, E4 Divisional Risks Political/ Reputation Business Performance Financial Safety MTR Corporation Railway Operation s Safety Risks Project Risks Railway Operations Safety Risk is an integral part of Enterprise Risk Management )w $ Business Units (Hong Kong, Mainland China and Overseas) Business Risks 4Eol( Enterprise Risk Committee (3 monthly) 4/17/2013 Page 32

33 Systematic Review of SCI Competence Management of Railway System Safety and Reliability Specialist Page 33

34 Enhancing Platform/Train Interface Safety Enhanced monitoring at platform Trial of different types of gap fillers Additional Platform Emergency Plungers Reducing Platform Gap Minimising Train/Platform Screen Door Gap and Detecting Trapping Bridging the Gaps Standardisation Page 34

35 Building Better and consistent HMI Human Factors Different Trains Different Cab HMI Standardised HMI - Grouping / Color / Logic Page 35

36 Operating a Safety Critical Task Human Factors Passengers will evacuate towards LOF. I will switch on modes KOT 23,LOF 22 Environmental System Controller Traffic Controller Independent Verification Mode Table Checked OK! Prompting by Decision Support System Computer-aided Decision Support (standalone) Press press Confirm Button to operate selected modes Fully FAO? Integrated Decision Support System Page 36

37 Integrated System Assurance Approach Integrated & holistic Equipment/ Environment People Procedure Organisation Systematic Update and review Implement Controls RISK CONTROL Identify & Evaluate Risks Register Risk Propose controls Asset Lifecycle Handover to Operations Design ASSET LIFECYCLE Commissioning Construction Page 37

38 Thank you Have a safe journey Page 38