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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

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

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23 rd international railway safety conference managing human factors in hong kong through

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


Railway system in hong kong

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


Oversight on safe railway operations

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


What is human factors

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)


Risk based model

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


Classification of human factor incidents

Classification of Human Factor Incidents


Trends of human factors incidents

Trends of Human Factors Incidents


Risk assessment by risk matrix

Risk Assessment by Risk Matrix


Risk assessment by risk matrix1

Risk Assessment by Risk Matrix


Analysis of high overall risk incidents

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


23 rd international railway safety conference managing human factors in hong kong through

Human Factors Incidents


Case 1 21 january 2010 east rail line failure of data t ransmission network

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


Failure of data transmission network at east rail line

Failure of Data Transmission Network at East Rail Line


Case 1 21 january 2010 east rail line failure of data transmission network

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


Failure of data transmission network at east rail line1

Failure of Data Transmission Network at East Rail Line


Case 1 21 january 2010 east rail line failure of data transmission network1

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


Case 1 21 january 2010 east rail line failure of data transmission network2

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


Eal train captain pressing d oor by pass b utton without occ authorisation

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


23 rd international railway safety conference managing human factors in hong kong through

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


23 rd international railway safety conference managing human factors in hong kong through

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


23 rd international railway safety conference managing human factors in hong kong through

Case 2: 8January 2012, East Rail LineTrain Captain Opened Doors of Train Stopping Short of Platform Rear End

With Courtesy of MTR Corporation Limited


Case 3 21 october 2010 tsuen wan line breakage of overhead line contact wire

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


Case 3 21 october 2010 tsuen wan line breakage of overhead line contact wire1

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


Case 3 21 october 2010 tsuen wan line breakage of overhead line contact wire2

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


Case 3 21 october 2010 tsuen wan line breakage of overhead line contact wire3

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


23 rd international railway safety conference managing human factors in hong kong through

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


23 rd international railway safety conference managing human factors in hong kong through

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


Case 4 rail breakage incidents at east rail line and tsuen wan line 2011

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


Case 4 rail breakage incidents at east rail line and tsuen wan line 20111

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


23 rd international railway safety conference managing human factors in hong kong through

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


23 rd international railway safety conference managing human factors in hong kong through

Thank You


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