IRMS - DTTAS Department of Transport, Tourism And Sport · A Review of Railway Safety in Ireland - Second Implementation Review IRMS Report No: 7335.01 Issue No: 03 Date: April 2001

A Report Prepared by International Risk Management ServicesOn Behalf of the Department of Public Enterprise

IRMSIRMS

International Risk

Management Services

International Risk Management Services (UK) LtdSuite 8.018 Exchange QuayManchester M5 3EJEngland, UKTel: +(44) 161 958 8800 Report No: 7335.01Fax: +(44) 161 958 8888 Issue No: 03E-mail: [email protected] Date: April 2001

A Review of Railway Safety in

Ireland - Second Implementation

Review

In Association with:

MHA Systems Limited Holmes Davies

Holmes Davies Partnership

PB Power Ltd.

A Review of Railway Safety in Ireland - Second Implementation Review

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Report No: 7335.01Issue No: 03Date: April 2001 Page i

EXECUTIVE SUMMARY

International Risk Management Services (IRMS), in association with its partner consultants,was commissioned in 1998 by the Department of Public Enterprise (the Department) toconduct a Railway Safety Study of the Iarnród Éireann (IE) network. The study wascompleted in October 1998 and a report “A Review of Railway Safety In Ireland” issued.Approximately one year after the issue of this report, IRMS and its partner consultants werecommissioned by the Department to carry out a review of progress being made by IE and theGovernment against the recommendations contained in the original report. Animplementation review report was issued reporting on the results and conclusions of thisreview in March 2000, entitled “A Review of Railway Safety In Ireland – ImplementationReview”.

Given the extensive nature of the improvements being made to the network, and the longterm nature of the remedial works being undertaken, a further implementation review wascommissioned in November 2000. This report contains the results, conclusions andrecommendations arising from this latest review.

The objectives of the implementation study were to carry out a review of:

• IE and the Department’s actual implementation of the study recommendations;

• the programme and actions contained in IE’s Railway Safety Programme.

As previously, the complete IE railway system including the DART suburban system andfreight 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 agreed with both theDepartment and IE for site visits to inspect aspects of the infrastructure and rolling stock.This took account of areas where unreasonable risks had previously been identified inaddition to those areas of the infrastructure identified by IE which have been subject to recentupgrade and improvement.

The review has considered the following topics:

• the safety adequacy of infrastructure and rolling stock;

• development of IE’s Safety Management Systems;

• the Risk Model developed for the initial Railway Safety Study, which was updated toreflect the latest changes in the condition of the infrastructure;

• consideration of changes to railway safety regulation, addressing both the recent moves toestablish an independent Railway Safety Authority (RSA) and relevant EU DirectivesImplementation.

The results of the review have revealed that IE has made substantial progress in improvingthe safety of the railway infrastructure since 1998 and the speed of improvement hasincreased since the last audit in late 1999. The hard issues of life expired infrastructure arebeing tackled effectively and the result should be a reliable and maintainable railway in thelong term. Much remains to be done however and it is important that IE continues tomaintain the good progress of the last year.


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With regards to safety management systems development, very real progress has been madein the InterCity and Suburban Operations Departments and in the M&E function, in theimplementation of systems at ground level, and in developing a robust safety culture throughgood communication systems, hazard management, regular safety committee meetings andsafety tours and the training and involvement of staff safety representatives. Whilst progresshas been made in the Infrastructure Department at HQ level, systems must now beimplemented at ground level where improvement in safety culture is currently highlydependent on the initiative of local managers and supervisors.

As for the regulation of railway safety, the study found that considerable progress has beenmade on the complete overhaul of the regulatory law, primarily through a new RailwaySafety Act, the draft of which was published for public consultation during the period of thisstudy. The future status and powers of the Inspectorate - to be called the Railway SafetyAuthority (RSA) – have been proposed by the Department but have not yet been ratified bythe Department of Finance. The direction in which the regulatory strategy is moving and theapparent determination to get there are encouraging. The proposal to establish a multi-partyconsultative body - the Railway Safety Advisory Council - is noted. The matter of a formalagreement over demarcation with the Health & Safety Authority has still to be finalised and itis recommended that this issue is resolved as soon as possible. It was also found that therehad been significant delays in transposing relevant European Union Directives into Irish law.However, at the time of the review more resources had been brought to bear on this matterand the back-log was being overtaken.

It is also recommended that as many as possible of the remaining tasks to establish the newregulatory regime be conducted in parallel, so that the whole package is clear to the industryand operating effectively from the earliest practicable time after making the new law. Itwould be beneficial to meet this end if the RSA could be established and progressivelystaffed in shadow form in advance of the Railway Safety Act coming into force.

The overall conclusions of the review are that, on the whole, there has been impressiveprogress across a wide range of areas. This includes improvements to IE’s infrastructure andmanagement systems and to the rigour of the regulatory system to oversee railway safety intothe future.

However, as would be expected given the scale of the work to be undertaken, there remainsmuch to do. In addition to seeing through the key issues identified in the last audit report, thefollowing areas are seen as critical to the achievement of further improvement:

• the urgent appointment by IE of a dedicated project manager to co-ordinate/facilitate thesafety improvement programme. IE to date have not appeared to appreciate the need forsuch a position, which has contributed to the workload difficulties faced by Departmentalstaff, particularly within the Infrastructure and Safety disciplines;

• the need for more strategic planning by IE across a range of areas (including manpowerplanning, investment decision making, business planning, etc). This is recognised by IEwho have commenced work on a strategic change management programme. IE isencouraged to continue the emphasis on this area;

• IE to improve the relationship with external parties, including the Railway SafetyAuthority, the Department and the media. Attempts need to be made to move towards amore positive Public Relations approach, one whereby the excellent work being


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undertaken is advertised rather than being characterised by a defensive attitude againstperceived attacks against the organisation;

• the Department to manage the making of the Railway Safety Act in the shortestpracticable timescale;

• the Department to establish, fund and staff the Railway Safety Authority in time for thecoming into force of the Railway Safety Act.

In summary, a sea change has taken place in safety management culture but this is causingstress in IE’s management and staff. Given this status, and the large amount of work to becompleted before a truly self sustaining safety culture is achieved, it is suggested that a finalbroad external audit be carried out on behalf of the RSA. This should be undertaken once theRSA has been commenced its duties and after a suitable period of time has elapsed, possiblyin 2002, in order to provide a benchmark for measurement of safety progress following thisaudit.


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Document History

Issue Author Date Reason for issue and comments

01 AJ Smith

DJ Maidment

ADF Pickett

D Harland

Apr 01 Draft for Best Practice Forum Review

02 AJ Smith Apr 01 Revised Issue Following Best Practice Forum

03 AJ Smith Apr 01 Final Issue


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Distribution Control Sheet

Version Date Compiled By Checked By Authorised By

01 April 01 AJ Smith

DJ Maidment

ADF Pickett

D Harland

TAW Geyer

P Cheeseman

AJ Smith

02 April 01 AJ Smith DJ Maidment AJ Smith

03 April 01 AJ Smith DJ Maidment AJ Smith

File Name: IE Second Implementation Review Final Report.doc Print date: 01/05/01

Distribution List

Name From To Comments

IRMS

1 copy each to:

AJ Smith

DJ Maidment

TAW Geyer

J Cooney

ADF Pickett

P Cheeseman

G Topham

R Hope

D Holmes

L Brunton

D Harland

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Department of Public Enterprise

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E Burke 01 C

C = Current Version (03)


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Report No: 7335.01Issue No: 03Date: April 2001 Page vi

CONTENTS

1. INTRODUCTION 1

2. OBJECTIVES AND SCOPE 2

2.1 Objectives 2

2.2 Scope 2

3. APPROACH 3

3.1 General 3

3.2 Safety Adequacy of Infrastructure & Rolling Stock 3

3.3 Safety Management System (SMS) Review 4

3.4 Risk Assessment 5

3.5 Railway Safety Regulation 5

3.6 Best Practice Forums 5

4. SAFETY MANAGEMENT SYSTEMS 6

4.1 Introduction 6

4.2 General Progress 6

4.3 Safety Audit Performance 9

4.4 Safety Culture at Ground Level 13

4.5 Conclusions 18

5. SAFETY ADEQUACY OF INFRASTRUCTURE AND ROLLING STOCK 21

5.1 General Progress 21

5.2 Locations Visited 22

5.3 Signalling Electrical and Telecomms Issues Arising from Site Inspections 22

5.4 Permanent Way Issues Arising from Site Inspections 24

5.5 Structures Issues Arising from Site Inspections 26

5.6 Electrification Issues Arising from Site Inspections 28


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5.7 Rolling Stock 30

5.8 Conclusions 31

6. CROSS-FUNCTIONAL PROJECT 33

6.1 Signalling Electrical and Telecommunications 33

6.2 Permanent Way 33

6.3 Structures 34

6.4 Electrification 34

6.5 Rolling Stock 34

6.6 Conclusions 35

7. UNREASONABLE RISKS 36

7.1 Definition 36

7.2 Progress on Previous Unreasonable Risks 38

7.3 New Unreasonable Risks Identified 40

7.4 Conclusions 41

8. RISK ASSESSMENT 42

8.1 Latest IE Risk Estimates 42

8.2 Status of the IE Risk Model 48

9. RAILWAY SAFETY REGULATION 49

9.1 The Railway Inspectorate - and Future Railway Safety Authority 49

9.2 Railway Safety Legislation 51

9.3 The Publication of Targets and Standards 53

9.4 Conclusions 53

10. PROGRESS AGAINST IE RAILWAY SAFETY PROGRAMME 1999-2003 55

11. PROGRESS AGAINST IRMS SUMMARY OF RECOMMENDATIONS 56

12. CONCLUSIONS 58


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13. RECOMMENDATIONS 60

13.1 Safety Management Systems 60

13.2 Infrastructure and Rolling Stock 63

13.3 Rail Safety Regulation 65

13.4 The Way Forward 65

14. REFERENCES 67

APPENDIX I - Listing of Sites Visited

APPENDIX II - Detailed Infrastructure Department SMS Findings

APPENDIX III - Status of Previously Identified Unreasonable Risks

APPENDIX IV - New Unreasonable Risks Identified

APPENDIX V - Review of Progress Against Railway Safety Programme1999 - 2003

APPENDIX VI - Status of Previous IRMS Recommendations

APPENDIX VII - Detailed Risk Assessment Results


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GLOSSARY OF TERMS

ADE Assistant Divisional Engineer

ALARP As Low As Reasonably Practicable

ATP Automatic Train Protection

CAWS Continuous Automatic Warning System

CBA Cost Benefit Analysis

CEI Chief Engineer Infrastructure

CES Chief Engineer Signalling

CI Cast Iron

CME Chief Mechanical Engineer

CTC Centralised Traffic Control

CWR Continuously Welded Rail

DE Divisional Engineer

DPE Department of Public Enterprise

ECO Electrical Control Operator

ETS Electric Train Staff

EMU Electric Motor Units

HMRI Her Majesty’s Railway Inspectorate

HR Human Resources

JD Job Description

IAMS Infrastructure Asset Management System

IE Iarnród Éireann

IR Industrial Relations

MW Maintenance of Way

NDP National Development Programme

OCS Overhead Catenary System

PARS Priority Assessed Risk System

PSU Power Supply Unit

PTS Personal Track Safety

PWI Permanent Way Inspector

REB Relocatable Equipment Building

RR Relay Room

RSP&G Railway Safety Principles and Guidance


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SET Signalling Electrical and Telecommunications

SMS Safety Management System

SRG Safety Review Group

SRS Safety Responsibility Statement

TU Trade Union

UK United Kingdom


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1. INTRODUCTION

International Risk Management Services (IRMS), in association with its partnerconsultants, was commissioned in 1998 by the Department of Public Enterprise (theDepartment) to conduct a Railway Safety Study of the Iarnród Éireann (IE) network.The study was completed in October 1998 and a report “A Review of Railway SafetyIn Ireland” [1] issued.

Following consideration of the report, the Irish Government established a High LevelTask Force involving IE which prepared the Railway Safety Programme 1999-2003[2] to implement the recommendations contained in the report.

Approximately one year after the issue of the original report, IRMS and its partnerconsultants were commissioned by the Department to carry out a review and audit ofprogress being made by IE and the Government against both the recommendationscontained in the original report and the objectives of the Railway Safety Programme.This work was completed in March 2000 with the issue of the report “A Review ofRailway Safety In Ireland – Implementation Review” [3].

This present report contains the results, conclusions and recommendations arisingfrom a further implementation review, conducted approximately two years after theoriginal study. IRMS’ partners in this work, as for the previous studies, were MHASystems Limited, Holmes Davies Partnership and PB Power Ltd.

The Consultants wish to acknowledge the continued assistance and co-operationoffered by the Department, Córas Iompar Éireann (CIE) and IE managers and staffthroughout the various studies. IE have just completed the first two years of a majorsafety programme. The chronic under-investment over the past decades, the complexand heavy engineering workload that is required by way of an enormous workprogramme, changes to both physical assets and management systems, and theincreasing demand for rail services, all place an enormous burden on the railway andit will take time to get all this work in place. It is in this light that the IRMS auditmust be considered.

This report brings together the results, conclusions and recommendations from anaudit covering progress towards improving the safety of the existing physical assets(both infrastructure and rolling stock), the Safety Management Systems (SMS) of IEand the proposed changes to railway safety regulation currently being proposed by theIrish Government.

This document represents the last planned external audit associated with IE’s currentRailway Safety Programme (RSP). Accordingly, consideration has been given withinthis report as to the adequacy of management systems and processes (both within IEand Government regulation) to continue to monitor and improve the safety of therailway system into the future.

This report represents the audit referred to in Section 12.8 of [1].


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2. OBJECTIVES AND SCOPE

2.1 Objectives

The overall objectives of this second implementation review study were to review:

• the progress of both IE and the Department in meeting the recommendationsarising from both previous audit reports;

• the progress of IE in addressing actions contained in the Railway SafetyProgramme [2];

• the progress of IE in closing out previously identified unreasonable risks1:

• any new areas of concern giving rise to unreasonable risks identified during theaudit;

• the extent to which management processes and systems within both IE andGovernment are adequate to ensure railway safety in Ireland into the future in theabsence of further planned external audits.

2.2 Scope

As previously, the complete IE railway system including the DART suburban systemand freight traffic was included in the scope of the study.

The audit was conducted between December 2000 and February 2001. Progress isgenerally reported up to and including these dates. However, it is noted that in manyareas progress is rapid, and further actions may have been completed before the issueof this report. A specific example relates to the mini Centralised Traffic Control(CTC) System which at the time of the audit had been postponed with an indefinitecompletion date. The Consultants now believe that the project is currently underreview.

Terrorism and security matters were again excluded from the scope of the studies.

1 The precise definition of this term is contained in Section 7.1 of this report.


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3. APPROACH

3.1 General

Prior to the commencement of the audit investigating the safety adequacy of IE’sInfrastructure and Rolling Stock, a summary of previous recommendations arisingfrom the previous IRMS reports [4] was sent to IE to allow them to update the table toreflect recent progress. In addition, a meeting was convened in October 2000 to allowthe Department and IE to summarise progress since the last audit and for theConsultants to present the audit programme.

3.2 Safety Adequacy of Infrastructure & Rolling Stock

The system was considered to include operations, design and maintenance aspects of:

• signalling/telecomms systems;

• level crossings;

• permanent way;

• railway structures (including bridges, cuttings, embankments, stations, buildingsand platforms);

• rolling stock;

• electrification (DART).

An integral part of this review was the undertaking of an update of the assessment ofthe risks arising in each of the above areas, as a result of any identified design,operations or maintenance deficiencies.

The safety adequacy audit concentrated on a review of progress against rectifyingdeficiencies identified during the previous reviews, especially unreasonable riskswhich required immediate rectification. However, as part of this audit, any newdeficiencies or unreasonable risks that were identified during the site visits wererecorded and notified to IE.

The study comprised a number of office audits and site inspections completed over athree-month period between December 2000 and February 2001. Any updated orrevised system design, operational and maintenance information was requested andobtained from IE and reviewed in their offices.

The programme of the site surveys incorporated visits to locations which, in theoriginal safety study in 1998 and again in 1999, either exhibited unreasonable risks orelse the infrastructure was in a particularly poor condition at that location. Since thiswas a sample audit, a representative selection of sites was selected, including thosethat contained many of the original unreasonable risks. In addition, a number of newsites were visited that were not surveyed during the original safety study in 1998 nor1999. The purpose of this was to discover whether unreasonable risks existedelsewhere that IE had not themselves identified, and also to detect whetherconcentration by IE on rectifying the unreasonable risks and infrastructure


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deficiencies highlighted by IRMS [1], [3] had resulted in other parts of the networkbeing neglected.

The opportunity was also given to IE to nominate a number of sites or locations whichthey believed exhibited particular improvements or where significant remedial workshad been carried out.

The site inspections were all undertaken accompanied by IE representatives. Defectswere discussed on site with IE representatives and for any items considered to be highrisk, remedial or mitigating measures were discussed on site.

Lastly, to identify whether IE is putting into practice the new standards, rules,regulations, and processes, the Consultants chose a typical IE cross functional Projectas an example case study. This exercise was jointly completed by the variousinfrastructure disciplines.

The list of sites visited is given in Appendix I. Scoring for the audits was on a systemconsistent with that used in both 1998 and 2000.

Using data and information collected as part of these short series of new siteinspections, the adequacy from a safety viewpoint of the railway systems and serviceswas re-reviewed.

3.3 Safety Management System (SMS) Review

The adequacy of IE's safety policy, systems, rules and procedures as embodied intheir SMS was re-assessed. This review was based upon previous experience ofSafety Management Systems implementation in the railway industry, industry bestpractice, and relevant codes, standards and guidance documents.

The IRMS team conducted interviews with CIE and IE Headquarters managers,attended InterCity and Suburban Implementation Team meetings and accompaniedinspections of the infrastructure throughout the system and the Mechanical &Electrical (M&E) organisation at Inchicore. The team also received and reviewed aconsiderable amount of SMS documentation prepared and disseminated in response tothe IRMS recommendations, and received copies of presentations made comparingimplementation progress against the IE plans.

The questionnaire used for the previous two SMS audits was re-scored, based uponprogress made in management systems development. Data to complete thequestionnaire were collected through a series of interviews with senior managers ofboth CIE and IE. In addition, audits were carried out at ground level through theconduct of a series of implementation workshops convened with a representativesample of IE staff.

In addition to re-scoring the questionnaire, an audit of progress was undertaken interms of the closing out by IE of previous SMS related recommendations.


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3.4 Risk Assessment

A key element of the original strategic review was to provide clear, precise, quantifiedand objective advice on whether the overall level of railway safety is adequate. Thiswas addressed by the development of a high-level risk model. The model wassubsequently updated during the subsequent implementation review [3].

Based upon the recent site audit visits to review the condition of the infrastructure androlling stock, the risk model was further updated to reflect the improvements in thecondition of the infrastructure. The risk statistics derived from the model (number ofaccidents, number of casualties and individual risk) were then recalculated.

3.5 Railway Safety Regulation

Previous reports [1], [3] had considered the adequacy of the railway safety regulatoryregime in Ireland, including the effects of transposing of EU Directives affectingrailway safety. This study examined the progress which had been made towardsmeeting the requirements of the previous recommendations. It also considers areaswhere current Department proposals go farther than previous IRMS recommendations(such as the appointment of a Railway Safety Advisory Council).

The relevant information collected for the study included some foreknowledge ofconsultancy work commissioned since the last review [5], supplemented byinterviews with the Chief Railway Inspecting Officer and the Assistant PrincipalOfficer in the Department who is dealing with the new legislation. Each of theseindividuals was able to table written evidence of the progress, such as operationalbudget preparations by the CRIO and legislation both made and in advancedprocedural stages (such as public consultation) from the administrative arm of theDepartment.

3.6 Best Practice Forums

The proposed approach to the review and the results arising were considered by ateam of transport safety experts from the IRMS led consortium through the conveningof two Best Practice Forums and compared with their experience of good practice onother comparable railway systems. Officials from the Department attended bothmeetings as observers.


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4. SAFETY MANAGEMENT SYSTEMS

4.1 Introduction

This section of the report describes progress made by IE in the development ofmanagement systems to control safety. It encompasses findings across the whole ofIE, including Infrastructure, Operations and Corporate Support and Planningfunctions. It should however be noted that, due to its nature, the management systemsreview of Infrastructure Department is very detailed and is described in full inAppendix II with only a summary of key findings provided in this section.

4.2 General Progress

It is very evident that considerable progress has been made in implementing the IRMSrecommendations since the first audit was conducted in 1998. Company corporatestandards have been produced and the InterCity, Suburban and MechanicalEngineering Departments have developed their own subsidiary standards andprocedures and disseminated these widely throughout the system. The InfrastructureDepartment has been active in drafting standards and procedures, but these have yet tobe finalised and therefore have not yet been promulgated to the ground level.

Resources have been, or are in the process of being, put in place to implement theSMS at management and ground levels. Safety Liaison Executives (SLEs) have beenappointed to all Operating Districts and Personnel and Safety advisory specialists arebeing appointed within the Infrastructure Department at HQ and Divisional levels.Safety Representatives at ground level have been appointed and trained and are takingan active part within the SMS’s in place.

It was evident that there is a high level of commitment by senior management to theimplementation of the IRMS recommendations. Much time is spent in meetings anddiscussions at the highest level on safety and all assured the team that funds had beenmade available for all safety expenditure considered necessary. Staff had beenrecruited to safety critical posts at ground level although there were ongoing problemsin recruiting staff in certain key grades and retaining them in the current economicboom in Ireland. After considerable industrial relations unrest, revised hours andconditions of work for train drivers had been implemented to counter the "long hourslow wage" culture of the organisation and further similar deals with other key gradeswere imminent.

A much improved safety culture was very evident at the ground level in the InterCityand Suburban (Operations) Departments and at the Inchicore Depot of the M&EDepartment. The Hazard Identification and Reporting Systems were operating well inthese functions and feedback to staff making the reports and follow up to correct thehazards was good, although there were a few cases where action by a differentDepartment was required when reaction speed was slower than desired. Theimplementation of the recommendation to allocate a sum of money to each OperatingDistrict (£30,000 in 1999; £50,000 in 2000 and again in 2001) had made a bigdifference in morale, convincing staff that management was serious in their


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commitment to safety improvement. Discussions regarding the further spend and anyprioritisation necessary involved supervisors and safety representatives fully - indeedthey were encouraged to submit items for consideration. All were also involved inregular site inspections.

The IRMS team found morale generally to be good at ground level and commitmentto both occupational and train safety to be high, despite the Industrial Relations (IR)problems and the lack of dissemination of the SMS initiatives in the InfrastructureDepartment. Undoubtedly the visibility of the investment programme, the widespreadintroduction of skill and communications training and the example of managementcommitment have had their effect.

A concern raised in the previous IRMS Audit report was the pace of implementation -the fear that revised and new elements of the SMS were being disseminated fasterthan those at ground level could absorb, together with the concern that much of thedocumentation had not been made "user friendly" for the appropriate audience. Thislesson appears to have been well learned and much consultation and effort has goneover the last twelve months in correcting this. For instance, the InterCity DepartmentSafety Plan for 2001 has been based on the IE Corporate Safety Plan but produced ina format suggested by supervisors and safety representatives that makes it much morerelevant to local staff and therefore likely to be retained and read.

Of course, in a programme as ambitious and wide-ranging as that adopted by IE afterthe original IRMS report, there are areas where progress has been difficult and furtherconsideration or action is required. Both the Infrastructure and Safety Departmentsadvised the IRMS Team at the start of the audit that the SMS requirements had not yetbeen disseminated to the Infrastructure Department staff at ground level and thereforea change in safety culture at that level was unlikely to be apparent. In fact, some goodpractice at local level in Infrastructure was apparent (particularly for LimerickJunction Division) but it was as a result of local management interest and rested onthe initiative of a few individuals who had decided to press ahead without waiting forHQ documentation.

Some training of Infrastructure staff has taken place where it is not dependent on thenew standards and procedures and a simple risk assessment technique for the use ofInfrastructure supervisors has been developed and piloted successfully. Howeverfurther implementation is now delayed due to IR problems involving somesupervisors.

The HQ level of the Infrastructure Department had undertaken a huge programme ofstandards and procedures development and revision, largely through the employmentof a number of consultancy companies. Because of the very large workload in thatDepartment falling on a few senior engineering managers, it had proved difficult tofully control and manage the output of the consultants and much revision of theirwork had become necessary before it was fit for dissemination. It was apparent thatmany of the standards and procedures being developed were heavily biased towardsUK practice in a very complex organisational and ownership structure and this wasnot always the best model for IE’s circumstances. The problems associated with thishave recently been recognised by IE and in-house managers are taking control of the


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programme, prioritising key standards and procedures to be completed andpromulgated to ground level staff.

Pressures of workload on current issues had meant that senior staff in the HumanResources (HR) and Safety Departments had had little time to step aside from thenecessary reaction to day to day events (many stemming from the IR problemsencountered over the previous year). This has meant that, with the exception oftraining, there had been difficulty in planning a longer term strategy for thedevelopment of policies and overall priorities.

The appointment of a senior manager responsible for the development of training inthe HR team has been very positive and the results are clearly visible in both thequantity and quality of training now under way. This indicates the potential forfurther advance if the HR and Safety Departments at HQ had dedicated managers forplanning and development in their respective organisations. New HR and Safetyposts have been appointed in the functions at HQ and Divisional/District levels(although some are only now in the process of recruitment and selection) and theseare beginning to make a difference. It was stated that these would release time at thetop levels to enable the strategic work to take greater priority. In view of the way thatproblems tend to escalate upwards in any organisation, the IRMS team is doubtfulwhether sufficient top level thinking time can be made available without theappointment of senior managers in each of those Departments "ring-fenced" fordevelopment and policy issues and protected from having to react to current day today issues. The HR plans to establish a Management Development Centre andsuccession planning and training programmes may provide, in the appointments to bemade to carry that through, the resources necessary to provide the planning capability.

The key requirement is to develop a long term manpower plan matched torequirements at managerial as well as operational levels and to incorporate this withina company strategic plan covering future traffic forecasts, new projects andmaintenance commitments, as well as the safety programme. The age profile in someDepartments, the advent of new major projects (such as LUAS) and the continuingdifficulty in remaining competitive for some key professions and trades make thecompletion of such a plan imperative if IE is to recruit and maintain the staffnecessary to ensure safety in the medium and long term. There is also evidence thatthe increasing workload to cope with new initiatives on senior management is creatingoverload and the risk of stress. The biggest inhibition to full implementation of theIRMS recommendations is the difficulty in recruiting and retaining skilled engineersand technicians in the Infrastructure Department, particularly where IE competes withthe IT and other "high tech" industries which can pay significantly higher salaries thanthe railway currently offers.

There is a well defined structure for implementing IE’s safety managementprogramme and the IRMS recommendations, both equipment and managementsystems related, co-ordinated at top level through the Safety Review Group (SRG),chaired by IE’s Safety Manager, and supported by the group of Departmental Safetymanagers led by another member of IE’s Safety Department. However, as statedearlier, there are many day to day safety issues which require resolution and IRMSbelieves the leadership and co-ordination of the safety improvement initiatives issufficiently important and time consuming to require a dedicated senior post. This


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could be created by strengthening the Safety Department team to release theDepartmental Manager to concentrate on the programme, or by appointing an overallProject Manager.

Despite the resolution of the dispute over the drivers’ restructuring, there continue tobe ongoing problems in the IR climate. There are tensions in some areas resultingfrom the dispute between trade union members over the new deal for train drivers andthe continuing existence in a few depots of disagreement between drivers will createunnecessary stress and will be an ongoing safety hazard. However, another keyconcern of IRMS is the way in which some staff with the apparent backing of TradeUnions appear willing to use safety issues as levers in the pay bargaining process.There has been movement on the “low wage, high overtime” culture and managementhas addressed many of the safety issues that concerned staff. It is now theresponsibility of the Trade Unions to ensure that essential safety initiatives,techniques and training are not inhibited by being tied to pay negotiations and formanagement to insist on the implementation of safety initiatives whereby the safety ofthe public, passengers and staff can be better protected.

4.3 Safety Audit Performance

The IRMS Team rescored all activities seen against the measured audit system usedduring the initial review [1]. The biggest improvement in the audit score could bemade by IE choosing to tackle all deficiencies in their SMS at once, albeit in asomewhat superficial manner, rather than concentrate on a few key areas in greaterdepth. This tends to be a weakness of all audit scoring systems, and must be born inmind when the following sections and scores are considered. The period followingthe initial audit in 1998 saw a tendency for IE to want to tackle all areas of weaknessin a rush and at a pace that could not be consolidated properly at ground level. Thishas now been largely corrected and progress is being made at a more sensible paceand absorbed by the local culture, although as noted earlier, much still remains to bedone, especially in the Infrastructure Department.

With hindsight, the IRMS Team feels that some of the 1998 review scores were toohigh in that the audit scoring system gave full points for a procedure in place,irrespective of the quality or depth of the procedure. IE has now in many areas put farmore comprehensive, effective and user friendly systems in place, but the measuringsystem does not give adequate credit in this regard. Thus in general, theimprovements put in place by IE in its SMS over the past two years are in actual factgreater than the change in scores discussed in the following sections may suggest.

A summary of the audit scores obtained and a comparison of these against the scoresobtained during the previous two audits are provided in Table 4.1. The overall scoreachieved for this audit was 75%. This represents a level of performance whichindicates strong management support to a positive and proactive safety managementsystem and culture, with the potential to move towards achieving comparison withsome of the best practices of leading world railways in the future.

This compares with an overall score in 1998 of 64% and in 2000 of 69%. Theseimprovements represent substantial progress over the course of the last three years.Improvement can be seen across all elements of IE’s SMS over the last two years,


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with particular improvement noted in management commitment, safety systems,training and development and contractor safety. The only area where improvementhas not been achieved since the last audit is that of regulatory interface, the reasonsfor which are discussed in detail elsewhere.

SMS Element 2001 AuditScore

Improvementfrom 2000

Audit

Improvementfrom 1998

Audit

1. Management Commitment 82% 4% 13%

2. Communications 67% 5% 12%

3. Safety Arrangements 64% 5% 9%

4. Safety Policy & Procedures 92% 4% 5%

5. Safety Systems 86% 9% 13%

6. Training & Development 52% 13% 20%

7. Emergency Planning 75% 1% 4%

8. Contractor Safety 73% 9% 17%

9. Purchasing 80% 4% 10%

10. Regulatory Interface 63% 0% 5%

Table 4.1: Summary of SMS Audit Results

4.3.1 Management Commitment

The latest audit score is 82%, compared with the 1998 review score of 69% and the2000 audit of 78%. The increase is mainly in the area of supervisory management,particularly in the Operations and M&E functions where there has been widespreadbriefing and communication training. One of the main areas still requiring furtheraction to improve the audit score is a need to set up prioritisation systems for safetyexpenditure, at both macro and micro levels.

4.3.2 Communications

The current audit score is 67% compared with 55% in 1998 and 62% in 2000. Theformal communications systems (safety committees etc) score highly, but there is stillimprovement to be made in the informal systems (briefing groups, toolbox talks)especially in the Infrastructure Department. The improved score reflects the safetycommunication taking place in the Operations and M&E Departments to involve staffat ground level.

4.3.3 Safety Arrangements

The audit score for this section is currently 64%. The previous scores were 56% in1998 and 59% in 2000. The main area of improvement has been the morecomprehensive issue of Job Descriptions and Safety Responsibility Statements forsafety critical staff. Areas of improvement that will increase the score include aregular process for updating these documents, explicit references to safety being of at


IRMS


least equal importance to cost control and quality management in individual andgroup role descriptions and regular appraisals of management and staff performanceincluding safety.

There was a realisation at the time of the last audit [3] that the IE establishment didnot include a Professional Head for Electrification. This caused concern in relationboth to the impending formalisation of electrical training, competency andcertification, and to the planned expansion of the electrified network and staffing.There is however positive progress to report on this issue. An ElectrificationEngineer post is to be established, reporting through the DE to the CEI. This mayinitially be an outsourced post, and the effectiveness of the arrangement is to bemonitored by an independent advisor to the CEI.

4.3.4 Safety Policy & Procedures

The current audit score is a very creditable 92%. This compares with what werepreviously high scores of 87% in 1998 and 88% in 2000. Nine out of the tenCorporate Standards, put together by IE’s Safety Department with the assistance ofvery experienced railway safety consultants, are now approved by IE’s SRG, anddissemination for implementation and the development of subsidiary railway anddepartmental standards by the functions. The tenth Corporate Standard (Procurementand Contractors) is in draft form, ready for submission to the SRG. One (on RiskManagement) is being reviewed by consultants with a view to re-issue. IRMSconsiders these high level standards to be generally robust and to form a good basisfor the derivation of subsidiary standards.

The audit team could find no railway or departmental standards, criteria or proceduresfor considering the safety implications of overcrowding on stations or trains. A recentreport by consultants, Halcrow (February 2001) reviewed IE’s strategy for controllingcrowding in the Dublin commuter area from an operations and service point of view,but made no comments or recommendations on safety aspects, although somereduction in risk will be implicit if the general recommendations are carried through.

Attention on improving occupational safety involving safety representatives has alsohelped to increase the audit score to this level. Implementation of policies in aconsistent way in the Infrastructure Department would see this score approach 100%.Completion of Infrastructure related standards in a format appropriate to IrishRailways is a necessary forerunner to this process.

4.3.5 Safety Systems

The current score is 86%. This is a significant improvement over the 1998 score of73% and 2000, 77%. A major step forward has been the introduction of a robust"management of change" process and the on-going development of the SYNERGIsafety information system (although it should be noted it is not yet live), accompaniedby the training of key staff in its use. The Operations and M&E functions havereached level 6 in the ISRS safety audit system, a good achievement. Whilst this ismaintaining management support there - and this is helpful for reasons of continuity –elsewhere ISRS has been dropped and is being replaced by a compliance audit systemmore relevant to the railway activities carried out. The compliance audit process has


IRMS


been designed for the high and middle levels of organisation but the specification forground (station) level compliance audit is still under development. No complianceaudits have yet taken place and shortage of available staff in the Safety Departmentindicates a further possible delay in completing the specification and implementingthe process. The audit score will improve when this is in place and operatingeffectively.

Corporate Standard No. 5 on Risk Management has been issued, but is currently beingrevised. It is important that the new standard clarifies that the ALARP principleapplies to the risk to groups of people (staff, passengers, etc.) from a whole activityand is not applied in isolation to the risk from one hazard, as a number of hazards withrelatively low risks may be aggregated to produce a risk from an activity that might behigher than considered acceptable. A more consistent use of risk managementtechniques at macro and micro levels in the organisation will also improve the auditscore further. Whilst some staff have been trained in risk assessment techniques andit has been used for some project evaluation, it has not yet been used as acomprehensive tool for risk control or safety investment prioritisation. Initial workhas been undertaken by IE to develop a pilot risk model for this purpose, the progressof which is reported in Section 8.2 of this report.

4.3.6 Training & Development

The audit current score is 52%. Whilst this is the weakest activity in the auditelements, it represents the area of greatest improvement, the previous figures being32% in 1998 and 39% in 2000. The training programme has been helped by beingmanaged by a dedicated Training Officer in the HR Department. Because of theformer lack of training, there has had to be concentration on certain subjects and stafflevels, particularly the supervisory and safety critical staff at ground level. Courseshave been developed and implemented on Safety Management, SupervisoryCommunications, Manual Handling, Personal Track Safety, and skills training fornewly recruited drivers, signallers etc. The increase in activity is reflected in thestatistics, 10,000 man days training provided in 1999 and 32,000 man days in 2000. Itis noted that the training of Infrastructure staff has been hampered to date by theabsence of agreed standards to train against. This problem should be alleviated oncethe relevant standards are issued.

The training centre at Inchicore has been developed and upgraded in status to attractthe right calibre of trainers and plans exist in the HR Department for establishing aManagement Development Centre which will support training and development ofstaff at higher organisational levels. When this is in place and operating routinelyand the training started has been extended to cover a wider level of grades, the auditscore for this element will substantially increase. A full manpower planning process,succession planning and the development of staff appraisal systems, incorporatingsafety as an integral part of management, are other key ingredients of a future robusttraining and development policy.

4.3.7 Emergency Planning

The current audit score is 75% which has changed little from previous audits - 71% in1998 and 74% in 2000. A Corporate Standard (No. 10 Emergency Response) has


IRMS


now been approved by the SRG and issued. Emergency plans exist for key locationsand some practices and drills have taken place. Scores would improve if this weremore comprehensive and if there were a top level "Crisis Management Plan" in place,to provide an effective IE response to any major accident or incident which threatensthe operation or reputation of the company.

4.3.8 Contractor Safety

The latest audit score is 73% compared with 56% in 1998 and 64% in 2000. Thisimprovement reflects better processes for selecting contractors and briefing them priorto work, but there is anecdotal evidence that safety incidents caused by contractorsand subcontractors still occur - the audit of contractor activities by their own systemsand independently by IE staff needs to be strengthened. The ownership of the safetyrole when staff are working in planned and emergency track possession arrangementsneeds further clarification.

The Corporate Standard on “Procurement and Contractors” (No. 8) is the only highlevel standard not yet issued, and its draft has been the subject of much debate andrevision. IRMS has been assured that the approval and implementation of thestandard is imminent. Only then can essential railway and departmental standards bedeveloped for all aspects, including the key area of contractor site management.

4.3.9 Purchasing

The audit score for this element is 80%. This improvement (the 1998 review scored70% and the 2000 audit, 76%) reflects the routine implementation of new procedureswhich were at the management discussion and early implementation stages at thetimes of the previous audits.

4.3.10 Regulatory Interface

The present audit score is 63%, the same as in 2000 and compared with 58% in 1998.This is the only audit element which has not improved in the last year. Theappointment of more Railway Inspecting Officers (RIOs) in 1999 enabled potentialcloser working relationships with IE, but IE’s reluctance to be proactive in sharinginformation with the RIOs has meant that there is significant scope for improvement.Current safety performance and the progress in implementing the safety managementprogrammes agreed with IRMS and the Department suggest that there is no need forIE to adopt a defensive attitude towards the safety regulator and that this requireschange as a matter of priority.

4.4 Safety Culture at Ground Level

In the 1998 review of safety, IRMS attempted to measure an audit score for groundlevel implementation, as the culture at the workface was very different from that atthe company’s HQ. One of the biggest challenges, recognised by IE, was to transferand inculcate a safety culture in the staff who deliver the railway service to thecustomers and who need to do so in a way that is safe for themselves and theircolleagues. IRMS conducted an attitude survey of all employees, inviting themconfidentially to complete a safety questionnaire which was returned by around 16%


IRMS


of the IE workforce. IRMS recommended that IE continue to measure safety cultureat ground level.

This has proved difficult to do in a way that was meaningful for the company. Anattitude survey was carried out by IE’s Human Resources Department, but it coveredother issues as well as safety and the low response and the existence at the time ofsevere industrial relations problems meant that the results were considered to be notrepresentative and possibly misleading. IE is currently considering how to evaluatesafety culture and were reluctant to support a repeat of the 1998 survey by IRMS asthey felt that lessons they had learned from earlier exercises would mean that theywould have little confidence in any new survey. IE are now understood to beconsidering what consultants might be engaged to undertake this culture audit in away in which the company would have confidence in the outcome.

IRMS therefore decided to test ground level attitudes and commitment by attendingthe Safety Implementation Team meetings instituted by the InterCity and SuburbanDepartments and to include observation of safety culture at ground level during theengineering inspection tours. Because of a wide variation in the safety culture foundin the different Departments, it was found unrealistic and unhelpful to try to assess anoverall audit score for IE for the ground level staff. The variations come aboutbecause of the different start points of the Departments and the need for theInfrastructure Department to complete and disseminate revised standards beforewidespread development of procedures and subsequent training can take place.

4.4.1 Operations (InterCity & Suburban)

Both InterCity and Suburban Departments (Operating) instituted ImplementationTeam meetings in 2000 to progress the dissemination and implementation of thecompany safety plans at the workface. The composition of each District Teamincluded the District Manager, Safety Liaison Executive, Stationmasters, Train CrewSupervisors, Signalling Supervisors and Safety Representatives. They meet regularly(monthly) and have a consistent agenda - prioritisation of safety expenditure to correcthazards, analysis of hazard reports and identification of corrective action required,accident or incident reports covering the previous period, briefing and discussion onnew standards or procedures, progress against the IE safety plan and IRMSrecommendations.

IRMS team members attended meetings at Dublin (North), Cork, Limerick,Waterford, Athlone and Dublin (Suburban). The commitment and enthusiasm of allgroups was obvious and the progress demonstrated was impressive. The supervisorsand staff safety representatives present assured IRMS that the commitment to safetyseen at these meetings only reflected the general awareness and interest of staffgenerally and that IE Operations staff had now made a significant positive change tothe safety culture of the Department. The Safety Representatives had all receivedsafety training, and had had the opportunity to input to the Operations Safety Plan for2001 which they felt was now user friendly and valued by ground staff who now sawits relevance to them. Last year some supervisors had been concerned at the pace ofchange, citing that too many documents on safety were being disseminated to staff forthem to absorb properly and that much was either irrelevant or in unsuitable language.


IRMS


This had been recognised by the company and had been put right. The pace of changewas now one that was controlled in an appropriate way.

Based on data collected at District level, these attendees were made aware thataccidents and incidents had reduced significantly since the start of the safetyimprovement programme and all commented on the value of the training they hadreceived enabling them to contribute to the improving performance. Regular teambriefings occurred, staff were made aware of accident lessons learned throughout thecompany and someone (jokingly) said that you could now measure the change inculture by the fact that high visibility vests regularly got stolen if left lying around -something that no-one would have bothered to do a couple of years ago !

Asked to identify the major constraints to further successful safety planimplementation, the main concern of the Implementation Teams was the company’sability to recruit the staff of sufficient calibre in key grades. IRMS concur with thevalidity of this concern.

The IR problems that had inhibited the introduction of essential safety procedures (egproper SPAD reporting, use of radar speed guns) had been overcome and thoseprocedures had been implemented. However, the use of radio for shunting had still tobe implemented. One team also highlighted the need for an explicit company drugsand alcohol policy, as recommended by IRMS in their original report [1], stating thatsupervisors and local management needed clear guidance on what support they couldreceive when tackling potentially contentious issues over suspect behaviour that waspossibly attributable to drugs or alcohol intake.

The InterCity Manager had instituted a "Mentor" system whereby all staff wereallocated to designated team or gang leaders for "one to one" guidance, counsellingand care. Whilst all agreed this was a good idea, it had not worked in practicebecause the arrangements laid down by HQ were too inflexible and quickly becameout of touch with reality, due to changes at ground level. The system needed to bereviewed and delegated for implementation to a much lower level.

The hazard reporting feedback arrangements were generally working well and theImplementation Team meetings reviewed corrective measures and took action whenthese were outstanding. There were a few complaints that when corrective action wasin the hands of another Department (mainly Infrastructure), correction and feedbackwas sometimes slow and often needed taking up two or three times. This is an areawhich will need consistent pressure. The appointment of safety advisory posts withinthe Infrastructure Department similar to the Safety Liaison Executives in theOperations Districts should however lead to an improvement in departmental interfacecommunication.

4.4.2 Mechanical & Electrical Engineering

The situation at ground level at Inchicore Depot very much reflected the IRMS teamfindings in the Operations function. The appointment of Safety Representatives,safety training, awareness of occupational safety hazards in the depot and theircorrection, the use of PPE, all had received commitment from the staff and localmanagement and safety performance had improved. The allocation of space in the


IRMS


depot as a "Safety Information Corner" where safety policies, communications andperformance were displayed was good practice and was similar to that found in someof the most safety aware railways in the world (such as in Hong Kong for instance).

4.4.3 Infrastructure

As noted earlier, both HQ Infrastructure and Safety Departments advised the IRMSTeam at the outset that safety plans, standards and procedures in the InfrastructureDepartment were still subject to review within the management at HQ level and hadnot yet been promulgated locally and therefore it was unlikely that there would be anyvisible significant improvement at ground level.

Observations largely confirmed this, although some local initiatives were progressingwhen the manager or supervisor had a personal interest. Because of the generalcompany awareness of the importance of safety, some individuals were not preparedto wait for HQ directives and instead put in place their own systems. While this isadmirable, it could create problems in getting a consistent application of newprocedures when the Department does publish its standards, systems and procedures,as some groups will have to change what they have developed and to which they willhave become accustomed.

Some communications training has taken place and a simple risk assessmenttechnique based upon a 5 x 5 matrix approach (known as the Prioritised AssessedRisk System, or PARS) has been developed and tested for the use of Infrastructuresupervisors in assessing priorities for minor remedial works and maintenance. It wasintended that this technique be used as a normal means for supervisors to assessmaintenance priorities. However, some supervisors have sought to claim that thisinvolves extra work and therefore should be part of pay negotiations. The use of suchsafety aids as negotiating items in pay bargaining is regrettable.

Safety Liaison Executives and Divisional Personnel Officers are only now beingappointed in the Infrastructure organisation and these should facilitate the rapidimplementation at local level once HQ officers have approved the new procedures asappropriate for IE and relevant to local staff. There is much to learn from theOperations and M&E functions in that their experience of introducing a new safetyculture could be useful in deciding upon successful tactics to adopt.

At the present time, there appears to be some tension between middle managementand HR managers, perhaps due to unfamiliarity and perceived lack of understandingof crucial issues by the parties concerned. Some progress has been made with theappointment of new HR staff to important infrastructure management positions. TheIR initiative must be taken forward on a united front by all levels of management. Atthe present time the organisation appears fragmented on this issue and it may be thatHR and engineering management require to develop a joint strategy for theachievement of safety before independently seeking to resolve a severe difficultywhich has existed for decades in the organisation.

As before, the absence of widely known, understood and controlled writteninstructions has not led to potentially dangerous situations developing as quickly asmight be expected. This is because enough experienced engineers, competent in theirsphere of activity remain in the IE industry. It was pleasing to note that the actual


IRMS


conditions on the ground in many locations had improved significantly. It was alsopleasing that there was immediate recognition and rectification of poor conditionswhen discovered.

The general level of morale amongst many staff has improved. This was particularlyevident at Limerick Junction. As a result, the ADE had not encountered Trade Unionresistance to safety measures being introduced at this location, although this was notalways the case at Dublin and at Athlone. Staff at Limerick Junction also appear to bemaking significant efforts to implement local initiatives to improve safety. The exactreasons why Limerick appear to be making greater progress than Dublin and Athloneare not immediately obvious. It is however recommended that IE attempt to learn thelessons of the successes achieved at Limerick and attempt to recreate these at Dublinand Athlone.

The briefing of all staff on the Annual Safety Plan was undertaken by the DE directlyand not delegated to the ADE. Staff are now reporting safety-related incidents andconcerns using the ‘green forms’ which go to Infrastructure DepartmentHeadquarters.

There is still however, to some extent, a culture of ‘get the job done’ withoutnecessarily thinking about the risks associated with the method of working. Somestaff still continue to work in hazardous conditions on the trackside with relativelypoor protection arrangements. The fact that staff numbers have increased and that ahigher proportion are relatively inexperienced will have increased the risk. Siteswhere staff were working close to the line and required look out protection generallyhad a Lookout in place. However, there seems to be low adherence in practice to theconcept of the ‘person in charge’ having control of safety and taking responsibility forsafe working and instructing the lookout where to stand, etc (although it isacknowledged that this is covered by IE’s latest Personal Track Safety trainingcourse).

An example of the poorly defined and multiple roles of the IE Lookout was noticed atEdgeworthstown. The platform on the loop line was being extended by contract staff.The project was being managed by the Projects organisation at InfrastructureDepartment Headquarters. IE had a Lookout on site. The loop line was underpossession to enable the excavation for the platform footings by excavator standing inthe loop ‘five foot’. The controlling signal box was opposite the site. The Lookoutwas fulfilling several roles:

1. acting as a lookout for men working;

2. controlling construction activity to prevent a machine from interfering with thesafe passage of trains on the open through line;

3. ensuring that the excavation and other works were being undertaken in a mannerthat did not affect the stability of the open track; and

4. advising the signalman that the line was fit for reopening to traffic later in the dayonce work was complete. (A T3 possession was not required as the site was withinstation limits).


IRMS


The Lookout had no written instructions or method statement. While the man was anexperienced permanent way gang member, the safe working of the site relied on hiscommon sense rather than training and competence.

Safety briefings to the IRMS team before proceeding trackside did not comparefavourably with industry best practice and were mainly only provided whenrequested. There was no record made of these briefings. Only one Lookout presenteda brief on the method of warning during the site visits.

It is impossible to be definitive as to whether the examples quoted above are isolatedincidents or are symptomatic of a more widespread culture. It is however IRMS’opinion that it is highly likely that they are representative of systematic failings whichIE will need to address through a continuing process of cultural change.

4.5 Conclusions

IE has made considerable progress in the last year in implementing its safetyprogramme based on the recommendations of IRMS contained in the 1998 safetyreview. Overall the safety audit score has risen from 64% in 1998, 69% in the 2000audit, to a current performance of 75%, ie 1,468 points out of a possible 1,968.Within this figure, element scores range from 63% - 92% (with the exception ofTraining and Development which scores 52%, a huge improvement over the previousyears’ very low base). Plans in hand to set up a management development centre,produce company manpower plans and develop succession planning and appraisalsystems will further improve this score provided those plans explicitly incorporate theappropriate emphasis on safety management.

Very real progress has been made in the InterCity and Suburban OperationsDepartments and in the M&E function, in the implementation of safety managementsystems at ground level, and in developing a robust safety culture through goodcommunication systems, hazard management, regular safety committee meetings andsafety tours and the training and involvement of staff safety representatives. Similarprogress is necessary in the Infrastructure Department where improvement in safetyculture is dependent on the initiative of local managers and supervisors, and untilsome systems, standards and procedures are ready for dissemination and briefing,local staff safety awareness and commitment will be at best "patchy", as far as the"soft" elements of safety management are concerned.

It was noted that IE has not yet been able to establish a satisfactory means ofevaluating safety culture at ground level and that surveys of staff attitudes, morale andcommitment to safety have been postponed until a more robust means of gaugingsafety culture can be developed. However, it was clear that safety is becoming moreingrained in the culture. It is pleasing to be able to report that the safety implicationsidentified on site inspections are now immediately recognised as problems by IE staffand the need for mitigation is understood.

The level of activity of IE managers is very high and it has been necessary to bring ina large number of consultants to develop standards and procedures, and trainingcourses and deliver some of that training. In the Operations, Safety and HRorganisations this has been manageable, but the amount of such work undertaken in


IRMS


the Infrastructure Department is so large that IRMS concludes that the existingInfrastructure senior management has not had the capacity to manage the work ofsuch consultants as closely as should have been the case. The result is that some of theoutput has not been appropriate for the IE situation, an excessive amount ofdocumentation has been produced which is causing problems in getting departmentalapproval and therefore few standards and procedures are ready to disseminate toground level Infrastructure staff. This has been recognised by IE and resources arebeing put in place to correct the situation and to identify priority standards andprocedures for completion.

The IRMS Team is concerned at the capacity of senior Infrastructure managers toabsorb all the additional tasks imposed by the safety management programme as wellas managing the huge amount of investment in track renewal and other aspects of thesafety hardware and equipment investment programme. The pressure of day to daytasks falling upon top management in the HR and Safety Departments also means thatthere is little time for these managers to devote to longer term strategic planning andpolicy development. IRMS note that specialist safety and personnel managers andadvisers are being appointed in the functions and this should release some capacity atHQ, but it is believed that senior positions should be created in those Departments tospearhead the development of future strategies and policies and provide posts vital tothe creation of forward managerial succession plans.

A lot of effort is being made into the recruitment of suitable safety critical staff andtheir training, but the availability of potential recruits, especially in the signalling andtelecommunications professions, remains a major problem, as IE cannot compete inthe labour market at a time of a booming Irish economy. Equally, IE finds it difficultto retain staff and the recruitment process in key grades barely keeps pace with thelosses incurred. The development of a company manpower plan is essential, toanticipate and put in place appropriate staff policies and strategies to counteract thisconcern in the longer term.

Overall, IR problems continue and are still regularly reported to impede forwardmovement even in items agreed to be safety-related. As stated in Sections 4.2 and4.4.3, staff consultations on the implementation of essential safety procedures andsystems ought to be carried out independently of negotiations concerning pay andconditions, and not become delayed due to other protracted negotiations and otherissues of contention. There is some evidence that the concept of competenceassessment is mistrusted. It should be made clear that the aim is to help people to dotheir job well and safely, it is not to deliberately to fail certain individuals, althoughclearly staff unable to demonstrate the necessary competencies must undertake furthertraining or fulfil other roles.

The Procurement Department has only been in existence for a short period of time inits present form. Excellent strides are being made to establish a system of control forthe procurement lifecycle. This momentum should be maintained.

Lastly, it is noted that IE has learned to pace the implementation of the safetyprogramme so that the initiatives can be properly briefed, discussed, absorbed andconsolidated before moving on - a problem apparent in the 2000 audit when somestaff at ground level complained at the amount and complexity of documentation they


IRMS


were expected to comprehend and implement in a very short time. It is moreimportant that IE prioritises and concentrates on the key programme elements andensures these are taken on board by all before trying to address (probablysuperficially) all recommendations ever made. It should be noted in this context thatthe initial IRMS review recommendations set dates for initiating programmes, notcompleting them.


IRMS


5. SAFETY ADEQUACY OF INFRASTRUCTURE AND ROLLING STOCK

This section provides a summary of the findings arising from the audit of IE’sinfrastructure and rolling stock. By necessity, such a review requires consideration ofa very large amount of information pertaining to complex engineering equipment.For brevity therefore, only a summary of this review is provided within this section.Full details of the review can be found within a series of technical reports coveringeach relevant discipline [6] – [10].

5.1 General Progress

Overall, the audit has found that considerable progress has been made in improvingthe safety adequacy of IE’s infrastructure and rolling stock.

Improvements in safety within the Signalling, Electrical and Telecommunications(SET) Department were identified as follows:

• refurbishment of many interlockings;

• repair of interlocking frames;

• improvements at level crossings, including repair or closure of iron gatescrossings;

• improved security at many signal cabins;

• renewal of worn out mechanical signalling assets;

• elimination of many redundant telegraph pole routes;

• re-servicing of Electric Train Staff (ETS) equipment;

• replacement of obsolete lineside communications systems and implementation ofa new lineside telephony system;

• elimination of fire hazards in safety critical equipment rooms;

• removal of risk associated with redundant wiring by cutting back and making safe;

• the Network Management Centre now includes a telecomms fault control;

• successful commissioning of signalling, electrical and telecommunications workson Clonsilla - Maynooth in conjunction with doubling of the line and provision ofnew stations;

• successful commissioning of signalling electrical and telecommunications workson the Malahide and Bray- Greystones extensions of the DART;

• safe introduction of new rolling stock on the DART ensuring compatibility withthe existing infrastructure;

• using separate Relocatable Equipment Buildings (REBs).

Improvements within the permanent way include:

• commendable mileage of new Continuously Welded Rail (CWR) installed;


IRMS


• substantial reduction in track defects;

• introduction of new tamping machines;

• overall evidence of improved management of the ageing track infrastructure.

Improvements relating to structures include:

• major improvements to building security;

• initiation of work to create a structures asset condition database;

• initiation of work to inspect tunnel conditions.

Improvements within the Electrification Department include:

• letting of a contract for the supply of a specialist overhead line access plant;

• establishment of substation access message procedure and log book;

• remodelling of the Centralised Traffic Control (CTC) control desk at Connolly;

• formalisation of Fairview Depot electrical safety procedures;

• harmonisation of circuit breaker re-closure procedures.

Finally, improvements within the Rolling Stock Department include:

• improvements in maintenance practices for the IE fleet;

• enhancements to the fabric of the Inchicore depot.

5.2 Locations Visited

A listing of sites and lines visited by the auditors is provided in Appendix I. Most ofthe surveying was carried out by means of a saloon inspection car provided by IE andshared by the auditors.

5.3 Signalling Electrical and Telecomms Issues Arising from Site Inspections

Infrastructure project work relating to SET performed over the last 12 months hasimproved safety and where work has been completed on refurbishing lever frames andmechanical equipment, this is of a good standard.

Uncertainty remains, however, in that the mini CTC project has been postponedwhich would have eliminated signalling infrastructure in poor condition, replacing itwith a modern, efficient signalling system. The postponement of this projectcontinues to cause major problems for the engineers faced with the task ofmaintaining worn out equipment. The provision of a specific safety managementsystem to address the postponement together with active safety monitoring, which hasbeen introduced in some areas, mitigates the risk of accidents but cannot in itselfprevent further deterioration of the infrastructure.

The documented SMS now requires to be extended to all other areas where majorworks have been deferred. This should cover each discipline affected by thecurtailment of such work. Where a documented SMS was previously recommended


IRMS


for specific signalling equipment in poor condition (e.g. Heuston and Claremorris),these have now been provided and the safety of the equipment is being monitored. Inaddition, SMSs have been provided for sites on the Galway line where the mini CTCproject has been postponed.

The action taken at Claremorris and sites on the Galway lines were examined on site.Claremorris was found to be satisfactory. There were however issues which arose onthe Galway line which, if repeated elsewhere would give rise to concern. These wereattributed to the postponement of the mini CTC project.

At Athenry and other sites, action had been taken to disconnect and put out of usethose items of signalling equipment which were considered to be in an unsafecondition. It was also noted, however, that the standard of maintenance at Athenrywas poor and that this had also contributed to the condition of the equipment. Thesignalling infrastructure remaining in operation was not in good condition andrequires refurbishment at the earliest opportunity.

The action proposed to be taken for Heuston as a result of the deterioration found inthe interlocking was discussed with the engineers concerned and it was suggested thatthe detailed plan should be subject to independent risk analysis. Heustoninfrastructure is of extreme importance to the network and any disruption caused willhave a severe impact on Dublin passenger services.

All mechanical interlocking frames are being systematically checked and repairedthroughout the network. Though the original timescale was not realistic due to thelack of resources, good progress has been made. It is suggested, however, that a fullydocumented SMS is also provided to ensure the safety in operation of the remaininginterlockings.

A general improvement in signalling and telecomms maintenance based on trainingreceived was in evidence, with the exceptions mentioned. In time, a more formalisedsystem of planned maintenance will consolidate this improvement.

One critical area is the testing and maintenance of facing points. This is a jointfunction between signalling and permanent way staff. On the Limerick and DublinDivisions this is working well and mechanical points examined were found to be ingood condition in all respects. On the Athlone division, the points gauge (which isthe responsibility of the permanent way staff) was wide by up to 15mm in manyplaces. The divisional engineer has been forced to prioritise resources due topostponement of the mini CTC project and is unable to carry out the work necessaryto bring the points into standard gauge. The signal engineer in the meantime hasintroduced a higher frequency of testing in order to maintain the safety of thesignalling system. This procedure (taking in to account gauge discrepancy) requires tobe formally documented until the permanent way work has been completed.

Good progress has also been made on recovery of redundant signalling andtelecommunications wiring, though again the envisaged timescale could not be met bedue to lack of skilled resources.


IRMS


Improved maintenance and servicing of ETS instruments together with the removal oftelegraph pole routes and provision of lineside cables has also resulted in a majorimprovement in safety of the signalling system.

In regard to controlled level crossings, where braking distance from the protectingsignal was found to be insufficient, marker boards are being provided at the correctbraking distance, as an interim measure. This is not an ideal solution and it is againrecommended that a risk assessment is carried out in order to justify the action taken.

Safety improvements have been made and work is progressing very well on closure,replacement or refurbishment of user worked level crossings, though it is stillnecessary to provide safety bays where sighting problems exist.

The CCTV system at Connolly is used for curved platforms where the driver is unableto view the carriage doors due to platform curvature or where mirrors are inadequate.It was estimated that 75% of the driver monitors are very difficult to use due tosunlight reflection problems, contrast settings and/or monitor positioning. In areaswhere only mirrors are used to view the doors, vandalism has proved to be a problem,again rendering the mirrors unusable in some cases. This is reported as a newunreasonable risk in Section 7.3.

5.4 Permanent Way Issues Arising from Site Inspections

There has been considerable progress on the implementation of infrastructureimprovements since the last visits in 1999. A commendable mileage of new CWR hasbeen installed to replace life expired jointed track. Unlike previous audits, the siteinspections identified very few examples of defects that would be unacceptable in therest of Europe. Station yard areas remain the locations with most problems. This hasbeen recognised and resources have been diverted to reach resolution.

The standard of installation has only been marred by the lack of staff and equipmentresource to remove scrap and excessive ballast on some sites due to inadequate ballastregulating equipment. Although the existence of lineside scrap has been commentedupon previously, the large track renewal programme has made the problemsignificantly worse. Although most of the material is in long lengths, not usuallysusceptible to vandalism, there are nevertheless many small items that make idealprojectiles.

The problems of lightweight and obsolete rails are being addressed by total trackrenewal. However, there remain many locations that will not be renewed for severalyears and the safe management of the ageing track infrastructure is vital. Rail andfishplates are now available to effect replacement of defects revealed by ultrasonictests and badly drilled rail ends by cascade from relaying sites. There was muchevidence that this was now being achieved and it is important to continue in order toeliminate the defect backlog.

It should also be noted that the new tamping machines, which had been inactive for aconsiderable period since their procurement due to IR problems, have now beenintroduced into service, which is to be welcomed. The fleet of plant available forpermanent way operations is still however not adequate in two key respects:


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• The lack of a fleet of modern ballast hoppers which would allow staff to placestone where it is needed and obviate the need to plough;

• The lack of materials handling equipment to allow the removal of scrap andserviceable material from the lineside for sale or reuse.

As forecast in the last audit [3] the problems arising from this inadequacy haveincreased with the new level of track renewal. It is understood that IE has alreadyinvited tenders for a fleet of ballast hoppers, although no such invitations have yetbeen issued for a train capable of lifting the large quantity of scrap produced by therelaying activity (a notice to invite expressions of interest in supplying suchequipment has however been issued).

As for both previous audits, the track gauge was checked at several locations at thetoes of switches. This is a critical area if the signalling equipment is to functioncorrectly. Many of the layouts examined within the Limerick and Dublin Divisionswere of relatively modern design and it was found these were generally close tocorrect gauge at the toes. In the Athlone Division where more older layouts wereexamined, many were found to be wide to gauge by up to 15 mm, which would beunacceptable to most other railway administrations. Signalling detection was,however, more consistently achieved, probably as a result of increased maintenanceattention by signalling staff. The problems appear to arise from incorrect soleplates,incorrect size holding down screws or fang bolts, and poor designs of soleplate. Themain action that IE have taken to resolve this problem is to replace decayedsupporting timbers and to increase the frequency of SET inspections. This isacceptable as an interim measure. The final solution will be either to replace thelayouts with modern designs or to undertake heavy maintenance to restore the correctgauge. This latter option would represent a large item of work as in all probability thegauge was incorrectly set at the time of installation.

The lack of adequate and understood standards available to staff on the ground stillmakes objective judgements difficult.

Many of the ongoing permanent way problems that IE face concern the trackconditions in station yard areas. Many of these locations have life expired jointedplain track and switches and crossings layouts of outdated design. In particular theswitches and crossings are almost beyond maintenance because new components arenot available and replacement serviceable components are rare and of poor quality.The layouts are correctly identified by IE as requiring renewal and at many locationsthe replacement materials have been on site for many months. However, it is notpossible to install them because the new material has been designed to remodelledgeometry to suit the mini CTC resignalling scheme. This scheme is delayed and as aresult the new track cannot be installed because it does not fit the current geometricalconfiguration. It is fortunate that good progress on the installation of CWR hasreleased maintenance resources in some Inspector’s divisions to deal with theseongoing problems. In the absence of increased inspection and maintenance, this couldbecome a safety problem.

One new unreasonable risk relating to the permanent way was identified (see Section7.3). This involved the unacceptably short piece of rail, only approximately 800mmfrom weld to joint, recently installed at Rosslare Strand. The rules for minimum rail


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lengths (4500mm) appear to be well known at all levels in the organisation. The railwas reported as replaced within a fortnight of discovery and IE have indicated thatstaff briefings have been undertaken to avoid a reoccurrence of this issue.

5.5 Structures Issues Arising from Site Inspections

5.5.1 Buildings

Much work has taken place to improve building security e.g. installation of locks andsecure doors, fire safety e.g. rewiring, removal of fuel burning stoves, clearing outdebris and the general condition of the building fabric. The first phase is almostcomplete with only routine snags outstanding. The next phase is underway withimprovements seen. CTC has been substantially refitted. As far as management ofthe engineering structures within buildings, e.g. station roofs, is concerned, this hasmade no progress to date, although the Chief Architect has a detailed inspectionprogramme planned later this year.

5.5.2 DART Footbridges

It was noted that DART footbridges are being replaced or reclad where replacement isnot necessary according to the Structures Engineer’s programme. The footbridges atSeapoint and Killiney stations are taking longer to develop than planned as thescheme must now incorporate disabled access facilities.

It was also noted that the station footbridge and public footbridge at the end ofGreystones station have been renewed as part of the DART extension project. Thefootbridges give some cause for concern in two respects. Firstly the station footbridgein particular is showing signs of significant corrosion. This is indicative of very poorpainting when fabricated. It is unacceptable for a paint system applied in a workshopto be failing after about 18 months even if it is close to the sea. Secondly, bothfootbridges have the main span constructed such that the bottom member is madefrom a rolled hollow section about 100mm wide. This provides a ledge fortrespassers to walk along with all the obvious dangers from falling. The likelihood ofelectrocution is mitigated by shedding plates but not from simply falling off on to thetrack and possibly a train. There should be a deterrent to walking along the bottommember, by the provision of either a plate at 45° along it or a collar of spikes. Thenew footbridge at Bray station erected in the past couple of weeks has a similarproblem.

5.5.3 Bridges

A bridge (UB 742) had been raised at Ballyhaunis to improve clearances for roadtraffic passing underneath and therefore reduce bridge strike risk. The methodinvolved fixing short metal sections to the girder ends and jacking the three maingirders using jacks placed on the top of the abutments. The bridge had been raisedabout 12 inches and shuttering placed across the face of the abutment to allowconcrete to be placed to form a new abutment bedstone arrangement. This methodwas safe in itself except that it was carried out while road traffic and pedestrians wereable to continue passing beneath the bridge. The consequences of the deck beingstruck or the shutter simply ‘blowing’ while supporting fresh concrete would have


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been extremely serious. The risk to pedestrians was partially mitigated by a scaffoldceiling above the pavement. But this would offer little protection in the event of theconcrete shutter blowing. It is understood that a further lift of 12 inches is plannedusing the same methodology. In both cases, if a method statement had beenproduced that gave consideration to the risks and a method of working developed toeither avoid or mitigate the identified risks, then a safer job would have resulted. Thisis identified as an unreasonable risk in Section 7.3.

An example of poor occupational safety was seen at Ballinasloe where scaffoldingwas struck following painting of bridge number 125 over the river Suck. Contractscaffolders were walking over the disused span with only a single scaffold board aswalkway between open cross girders. It would have needed only a minor slip, trip ormisplaced footing for a man to have fallen about 4m in to the river below. There wereno life jackets worn, no safety boat available or method of securing men to the bridgewith harnesses as an alternative. There was no method statement produced by the DEorganisation for the entire job. This is also identified as an unreasonable risk inSection 7.3.

5.5.4 Structures Management

The IE bridge management project will provide an excellent database and conditionreport of all structures on a one-off basis. There is however a concern about howinspections will be carried out thereafter. There is no plan at present to move awayfrom the current system within the Divisional Engineers’ organisations. The methodof recording condition is inadequate for anything but small structures. There isevidence that routine minor maintenance is not always being carried out at the rate itshould be as resources are concentrating on the huge new build effort.

5.5.5 Bridge Strike Management

The recent risk assessment exercise needs to be finalised and then used to drive aphysical works programme. The programme of vulnerable overbridge interfacesneeds strengthening. The recent disaster in the UK demonstrates the catastrophicconsequences that can result from a road vehicle on the track. Some very flimsyoverbridge parapets were seen in this regard.

5.5.6 Tunnels

Following the work by external consultants on tunnels, IE needs to sustain itsknowledge of the tunnels’ condition by inspecting them routinely. Limerick JunctionDivision has carried out one inspection, which is a good start.

5.5.7 Platforms

The new station at Grand Canal Dock was inspected. It is an impressive new stationwith high standards of passenger facilities. There were however a few concernsresulting from the visit. Firstly again, the outside of the footbridge span can bewalked along albeit it is not a box section. Secondly, the size the platform, whilebeing built to IE minimum standards, is narrow at 2.5m. At busy times when all thecommercial development is open in the neighbourhood there will be a risk of


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overcrowding on the platform at peak hours. Finally, if someone were to stand on theseats at the back of the side platform the rear fence is too low to stop them falling overthe side if they were to over balance. It is suggested that the fence is raised locally atseat locations.

It was noted that a retaining wall foundation had been undermined as a result ofexcavation work on the approach to Claremorris station from Athlone. This couldresult in a possible train derailment if the cutting slips. This is identified as anunreasonable risk in Section 7.3.

Very badly damaged coping stones were noted on Claremorris station platform 2,with the potential to lead to falls from the platform. This is also identified as anunreasonable risk in Section 7.3.

5.5.8 Fencing

It was noted that new fencing had been erected too close to the track at the BarbersTown level crossing near Clonsilla. This removed the safe space available for peopleto stand clear of trains. This is identified as an unreasonable risk in Section 7.3.

5.6 Electrification Issues Arising from Site Inspections

At the last audit, the new equipment at Bray Substation was inspected; however thisinspection was somewhat superficial, as the equipment was not fully commissionedand was not yet taken over by IE. During this audit however, the new equipment atMalahide Substation was inspected in detail, and its operational safety featuresdiscussed with IE staff. As a result, a new unreasonable risk has been identifiedconcerning the safety of maintenance staff undertaking work on high voltage andtraction supply equipment.

The standard of construction is not in question; however, the risk arises because of thelack of safety interlocks in comparison with the earlier Siemens-supplied substations.Safe working on any complex high voltage equipment relies on a sequence of:

• switching off;

• isolating and locking off;

• earthing;

• releasing the equipment for work.

The last step (releasing for work) can either be achieved through mechanicalinterlocking - as is the case with the original Siemens substations – or throughprocedures and written Permits to Work. The new risk results from interlocking notbeing provided on the substations, whilst unfortunately there is no written Permitprocedure in place (since there was no need for such a procedure with the olderinterlocked equipment). There is therefore a risk arising from both the lack of such aprocedure and from maintenance staff now being faced with two types of equipmentwith different operating and safety requirements.


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A range of remedial actions are recommended to address this risk, both equipmentand management systems related:

• as a short-term measure, take extra additional care in the new substations;

• consider urgent retro-fitting of interlocking on the new equipment;

• longer term, introduce a substation Permit to Work system (needed for morecomplex operations anyway;

• ensure for the future that those procuring equipment liaise with those who are tooperate/maintain it.

At the last audit an operational query was raised concerning the provision of load-measuring auto reclose equipment on the feeder dc circuit breakers. In the event of ashort circuit tripping, the equipment makes an assessment of the loop impedance ofthe circuit (i.e. whether the fault still exists); and, if favourable, allows the operator toreclose the breaker. It will try to do this three times, and if unsuccessful will thenlock out. As configured at present, this state requires a substation visit to reset thelock-out before further attempts can be made to reclose the breaker. DART has nowinitiated a modification with the Contractor to remove this lock-out feature. As themodification still requires the intervention of the Electrical Control Operator (ECO) tore-close a circuit breaker after a fault trip, the load-measuring circuit simply preventsthe ECO from re-closing on to a short circuit, this risk is now considered to be closed.

Corrosion has become apparent, on some overhead line fittings in the tunnels on theGreystones extension. ADtranz has now changed these for corrosion-resistant fittingsand Minoroc droppers under the terms of their contract.

Exposed mains voltage terminals were noted previously in the motorised isolatorcubicles when open for manual operation. It is now noted that it is not necessary togain access to this cubicle during manual operation of the isolator, but this is yet to beconfirmed by the Contractor.

An unreasonable risk had been noted previously, in that the cross section of contactwire used on the extensions is different from that elsewhere on the electrificationsystem. The AC-107 wire has a narrower top lobe than the BC-107, requiringdifferent mid-span splices and section insulator end-fittings. There is a potential riskof a wire parting if the wrong splice or end fitting is used. This risk did not existbefore. The OCS staff now clearly recognise this new risk. It has been accepted thatthe risk can be managed, by clearly segregating and marking (perhaps by differentcolours) drums of spare wire and associated fittings, and allocating these as section’A’ for the original DART and ‘B’ for the extensions. It is also appreciated that,when the time comes to renew contact wire, the section appropriate to the locationmust be used, without mixing sections anywhere on the system. These mitigationmeasures have yet to be implemented, and therefore are still to be audited. At present,all ADtranz spares are held at Inchicore, separate from existing Siemens spares, socare is taken not to mix stock.

The other unreasonable risk noted previously related to the absence of adequateoverhead line access equipment. A contract for such equipment has now been placed,with delivery expected in November 2001. The risk is being managed acceptably in


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the interim. It should however be ensured that the equipment is introduced intoservice, after staff training, at the earliest possible date.

5.7 Rolling Stock

5.7.1 Detailed Inspection of the IE Fleet to Assess Condition and Maintenance Quality.

It was confirmed that 15% of the fleet (by rolling stock class) had been subject to adetailed inspection by external consultants to assess condition and maintenancequality, as previously recommended by IRMS. The report prepared by the consultantshad identified a number of inadequacies in maintenance across all areas of the fleet.The Chief Mechanical Engineer (CME) has been quick to address the inadequaciesidentified by tasking the relevant Sectional Managers to prepare a departmental actionplan to address the issues within their area. The issues identified, in the main, havebeen addressed on the vehicles although some work is still ongoing. Where it hasbeen necessary to make changes to maintenance documentation this has been (or isbeing) undertaken.

The CME had also commissioned the external consultants to suggest initiatives tofurther enhance and develop maintenance practices on the IE fleet.

5.7.2 A Review of The Relationship Between Operational Instructions and Rolling StockDocumentation

It was noted that as part of the studies undertaken by the external consultants, theissues associated with acceptable integration of operator’s log sheets and maintenancedepot log books had been considered. As a result, it is now a daily practice forinformation from drivers reports, operators daily incident reports, and depot shift logbooks to be collected to develop a daily picture of activities in the field, programmecorrective maintenance and develop trend analysis. This represents a safetyenhancement from previous practices.

5.7.3 Rationalisation of the Maintenance Documentation

It was noted that the CME has embarked on an exercise of rationalising maintenancedocumentation with the following initiatives:

• development of examinations and maintenance instructions into a format suitablefor storage in a maintenance instruction database;

• embellishment of examinations and maintenance instructions with photographicinformation showing locations and exploded views etc;

• use of IT to control the issue of documentation to the shop floor and provide‘hyperlinking’ of all relevant information required by the maintainer;

• specifying these initiatives in the technical specifications for new rolling stockallowing direct integration of new information;

• initiating the preparation of maintenance manuals for (initially) MkIII coaches andClass 2600 & 2700 DMUs.


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The initiatives are ongoing and progress is deemed adequate. It is understood thatonce the proposed organisational changes to the Technical Manager’s Departmenthave been ratified and implemented, responsibility for the production and co-ordination of the documentation will pass to the Maintenance Engineer’s sectionwithin the reorganised Technical Manager’s Department.

Ongoing progress should be monitored to ensure ongoing effectiveness andmaintenance of the initiatives.

5.7.4 Independent Inspections on Major Maintenance And Repairs

It was noted that the CME had commissioned external consultants to undertake anaudit (or independent inspection) of IE vehicles to establish the effectiveness ofoverhauls. The review identified a number of technical and process related issues.

More fundamentally the consultants have suggested that following their maintenanceinspection of the fleet, significant benefits (both financially and technically) can berealised by moving towards a regime of balanced examinations2 (as used elsewhere)instead of the current regime of A Exam (48 hrs), D Exam (6 months) and GeneralRepair (3.5 years). It is understood that savings in the order of 26% in down timehave been suggested. Provided this is well managed, there should be no safetyimplications.

The CME is currently considering the possibility of trialing 2 MkIII trainsets underthe regime of balanced examinations. Ongoing progress should be monitored toensure ongoing effectiveness and implementation of the initiatives.

5.7.5 Site Inspection Issues

No specific issues arose from the visit to the rolling stock depots, nor the various cabrides. However, during a tour of the Inchicore works site it was noticed that asignificant effort had been concentrated on improving the fabric of the buildings, andin particular that a number of shops had been re-roofed, and fitted with new lightingand heating systems. It is understood that the remaining shops will be attended to in arolling programme.

5.8 Conclusions

Overall, it is concluded that considerable progress has been made in improving thesafety of IE’s infrastructure. Much has been achieved since 1998 and the speed ofimprovement has accelerated since the date of the last audit in 1999. The hard issuesof life expired infrastructure are being tackled effectively and the result should be areliable and maintainable railway in the long term.

2 Balanced examination is a combination of examination, repair and overhaul, rather than the traditionalapproach of separate examination, followed by repairs and overhaul at other periods.


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However, given the chronic under-investment on the railway over the past decades,and the complex and heavy engineering workload that is required to correct theinfrastructure, much remains to be done.

Perhaps of most concern is the status of the mini CTC project. This would haveeliminated signalling infrastructure in poor condition, replacing it with a modern,efficient signalling system. The postponement of this project continues to causemajor problems for the engineers (in both the signalling and permanent waydisciplines) faced with the task of maintaining worn out equipment. The provision ofa specific SMS to address the postponement together with active safety monitoring,which has been introduced in some areas, mitigates the risk of accidents but cannot initself prevent further deterioration of the infrastructure. Some means of getting thisproject back on track is required as a matter of urgency.


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6. CROSS-FUNCTIONAL PROJECT

To identify whether IE is putting into practice the new standards, rules, regulations,and processes, it was proposed by IRMS that a typical IE cross functional Project(such as major re-signalling or the purchase, commissioning and introduction of anew fleet of rolling stock) be chosen as a case study.

The case study selected was the introduction of the Alstom class 8200 DART EMUs,It was jointly completed by the various infrastructure disciplines in February 2001.

It was noted that for the procurement of the Class 8200 EMU, IE had implemented therequirements of Company Standard No. 6 (Safety Validation of Changes in Plant,Equipment, Infrastructure, or Operations) from the testing phase of the project only.This had been due to the fact that the procurement of the stock had predated theintroduction of the standard. The project outlined that they had also conducted, usingexternal consultants, a retrospective design audit.

Although the implementation of Company Standard No. 6 has only been applied fromthe testing phase of the project, it has been applied in a logical and diligent manner.The documentation presented showed a clear cross-functional relationship with alldepartments contributing as appropriate. It was also demonstrated that appropriateapproval was obtained at each phase.

This rolling stock project has provided a valuable learning exercise in itsimplementation. The identification and mitigation of risks, not undertaken before in astructured way, has been a key element in the introduction of these trains.

6.1 Signalling Electrical and Telecommunications

Company Standard No. 6 was used to assess the affects of change to the infrastructureduring the testing and bringing into service of the new DART Rolling Stock. Alstomproduced a signalling compatibility document demonstrating compliance with theinfrastructure specifications provided by IE. These documents were all independentlyassessed by external consultants and found to be acceptable.

The work undertaken seemed to produce a greater understanding between the projectteam of the issues involved and promoted a safer culture by requiring the necessaryauthorisations before the potential introduction of risk. It also seemed to improve theoverall project management which improves safety by ensuring project planning ismore rigorous and achievable.

6.2 Permanent Way

The study took the form of an audit of the technical civil engineering infrastructureissues that need to be addressed if no additional risk is to be imported onto thenetwork. Three key areas were audited:

1. gauging;

2. track forces;


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3. derailment resistance.

The audit demonstrated that the risks involved in the introduction of the new trainswere either controlled or confirmed to be no worse than current stock. The main areaof deficiency concerned the lack of standards against which compliance could beassessed. Notwithstanding this, British and European standards were referencedwhere appropriate.

Much of the audit was satisfied by the fact that the new trains have identical bogies tothe 8100 stock that has given many years of trouble free service. It was thereforeaccepted that the new trains imposed no additional risks for many derailmentresistance and track forces issues. However, this will not be the case for most othernew rolling stock and it is recommended that this is an area for development.

External independent consultants provided independent confirmation of theacceptability of civil infrastructure issues.

6.3 Structures

No formal assessment of underbridge capacity has been undertaken for the newEMUs. However, as the axle weight of the new trains is less than that of some trainsalready using the route it is reasonable to accept that a formal assessment is notneeded. This conclusion or assumption has not been recorded as part of the process ofintroducing the new rolling stock.

An assessment of clearances from structures (such as platforms, bridges, tunnels, etc)had been undertaken and this was found to be acceptable.

6.4 Electrification

An audit was carried out in discussion with the Overhead Catenary System (OCS)Depot Manager about the electrification aspects of the new DART stock. Noincompatibility problems had been identified, and the isolation procedures establishedfor earlier stock are applicable to the new stock.

6.5 Rolling Stock

The CME has taken a positive approach to the use of external consultants to assist inthe design and construction validation of the rolling stock. This has been underpinnedby the issue of ‘comfort letters’ by the consultants at various design, construction andtesting stages.

It was also noted that via the experiences gained during the procurement of the Class8200 EMU, CME Technical Standard No.1 had been developed. This will integratethe requirements of Company Standards No. 3 ‘Changes in Organisations’, No. 5‘Risk Management’, and No. 6.

The development of the specification, supported by the use of external consultants toprovide technical advice, is seen as a positive step.


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For the procurement of the Class 2900 DMU, a detailed technical specification hasbeen prepared that details a number of safety-related requirements. This details therequirements necessary for the contractor to supply appropriate and sufficientinformation to allow compliance with Company Standard No 6 and TechnicalStandard No 1 to be assessed. It was also noted that external consultants hadreviewed the documentation and that appropriate Certificate of Approval (E Stage)had been obtained prior to the project proceeding to the tender stage.

6.6 Conclusions

The findings of the case study revealed that although the implementation of CompanyStandard No 6 only occurred from the testing phase of the project, it was applied in alogical and diligent manner. The documentation presented showed a clear cross-functional relationship with all departments contributing as appropriate. It was alsodemonstrated that appropriate approval was obtained at each phase.

The identification and mitigation of risks, not undertaken before in a structured way,has been a key element in the introduction of these trains. The audit furtherdemonstrated that the risks involved in the introduction of the new trains were eithercontrolled or confirmed to be no worse than current stock.

It is noted that the issue of fire safety and evacuation procedures in the event of anemergency would be worthy of further study. Current procedures require allpassengers to evacuate through the driver’s door. Signage is not currently adequate inthis regard, and thought is required regarding steps to be taken for evacuation in theevent of driver incapacitation.


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7. UNREASONABLE RISKS

7.1 Definition

7.1.1 General

Under the terms of the Department’s Brief, IRMS were required to identify “anymatters which will give rise to an unreasonable risk and require urgent remedialaction”.

Unreasonable risks were subsequently broadly categorised as those items of theinfrastructure, systems, or processes that either posed an immediate risk (of fatality orinjury) to passengers, public and/or staff, or represented practice that fell far short ofthat expected as ‘Best Practice.

Additional clarification and explanation of the term is provided below.

7.1.2 ALARP Principle

The ALARP principle is the fundamental basis of most health and safety legislation,including that applicable to railway operations.

This principle states that there are generally three levels of risk. These arerepresented in Figure 7.1.

Negligible risk

Intolerableregion

Broadly acceptableregion

(No need for detailedworking to demonstrateALARP)

The ALARP or Tolerabilityregion (Risk is undertakenonly if a benefit is desired)

Risk cannot be justifiedsave in extraordinarycircumstances

Tolerable only if risk reductionis impracticable or if its cost isgrossly disproportionate to theimprovement gained

Tolerable if cost ofreduction would exceedthe improvement gained

Necessary to maintainassurance that riskremains at this level

Negligible Risk

Figure 7.1: ALARP Triangle


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The legal principle is that all industrial risks should be reduced to levels that are ‘AsLow As Reasonably Practicable’. The ALARP principle allows cost to be taken intoaccount.

If a risk lies in the Broadly Acceptable region then there is no requirement to reducethe risk further, as the risk is already so low that further efforts to reduce it could notbe justified. If, however, the risk lies in the Intolerable region, risk reductionmeasures must be taken, regardless of the cost and complexity, in order to reduce therisk as far as is practicable towards the Broadly Acceptable region. If the level of riskcannot be reduced below the Intolerable limit, then the activity should cease or neverstart.

The area between the upper and lower limits is called the ALARP region. If the risklies within these two extremes, then cost/benefit calculations should be conducted todetermine the cost effectiveness of options for further risk reduction. If these analysesshow that the benefit of a particular risk reduction measure outweighs the cost of itsimplementation, then it must be undertaken. If on the other hand, the cost of itsimplementation is grossly disproportionate to the benefit gained, then there is norequirement to proceed with the risk reduction measure, although alternative lowercost risk reduction measures should be sought.

Such cost/benefit analyses require the reduction in risk levels, in terms of reducedfatalities/injuries, to be converted to a financial value.

It is also important to understand that risk tolerability can only be judged upon thecomplete risk spectrum that a person is exposed to from a particular activity, forexample a risk from a complete railway journey not just the risk during boarding oralighting, or from a train derailment at a particular junction.

7.1.3 Clarification of Unreasonable Risk

An unreasonable risk is NOT the same as an 'Unacceptable Risk' or 'Intolerable Risk'.An unreasonable risk will apply to a particular element of a journey, or a particularhazard at a specific location. Therefore, it cannot strictly be compared with ALARPacceptability limits.

An unreasonable risk is considered to occur from one or more of the followingfailures:

1. significant failures3 which violate Iarnród Éireann’s (IE) own ‘standards’4, or;

2. significant failures where the IE ‘standard’ is considered inappropriate orunsuitable, or;

3 A ‘significant failure’ is defined as a failure or deficiency of rolling stock, infrastructure, management systemsor operating procedures, of a type that has a high likelihood of causing fatality, major injury or multiple repeatsof minor injuries to persons (whether staff, contractors, passengers or public), or causing significant damage toinfrastructure or rolling stock

4 IE rules, procedures, standards, written systems of work, official guidance, etc.


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3. significant failures where no IE ‘standard’ currently exists.

AND

a. the failures have not been previously identified by IE, or;

b. inadequate temporary mitigation has been implemented to mitigate the failure, or;

c. a long term solution has been planned and programmed within a reasonabletimescales but the solution is considered inadequate, or;

d. an adequate long term solution has been proposed for which the timescales are toolong, or;

e. the failure has system-wide implications which have not yet been investigated andcontrol measures proposed.

7.1.4 Unreasonable Risk Review and Explanation

Each unreasonable risk identified by the Consultants has been peer reviewed by theIndustry Best Practice Forum to ensure that it meets the above definition criteria.

Each unreasonable risk has been:

• clarified as to why it is considered unreasonable;

• classified by group of persons the risk applies (passengers, public, etc.);

• classified according to level of potential consequence (e.g. multiple fatality,single major injury etc);

• allocated a proposed timescale for rectification.

A distinction has been drawn between the original identified hazard that poses theunreasonable risk, and the fact that this hazard may also be evidence of a systematicfailing elsewhere on the railway. For the former, this can and should be rectifiedwithout delay. However, the systematic failures throughout the railway may takelonger to rectify, but given that they are unrevealed and may be numerous, they aresignificant.

7.2 Progress on Previous Unreasonable Risks

Unreasonable risks and items requiring urgent remedial action had previously beenreported by IE as already ‘in hand’ or ‘completed’. IE has put into action a plan toaddress and rectify the unreasonable risks outlined in the previous IRMS audit reports[1], [3] and these are closely monitored by management. The monitoring documentwas made available during this audit and the reported position verified.

Appendix III contains details of each unreasonable risk identified against each of theinfrastructure disciplines and locations. Progress as at February 2001 is reported inthat Appendix.

It is important to acknowledge that in the original safety study [1], a 15-yearprogramme was envisaged for the rectification of many of the serious infrastructuredeficiencies. The first 5-year segment of this was incorporated in IE’s 5 year RailwaySafety Programme 1999-2003 [2] which is further supported by the National


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Development Programme (NDP) up to the end of 2006 which also includesdevelopmental works for the Railway. IE has now completed over two years of theSafety Programme. The chronic under-investment over the past decades, the complexand heavy engineering workload that is required by way of an enormous workprogramme, hard and soft issues, and the increasing demand for rail services, place anenormous burden on the railway and it will take time to get all this work in place.

Despite this, the audit has identified that there is significant progress on the mitigationof unreasonable risks reported at the original survey and during the last audit.Incidentally, there has been significant progress too on the elimination of the moreminor risks identified in the original and second reports. There is now evidence thatmany of these minor issues have been discussed with the work-force, and theappropriate action taken. The present audit has confirmed that these agreed solutionsare now filtering through to the emerging procedures.

With the exception of three risks, all unreasonable risks identified during the previousaudits have now been fully resolved, or acceptable temporary mitigation measureshave been put in place until such time as the risk can be permanently addressed5.

The three unreasonable risks that have not yet been dealt with all relate to signallinginfrastructure:

• with respect to the testing of all mechanical interlocking, although the work iswell underway, the original timescales set were not realistic due to the lack ofresources for this specialised activity. This work will continue until completion;

• it was reported in the initial audit [1] that the design of a control circuit could leadto a safety critical failure in colour light signals. Further audit activity wasrecommended to ascertain the scope of the problem identified. IE has said that noaction has been taken on this item, since it is believed that alterations will give riseto greater risk. It is recommended that a risk analysis be conducted to justify thiscourse of action;

• lastly, the facing point lock on the Barrow Bridge has not yet been installed andfurther consideration of the design to prove that the rails are correctly alignedprior to signalling of the route is required. In the interim, IE is managing thesituation carefully.

In addition, there were other unreasonable risks for which although the originatinghazard has been dealt with, either further examples were found during the latest audit(slippery and missing bridge walking boards for staff and the lack of fire detectionand protection equipment in some new signalling equipment rooms) or else theproblem has repeatedly re-occurred (broken glazing in Bray Station roof). There arein addition a large number of unreasonable risks for which the original risk has beenrectified or mitigated, yet the risk was evident of a possible systematic failing thatrequired other, or on-going, action elsewhere. It will thus be necessary for IE to

5 It should be noted that during the audit IRMS checked most, but not all, previously identified unreasonablerisks on-site. This comment thus relies in some cases to IE’s responses to each unreasonable risk as reported inAppendix III.


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ensure that a realistic programme is put in place for these longer term or ongoingactions, and that it closely reviews and manages these actions until they are fullycompleted.

7.3 New Unreasonable Risks Identified

Appendix IV contains a list of new unreasonable risks identified during the recentaudit together with a response from IE as to the actions taken.

A total of 8 new unreasonable risks were identified during the audit. These are asfollows:

1. weld installed too close to fishplated joint;

2. lack of safety interlocks for access to high-voltage substation equipment onDART extensions;

3. unsafe method of scaffold dismantling over water;

4. unsafe method of bridge raising;

5. fencing erected too close to the track;

6. damaged platform edge coping stones;

7. retaining wall foundation undermined;

8. unusable DART Driver Only Operation CCTV and mirrors.

The potential for new unreasonable risks to manifest themselves will always remain.It is thus crucial, as noted in previous audit reports, that IE implements a regularprogramme of independent audits to identify and rectify such issues themselves intothe future.

The details of each new unreasonable risk were reported to IE to allow them toinclude their response to the risk, together with information on its current status.These are reported in the last column of the table shown in Appendix IV.

Of the eight new unreasonable risks, IE has reported that four have been fully clearedor resolved (item numbers 1, 3, 4 & 5). For two of these (1 & 5), no further action isrequired, although IE may want to investigate why and how they arose in the firstcase. It is also noted that IE do not consider item number 4 as an unreasonable risksince they contend that the public were not put at risk. However, if a structuredmethod statement had been prepared in advance of the work proceeding which hadconsidered all reasonable foreseeable hazards including a road vehicle striking thescaffolding or the shutters bursting over a pedestrian, the need for robust means ofrisk mitigation would have been self-evident.

Unreasonable risk no. 2 has been mitigated in the short term by locking-up the accesskey and fitting warning signs. A longer-term permanent solution is beinginvestigated. Item numbers 6, 7 & 8 are ongoing tasks that will require short termmitigation measures, and a longer term solution to be implemented.


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Unreasonable risk 8 is potentially more serious, and a technical solution will takelonger to implement. The response from IE to this hazard, noted in Appendix IV, isnot considered acceptable. There is a real risk with Driver Only Operation Dart trainson curved platforms that a ‘dragging accident’ can occur such that a passenger istrapped in the train doors as it departs and they are dragged along a platform andpotentially under a train. This is exacerbated during peak hours when crowding onplatforms may obscure the driver’s visibility. IE are recommended to address thisissue as a matter of urgency. In the interim, measures such as additional platformstaff should be considered to assist drivers in departing their trains.

Item numbers 3, 4, 5 & 7 are evidence of the continued need to closely manage theactivities of staff and contractors and to ensure that they abide by agreed methods ofwork and standards.

7.4 Conclusions

The audit has identified that there is significant progress on the mitigation ofunreasonable risks reported at the original survey and during the last audit. There hasbeen significant progress too on the elimination of the more minor risks identified inthe original and second reports. There is now evidence that many of these minorissues have been discussed with the workforce, and the appropriate action taken.

With the exception of three risks, all previously identified unreasonable risks havebeen now been resolved or acceptable temporary mitigation measures have been putin place until such time as the risk can be permanently dealt with.

A total of eight new unreasonable risks were identified during these audits of whichhalf have already been cleared, and the remaining risks are being managed in theinterim or involve ongoing work.

IRMS remain concerned with IE’s ability to:

• go beyond the specific unreasonable risks identified to deal with systematic ornetwork wide issues;

• foster a questioning attitude based on a rigorous process of considering allreasonably foreseeable hazards and putting in place appropriate risk mitigationmeasures before an activity is undertaken;

• develop and implement a regular programme of in-house audits to identifyunreasonable risks on the network.

It is considered that a comprehensive programme of external independent audits willcontinue to be required into the future until IE have satisfactorily addressed each ofthe above issues.


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8. RISK ASSESSMENT

8.1 Latest IE Risk Estimates

8.1.1 Introduction

A risk model was developed as part of the original audit6 [12] based uponinfrastructure site surveys and various operational parameters such as the frequency oftrain service and the numbers of passengers using the rail network. The risk modelwas subsequently updated in 20007 [3].

The model divides up the network into a total of 37 sub-sections and consists of threeinterlinked elements:

• the predicted frequency of collisions and derailments;

• the likely number of casualties arising from such events;

• the level of collective and individual risk arising from collisions and derailments,gained by combining the above two parameters.

More detailed discussion of the working of the model can be found in [13].

As before, it should be noted that this risk model only addresses failures associatedwith signalling, permanent way and rolling stock assets. Failures associated withother aspects of the railway, such as train driver errors, accidents at stations, etc areexcluded. This means that the risk estimates produced may represent under-estimatesof the true total risk.

8.1.2 Changes Made to the Model

The model has been updated for this study to account for the following changes:

• condition of assets as assessed by the IRMS infrastructure audit teams;

• the latest data pertaining to the number and type of infrastructure assets, assupplied by IE8;

• the latest train frequency and patronage data, as supplied by IE;

6 It should be noted that the 1998 risk assessment results as reported in the original study [1] were subsequentlyrevised in December 1998 following the issue of revised infrastructure asset data provided by IE. It is therevised data which are used within this report as the basis for the 1998 predictions, NOT the data containedwithin [1].

7 The 2000 update did not revise the risk calculations for all lines – only those which were specifically audited atthat time.

8 In practice, the data supplied by IE for SET on this item was very sparse and its accuracy is thereforeuncertain.


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• modifications to train operating speeds, in particular taking account of where IEhave introduced Temporary Speed Restrictions (TSRs) to control risk fordegraded infrastructure conditions. This was necessary as IE’s current strategy forrisk control is dependent upon the impositions of TSRs until infrastructure can berepaired or replaced.

8.1.3 Key Risk Improvements

As a result of the new infrastructure site survey results, the asset condition scores forthe following signalling equipment were generally revised downwards:

• electrical signals;

• relay interlocking;

• mechanical interlocking9;

• electronic interlocking;

• clamp lock points;

• electro-pneumatic points;

Examples of improvements include elimination of bare wires, improved maintenance,improved housekeeping, better training, improved security, better infrastructure co-operation, updated drawings and improved fire safety.

For permanent way, the replacement of defective jointed track with CWR hasdrastically reduced the previously identified hazards on those lines and thussignificantly lowered the risk of derailment. Specifically, the permanent way for sub-sections 29 (Connolly – Mullingar) and 30 (Mullingar – Carrick on Shannon) hasbeen completely replaced with CWR10.

8.1.4 Locations

Appendix I provides a listing of all parts of the network visited by the audit team.The risk model has been updated in line with the findings for these sub-sections. Inaddition, IE provided a list of areas not visited by the audit team where new track andsignalling assets have been installed and commissioned. The risk model was alsoupdated in the light of this information.

8.1.5 Railway Operational Statistics

The risk model necessarily contains details of the number of trains operating overeach route of the network, and the number of passengers transported. As part of thisstudy, IE provided IRMS with revised data on train services and passenger statistics.

9 Note that asset condition scores went up on lines 29 and 30 due to the poor condition of mechanical frames.

10 There has also been considerable laying of CWR on other lines, however the model conservatively only takesaccount of the advantages of CWR if the track within the sub-section has been totally replaced.


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These indicated that passenger flows have increased significantly since 1997 on thefollowing routes:

• Dublin – Northern Ireland (around 39%);

• Dublin – Rosslare Europort (around 13%);

• Dublin – Cork (nearly 13%);

• Portarlington – Galway (nearly 8%);

• Cherryville Junction – Waterford (nearly 4%); and

• Ballybrophy – Killonan (around 2%).

Passenger flows have decreased since 1997 on the following routes:

• Athlone – Westport/Ballina (down 17%);

• Cork – Cobh (down 15%);

• Mallow – Tralee (down 13%); and

The trend indicates that, overall, passenger flows have increased on the IE rail system.It should however be noted that there is a concern that the strike during 2000 mayhave skewed the passenger data. IE did indicate that the passenger flows providedwere adjusted to account for the strike but there remains a possibility that this mayhave caused some anomalies that have led to inaccurate passenger flows for thoselines.

Data provided by IE also indicated that the passenger train frequency has increasedfor 16 of the 37 sub-sections (primarily on the Cherryville Junction–Waterford,Dublin–Cork, Athlone–Westport, and Dublin – Sligo routes). Conversely, the freighttrain frequency has mostly decreased for the same routes.

8.1.6 Results

8.1.6.1 Annual Accident Frequency

The overall accident frequency is predicted to be 6.7 accidents (train collisions orderailments) per year. For basic comparison, IE historically experiencesapproximately 4 passenger train derailments and around 1 passenger train collisionper year on the main lines (based upon data taken from 1993 to 1999). The overallresults of the model thus accord reasonably well with historical experience on thenetwork.

Comparing this value to those calculated by the model in 1998 and 2000 shows anoticeable decrease in predicted accident frequency, as shown in Table 8.1. This canbe attributed to the improvements in permanent way and signalling infrastructuremade during this period.


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Date of Risk Model 2001 2000 1998Annual Accident

Frequency (per year)6.7 9.4 10.0

Table 8.1: Annual Accident Frequency Predictions

The 10 sub-sections with the highest predicted annual train accident frequency aregiven in Appendix VII. These results demonstrate that the likelihood of collisions andderailments has decreased for most lines in the IE network when compared with thepredictions of the 2000 and 1998 models. Overall, of the 37 sub-sections, a total of34 are predicted to have a lower accident frequency than previously estimated fromthe 1998 model. The 3 lines that have increased (Athenry-Galway, Athlone-Claremorris and Carrick on Shannon-Sligo) show a slightly higher potential foraccidents arising from the degraded condition of mechanical points and interlockingin these areas11, as compared with the 1998 predictions.

8.1.6.2 Collective Risk Predictions

The overall passenger collective risk is predicted to be approximately 5 EquivalentFatalities per year due to collisions and derailments. Again the collective risk valuesshow a significant decrease from the values calculated in the 1998 and 2000 riskmodels. Table 8.2 presents this comparison.

Collective Risk(Equivalent Fatalities

per Year)

2001 Model 2000 Model 1998 Model

Passenger 4.6 7.2 7.8

Table 8.2: Collective Risk Predictions

The 10 sub-sections with the highest predicted annual passenger collective risks aregiven in Appendix VII. Overall, of the 37 sub-sections, all bar one (Athenry-Galway)are predicted to have lower collective risks than previously estimated from the 1998model. The increase in collective risk for the Athenry-Galway sub-section is due tothe degradation in the condition of mechanical points and interlocking, as previouslynoted in Section 8.1.6.1 above12.

The equipment contributions to the total passenger collective risks on all sub-sectionsare given in Table 8.3. As can be seen from this table, the total predicted collectiverisk arising from signals, interlocking, level crossings and permanent way have

11 Due to the further degradation of equipment that was due to be replaced by the mini CTC system.

12 Even though the frequency of accidents has increased on the Athlone-Claremorris line, the collective risk hasdecreased due to a lower number of passengers per train (and thus lower casualties) estimated by IE for this linefor 2001 as compared with 1998. In addition, even though the frequency of accidents has increased on theCarrick on Shannon-Sligo sub-section, the imposition of a TSR on the line results in lower casualties and thuslower collective risk.


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significantly decreased. The total risk arising from points and train detection hasremained more or less static. The total collective risk arising from rolling stock faultsremains low.

The results indicate that IE should address the condition of the points as a matter ofpriority if substantial risk reduction across the network is to be achieved.

Asset Type Collective Risk (EquivalentFatalities per Year)

Model Year 2001 2000 1998

Signals 0.78 2.24 2.58

Interlocking 0.11 0.63 0.72

Points 2.70 2.79 2.83

Train Detection 0.63 0.59 0.59

Level Crossings 0.05 0.17 0.17

Permanent Way 0.20 0.64 0.79

Rolling Stock (Derailment) 0.07 0.07 0.07

Table 8.3: Equipment Contribution to Collective Risk

It should be noted that, whilst permanent way contributes a substantial proportion ofthe overall accident frequency on lines with jointed track in poor condition, overall itmakes little contribution to risk levels because the busy lines already consist of CWR,and the consequences of derailment are much less severe than collisions.

8.1.6.3 Individual Risk

Passenger individual risks are calculated for each sub-section based on the collectiverisk for that sub-section, the total number of journeys per year in that sub-section, andthe risk exposure for different passengers. Thus sub-sections with low collective risksmay still have a high individual risk because a few passengers may be making manyjourneys each on that line.

The 3 sub-sections predicted to have the highest passenger individual risks from the2001 model are presented in Table 8.4.


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Sub-Section Route Individual Risk (Equivalent Fatalities perYear)

2001 2000 199829 Connolly - Mullingar 1 in 6,000 1 in 6,400 1 in 4,5003 Bray – Arklow 1 in 6,800 1 in 6,30013 1 in 6,30025 Athlone - Claremorris 1 in 7,500 1 in 8,10014 1 in 8,100

Table 8.4: Sub-sections with Highest Passenger Individual Risks (>1 in 10,000 per year)

Overall, of the 37 sub-sections, all bar two (Athenry-Galway and Athlone-Claremorris) are predicted to have lower individual risks than previously estimatedfrom the 1998 model. The increase in individual risk for these sub-sections is due tothe degradation in the condition of mechanical points and interlocking on theselines15.

It is instructive to note that in the original 1998 study16 a total of six lines werepredicted to have individual risks in excess of 1 in 10,000 per annum. This has nowbeen reduced to three. Furthermore, in 1998 the highest individual risk was estimatedto be 1 in 4,500 whereas now the highest risk is some 25% lower at 1 in 6,000. Thisrepresents around 70% of the intolerable risk limit of 1 in 4,000 set in [1].

The sub-section with the highest individual risk is still predicted to be Connolly –Mullingar. The individual risk on this line has slightly increased from the 2000 modelestimate, although it should be noted that it is still improved from the 1998 prediction.This increase is mainly due to degradation in the condition of mechanical points andinterlocking, which is due in turn to the delay in the introduction of mini CTC. Therisk on the Bray – Arklow line is predicted to have decreased somewhat from the1998 and 2000 estimates, due to improvements in infrastructure condition on this line.The individual risk on the Athlone – Claremorris line has slightly increased from the1998 and 2000 estimates. This slight increase is primarily due to the degradation incondition of the mechanical points, which is again due to the delay in the introductionof mini CTC.

Twelve sub-sections of the IE railway network are predicted to pose individual risksto passengers that are above 1 in 40,000 per annum (ie within a factor of ten of theintolerable limit, as defined in [1]). These are shown in Appendix VII. This compareswith nineteen such sub-sections predicted in 1998.

13 The 2000 value is the same as the 1998 value as the risk on this line was not reassessed at this time.

14 The 2000 value is the same as the 1998 value as the risk on this line was not reassessed at this time.

15 Even though the degradation of mechanical points and interlocking has also affected the Carrick on Shannon-Sligo line as noted in Section 8.1.6.1, the imposition of a TSR on the line results in a lower individual risk thanfor previous model estimates for this sub-section.

16 As revised in December 1998 (see footnote 6).


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8.1.7 Conclusions

The revised risk assessment demonstrates that the efforts being made by IE toimprove the condition of the railway are leading to reduced passenger risks.However, whilst the risks have been reduced there is still considerable room forimprovement on many of the sub-sections. It is therefore recommended that IE’sefforts continue with emphasis being placed on the key contributors to both thecollective and individual risks.

It is however important to recognise the limitations of this approach. The analysis isrestricted to risk resulting from train collisions or derailments caused by infrastructuredefects only. It has been a central recommendation of both previous audit reports thatIE develop their own detailed model as a tool to guide future infrastructure investmentstrategies. The status of this work is considered in the next section.

8.2 Status of the IE Risk Model

IE commissioned the development of a pilot risk model study following the issue ofthe last audit report. The purpose of this pilot study was to investigate the feasibilityof developing a network-wide model that would be able to both accurately predict riskprofiles and provide a measure of the benefits to be gained from differentinfrastructure investment proposals.

The Cork-Cobh section of the network was chosen as the basis for the pilot study, theresults for which have recently been presented to IE for discussion. The resultsobtained by the model are currently being evaluated by IE.

The development of this pilot study is a very welcome first step on the part of IE toembrace a risk management approach as an element to aid management decisionmaking for investment appraisals and prioritisation. There is however some evidenceto suggest that there is a still some substantial suspicion of the benefits to be obtainedby such an approach in certain quarters within IE. In addition, it is IE’s belief thatthere is a requirement for the railway to achieve a minimum engineering standard(which in its belief is some years away) before the adoption of a risk based approachfor further investment is necessary.

In the meantime, in the absence of the adoption of risk based decision making, IE hasno objective means of justifying their annual investment requests of Government. Itis the IRMS’ belief that the Department should seek some concrete steps on the partof IE for more formal and objective investment decision making as a matter ofpriority. It may be appropriate in this regard to consider convening a high levelseminar involving senior managers of IE, the Department and the Railway SafetyAuthority (RSA) to agree a comprehensive process for the request and approval offuture funding requirements. The continued development of the risk model willalmost certainly be a central element of any such future system and thus IE is stronglyurged to continue its development and to ensure the required level of organisationalcommitment to the project.


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9. RAILWAY SAFETY REGULATION

The first IRMS report on Railway Safety in Ireland [1] contained a significant numberof detailed recommendations for the future regulation of railway safety. The secondreport on the progress made [3] grouped the initial recommendations because many ofthem were on the way to solution collectively within a few large packages of change.That remains the situation now so this report will also deal with the big-picture issuesrather than the detail which is being swept up within the reforms in progress.

The summary of recommendations in the last report [3] grouped the remaining actionsfor the Department into three high-level headings as follows:

• consolidation of the role, resources and reporting lines of the RailwayInspectorate;

• finalisation of new railway safety legislation.

• the Railway Inspectorate to ensure that appropriate targets and standards arepromulgated to the industry.

Each of these issues is now considered, along with more detailed issues raised duringthe first audit, where appropriate.

9.1 The Railway Inspectorate - and Future Railway Safety Authority

9.1.1 Human Resources

IRMS previously found the Railway Inspectorate significantly under-resourced for itscurrently mandated role, and was likely to be come more so in any future, potentiallymore demanding, regulatory system. The initial recommendation of recruiting twomore inspectors in advance of any other changes has now been implemented and anadministrative officer has been assigned to the Chief Inspector. These are welcomefirst steps.

But the radical proposals for new legislation demanded a more thorough-goingreview of the organisational structure and staffing needs of the Inspectorate for thefuture. Since the last audit, such a review has been commissioned by the Department[5]. Its recommendations are, in summary, that to effectively monitor and regulaterailway safety in Ireland in a new 'safety case' regime there would need to be anInspectorate comprising a Chief Inspector, supported by two senior and four otherinspectors and two administrative support positions.

These recommendations for Human Resources have been accepted by the Departmentbut have not yet been authorised by the Department of Finance. To a degree thestaffing proposed depends on the demands of new legislation still in development(described in more detail below) but the further resources really need to be in place intime for the implementation of the new legislation. Meanwhile there remains a highcurrent workload, both in tracking the current performance of IE in times ofsignificant change and in connection with the new railway developments in Ireland(notably LUAS). In addition, considerable effort is also needed towards simplyplanning and managing the changes to the role and position of the Inspectorate.


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For these reasons, it is recommended that as soon as the draft legislation has passed itsconsultation phase, assuming the main strategy is clearly going to be made law, then aprogressive recruitment campaign for the necessary strength of the future RSA shouldbe implemented, and that body established as completely as possible in a shadowform so that it can be fully effective when the new Act comes into force.

Other resource issues which have been referred to in earlier reports are:

• developing the skills and knowledge of the inspectors in post;

• having access to external expertise when needed.

The present Chief Inspector gave ample evidence of excellent developmentalopportunities he had already given to the new inspectors and it is clear that under hisleadership a sound strategy will continue.

As to the availability of external expertise, the services of a railway safety consultantare directly available to the Chief Inspector now on an 'as required' basis, whilst theDepartment’s Assistant Secretary has indicated that he is always prepared to authorisefurther consultancy work where necessary. The Chief Inspector will have fullauthority to engage outside expertise following the formation of the RSA, within theconstraints of his budget allocation and requiring the use of standard Civil Servicetendering procedures. The availability of external expertise thus appears satisfactory.

9.1.2 Status, Structure and Reporting Lines

A number of possible options as to the organisational position of the Inspectoratewere outlined and discussed in the original IRMS report [1]. Eventually theDepartment has adopted quite a radical independent line, which IRMS fully supports.In summary it involves the statutory establishment of a Railway Safety Authority(RSA) funded by government, and guided as to policy by the Minister for PublicEnterprise, but having full autonomy in the performance of its regulatory duties. Thisindependence would be further emphasised by its being located separately from thecentral government offices. The proposed legal structure and status of the RSA ismodelled on that of other regulatory bodies in Ireland. Again this proposal cannotstrictly be implemented until the necessary legislation is in place, but somepreparatory work by the Chief Inspector is in hand (such as planning of office needsand budgets). IRMS welcomes this and recommends that it should continue so thatthe necessary provisions are made to ensure the RSA is up and running when thelegislation does come into effect.

A somewhat less satisfactory position is the matter of liaison with the Health andSafety Authority (HSA) to ensure clarity between the respective roles of the RSA andthe HSA. This concerns particularly, but not solely, the monitoring of railwayemployee safety issues. It is recommended that the future RSA should be the soleregulatory body for all railway activities and the employment safety issues that mightarise. The Chief Inspector believes that to follow this path could result in hisresources being diverted away from the greatest hazards of railway operation, andthose potentially involving the public, towards relatively low risk issues concerningemployees who are not directly involved in the safety of the operational railway. Theresult of this philosophy is that HSA should deal with enforcement of health & safety


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legislation in the likes of railway offices and workshops, leaving all mattersconcerning the actual running of the railway to the RSA. This remains a variancefrom IRMS recommendations but is an option which is workable provided a clearagreement is drawn up as to the lines of demarcation. Unfortunately such anagreement, or 'Memorandum of Understanding' has not yet been finalised. This isdisappointing and it is recommended that this be finalised as soon as possible.

As to the reporting lines of the RSA, the future presents a logical and acceptablesituation in which the RSA has a high level of independence but ultimately mustaccount for its actions to the House of Oireachtas, via the Minister of PublicEnterprise. It must do this by annual reports both of its income and expenditure andof its activities in the performance of its functions. In addition it must provide anyparticular information or advice on matters of railway safety which the Minister mayfrom time to time require.

The Minister may issue general policy guidelines which the RSA must comply withand in addition the Railway Safety Advisory Council (RSAC - described below)which is being established may generate recommendations which the RSA mustconsider.

9.1.3 Railway Safety Advisory Council

It is convenient in this section to describe briefly the constitution and functions of theRSAC, which did not stem from an IRMS recommendation but from a Ministerialdecision and announcement. The Council will comprise up to twelve personsrepresenting a range of interests in railway safety, including the railway undertakings,their employees, the public, an independent expert and a member of the RSA. Theduty of the Council is to consider issues relevant to railway safety and to makerecommendations, as appropriate, to the RSA or to the Minister, and it may publishthose recommendations. Thus there will be a very open forum in which railwaysafety issues can be debated by representatives of what might be, but hopefully willnot be within the spirit of the Council, differing interests. No action has been taken tocreate the RSAC; the authority to create it comes with the making of the new RailwaySafety Act. But as with the RSA, there is potential value in planning, and perhapsestablishing in shadow form the RSAC, so it is effective from an early date after theenabling legislation is made. IRMS also learned, and finds it entirely appropriate, thatthe administrative support for the RSAC will be within the RSA, to which end anadditional administrator has been proposed over and above the already assessedstrength of two.

9.2 Railway Safety Legislation

9.2.1 The Proposed Railway Safety Act

The initial IRMS report [1] made a number of detailed recommendations about up-dating legislation for the regulation of railway safety in Ireland. The second report [3]acknowledged that the Department intended to incorporate all the particularrecommendations into a new and comprehensive Railway Safety Act. The drafting ofthe new act has been a longer process than anticipated by the consultants, but at the


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time of drafting this report an important milestone had been reached in that theDepartment’s proposals for a Bill were out for public consultation.

Assuming that consultation does not result in very radical changes, the draft has thento be subject to legal review of its drafting and then passed by both Houses of theIrish Parliament, in accordance with the usual democratic processes, before becominga new Act. The necessary processes are such that, if parliamentary time permits, thiscould all be accomplished within 2001. IRMS welcomes this very positive stepforward and strongly recommends that all necessary resources are applied to ensurethe Bill is not subject to any further avoidable administrative delay. It is believedthat, although some details of the implementation may vary slightly from IRMSexpectations, the draft Bill adopts the spirit of all its recommendations to theDepartment about new railway safety legislation.

9.2.2 European Directives involving Railway Safety

The initial review [1] pointed out that some EU Directives had not then beentransposed into Irish law. The subsequent review [3] noted that some progress hadbeen made and further work was in hand. This report has found that some relevantDirectives made as early as 1996 still have yet to be transposed. It appears thatinsufficient resources have been applied to keep pace with the tasks imposed by theDirectives and subsequent revisions. More resources are now being applied however,and the Department appears to be managing the outstanding work satisfactorily suchthat all currently outstanding issues are currently receiving attention and otherpotential further requirements are being monitored. The completion of overdueactions is exemplified by one relevant new set of regulations signed in January 2001and two more in draft currently being considered by the Office of the AttorneyGeneral.

As to the relationship between EU Directives and current Irish proposals, it isbelieved that nothing in the draft Bill is at odds with anything emanating from the EUregarding the regulation of railway safety. In fact it is supportive of and facilitatesopen access whilst maintaining safety, a requirement from Europe, through requiringeach railway undertaking (infrastructure controller or train operator) to produce asafety case demonstrating its competence to manage safety effectively. This processwill also better enable the RSA to issue the mandated Safety Certificate to reassurethe access allocation body that a given operator has shown this competence.

The specific requirements of EU Directives are generally not within the proposed Billbut are being transposed into Irish law as Regulations. This is proving a prudent wayto implement them because already amendments (largely of a detailed andadministrative nature) have been made or are imminent to several Directives whichhave only recently been transposed into Irish law. So the Irish interpretations willneed to be revised again which, if the Directives were within primary legislationinstead of Regulations, would be a very difficult and time-consuming process.

As to foreknowledge of developments, IRMS has learned that the Department has aPermanent Representative in Brussels for the transport portfolio who can keep fullyabreast of relevant thinking in Europe. Where appropriate either he or participantsfrom Dublin attend meetings dealing with both the administrative and technical


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content of European standards for railways. This all appears to be an entirelyadequate level of knowledge-gathering and participation by the Department in theEuropean dimension of railway safety developments including, where appropriate,recognition of the unique Irish situation of having no physical railway connectionwith any other member state.

In summary, regarding EU directives bearing on railway safety, the Department:

• has adequate representation in Europe to keep abreast of developments;

• contributes positively from the Irish standpoint to the drafting processes;

• has procedures in place to transpose Directives into Irish law.

IRMS has no further recommendations to make on this matter.

9.3 The Publication of Targets and Standards

To a large extent the work under this heading needed to follow the drafting of theprimary legislation and so has not progressed so far as the other issues reported above.As a first step, draft guidelines as to appropriate contents of a railway safety case wereunder public consultation during the period of this study. This work is supportive ofthe requirement in the draft Bill that the railways must prepare a safety case whichmust be accepted by the RSA.

It is also the wish and intention of the Chief Inspector to publish some high-levelprinciples for the design and construction of railway infrastructure and rolling stock,and an invitation to tender for this work is proposed. In order to avoid inhibitingtechnological developments it is probably preferable that technical standards be goal-setting principles, but the exact scope and style of them has yet to be determined.

The issue as to whether numerical risk tolerance criteria should be published by theRSA is also currently under consideration. It is important that such criteria aredebated in the public domain before adoption. It may however be wise to plan andprepare for publication, including increasing public understanding of risk issuesthrough some form of prior media liaison work. Such strategies are probably bestdeveloped by the RSA after its formation, and perhaps aired at the RSAC beforegoing public. This important matter now forms a new recommendation for the RSAto take forward in its work programme.

9.4 Conclusions

Clear progress is being made towards a new railway safety regime in Ireland. Thefuture size and structure of the Inspectorate (to be called the Railway SafetyAuthority) has been agreed. Far-reaching new regulatory legislation is in well-developed draft form and undergoing public consultation. The development ofsupporting guidance is in hand. In order to minimise the total time to operation of thenew regime, IRMS recommends that when the draft Bill is through its consultativephase as many tasks as possible in support of its implementation be conducted inparallel, so that it can be made law and enforced in a real and practical way at theearliest possible date. In addition, it is also important that a workable operational


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agreement with the Health Safety Authority be put in place to satisfactorily monitoremployee safety issues.


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10. PROGRESS AGAINST IE RAILWAY SAFETY PROGRAMME 1999-2003

This section of the report considers progress made by IE against the requirements setout in the Railway Safety Programme 1999 – 2003 [2].

A high level task force from the Department and IE prepared a safety investment andimplementation programme, based on recommendations from the 1998 IRMS safetyreview and other IE internal safety studies. This activity resulted in the production ofthe Railway Safety Programme [2].

A detailed review of IE’s progress against the requirements of the RSP is provided inAppendix V of this report. The total planned investment expectation for the 5 years,as stated in [2], was £430.6 million. The aggregate first two years spend was plannedat £182.3 million, and actual spend against this was £171.4 million. The mainshortfalls were on signalling and level crossing modernisation (due to difficulty inrecruitment and retaining SET staff, delays in the mini CTC scheme and delays ingetting agreement from landowners for level crossing work). This was offset to someextent by an accelerated programme of track renewals, and additional work oncuttings and embankments revealed as necessary by a more recent safety studyconducted by external consultants on behalf of IE.

Overall, IE have made generally good progress in meeting the requirements of theRSP for the first two years, although in a number of areas the requirements as noted inthe RSP have been superseded by subsequent events. The major exception to thisfinding is the delay in the provision of mini CTC. The postponement of this projecthas had a very severe effect on the ability of IE to maintain its signalling andpermanent way assets, particularly on the affected routes (see Section 5 of this reportfor further details).

As a result of increased unit costs and the large amount of investment needed incutting and embankment work, the total expenditure for the 5 years is now estimatedby IE as approximately £566 million compared with the £430 million forecast by thetask force in 1999. This is a significant increase and requires detailed justification toGovernment. IE believes that the railway infrastructure is currently well below aminimum acceptable standard and that it would not be possible to choose betweencompeting investments if all of the requested £566 million were not available.However it is essential for the setting of internal investment priorities, and to preparefor a future period when Government finance might not be so readily available, thatIE set about developing and implementing rigorous systems of investment appraisalsinvolving the use Cost Benefit Analysis techniques. It is also important to recognisethis information is vital to Government if national priorities from competinginvestment options (health services, social services, etc) are to be properly selected.

As recommended in previous audits, it is vital that IE revises the Safety InvestmentProgramme annually on a rolling programme basis, as a means of establishing therailway’s funding needs from Government. This should involve the detailedjustification of the proposed spend, as described above.


IRMS


11. PROGRESS AGAINST IRMS SUMMARY OF RECOMMENDATIONS

Following the last IRMS audit [3], a summarised list of all recommendations madeduring the original study and subsequent audits was compiled [4]. This list containeda total of 247 recommendations, (including some for the Department and the RailwayInspectorate), together with a proposed timescale for their commencement for thoseidentified during the first railway safety study.

Prior to the current audit, IE reviewed this list and provided a detailed and justifiedupdate of progress against each recommendation to the IRMS team [11]. This actedas a basis for the planning of this audit. A number of responses were also receivedfrom the Department at this time.

Appendix VI provides a summary of progress against IRMS recommendations. Areview of the data contained within Appendix VI reveals that IE has addressed themajority of these recommendations and has made considerable progress in theirimplementation, including the correction or identification of the unreasonable risksidentified in previous reports. Many of the recommendations especially those on thedevelopment and maintenance of SMS, are ongoing requirements being built into theroutine management process of the company. Overall, it is concluded that IE aremaking generally reasonable progress on closing out previous recommendations,given the extent of the work being undertaken. IE must ensure that all remainingactions necessary to fully close out each recommendation are actioned withinreasonable timescales.

There are however a handful of important recommendations which have not yet beenactioned (all of which have been referred to in some detail elsewhere in the main textof this audit). In summary, these are as follows:

• absence of a planned maintenance regime for the Signal Engineering andTelecommunications Department;

• no progress in developing a robust quality management system (based on ISO9000) in any engineering activity;

• lack of strategic long term plans, except in engineering investment;

• no progress in integrating business and safety;

• no progress in developing a satisfactory means of auditing safety culture (althoughplans exist to seek consultancy help to achieve this);

• no implementation of the planned safety compliance audits (although thespecification for them is 70% complete);

• no progress in the development of Key HR policies on manpower planning,management development, succession planning or appraisal systems (althoughresources are planned to address these issues shortly);

• no programme of regular audits to identify unreasonable risks on the network;

• no risk assessments, including an analysis of human factors, of train operationsduring abnormal and/or degraded conditions (although IE point out, with some


IRMS


justification, that the simplicity of the IE network compared with other Europeansystems, and the IE policy of carrying out major infrastructure renewals when theservice is shut down reduces the type of risk that this recommendation was aimedto address).

It is important that the status of all recommendations made by IRMS are trackedthrough until satisfactory completion. It is therefore proposed that both IE and theDepartment should maintain an action log for IRMS’ recommendations that should besubject to regular review and update until all identified actions are satisfactorilycompleted.


IRMS


12. CONCLUSIONS

On the whole IE has made impressive progress across a wide range of areas:

• improvements in management and staff commitment to safety;

• substantial progress in improving the safety of the infrastructure equipment;

• strides in SMS development and implementation, particularly in regard to theOperations and Rolling Stock Departments;

• easing of IR concerns in some areas;

• better pacing of the implementation of the safety programme;

• initial work commenced on the development of a network wide risk model for usein future investment planning.

At the conclusion of the 2000 audit, six major areas of attention were identified.These are shown in Table 12.1 below, together with a summary of the latest status ofthese issues.

2000 Audit Issue 2001 Status

1. IE to close out all identified unreasonable risksand to prepare and implement an auditprogramme to identify faults and failures acrossthe network

Good progress in closing out existing unreasonablerisks. No evidence to date of the implementation of asystematic audit programme by IE.

2. Development of a well managed riskmanagement programme to prioritise futureexpenditure, supported by appropriate riskmodelling techniques

Initial work undertaken to develop network wide riskmodel. Need to see commitment to approach fromIE management.

3. Ensure the proper management of the activitiesof all third parties working on the railway

Significant improvement in this area but evidencethat there are continuing difficulties in adequatelycontrolling third parties.

4. Recruitment of staff with the necessary skillsand expertise

Continuing problems with recruitment, particularlywithin Infrastructure Department.

5. Resolution of outstanding IR concerns IR issues appear to be easing in some areas, but arestill regularly reported to impede progress on safetyissues in others.

6. Ensure the effectiveness of each initiative byensuring they are undertaken in a structuredmethodical fashion. This in turn requires thefuture work programme to be prioritised toensure that IE do not try to do too much, tooquickly

IE has learned to pace the implementation of thework programme in a more sensible way. There isstill however a need for a prioritisation of futurework.

Table 12.1: Summary of Status of Key Issues

As can be seen, IE has made progress in all areas. However, as would be expectedgiven the scale of the work to be undertaken, there remains much to do. IE is thusurged to continue addressing each of the above six areas as matters of priority.


IRMS


With regard to the regulation of railway safety in Ireland, clear progress has beenmade in agreeing the size and structure of the new Railway Safety Authority and inbringing together the legislation under which it will function. The momentumgenerated must be carried forward to ensure the enactment of the legislation at theearliest possible opportunity.

In summary therefore, significant strides have been made in improving the safety ofthe railway system in Ireland. This includes improvements to IE’s infrastructure andmanagement systems and to the rigour of the regulatory system to oversee railwaysafety into the future. Much however remains to be accomplished. In addition toseeing through the key issues identified in the last audit report, the following areas areseen as critical to the achievement of further improvement:

• the urgent appointment by IE of a dedicated project manager to co-ordinate/facilitate the safety improvement programme. IE to date has not appeared toappreciate the need for such a position, which has contributed to the workloaddifficulties faced by Departmental staff, particularly within the Infrastructure andSafety disciplines;

• the need for more strategic planning by IE across a range of areas (includingmanpower planning, investment decision making, business planning, etc). This isrecognised by IE who have commenced work on a strategic change managementprogramme. IE is encouraged to continue the emphasis on this area;

• IE to improve the relationship with external parties, including the Railway SafetyAuthority, the Department and the media. Attempts should be made to movetowards a more positive Public Relations approach, one whereby the excellentwork being undertaken is advertised rather than being characterised by a defensiveattitude against perceived attacks against the organisation;

• the Department to manage the making of the Railway Safety Act in the shortestpracticable timescale;

• the Department to establish, fund and staff the Railway Safety Authority in timefor the coming into force of the Railway Safety Act.


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13. RECOMMENDATIONS

13.1 Safety Management Systems

13.1.1 General

1. IE should move forward with their proposed strategic planning initiative as amatter of priority (Section 4.5).

2. IE should revise the 1999-2003 Railway Safety Programme for the years 2001-2005 as a matter of urgency, and review and publish it annually so that it becomesa rolling programme (Section 10).

3. IE should either appoint a specific Project Manager or release the existing Co-ordinator and Chairman of the SRG (IE Safety Manager) from other day to dayduties, to concentrate on the implementation of the safety developmentprogramme as a matter of priority (Section 4.2).

4. IE should review the capacity to manage the consultancy programme in theInfrastructure Department (Section 4.5).

5. IE should appoint senior managers in the Human Resources and SafetyDepartments at HQ to spearhead the development of future policies and strategies(Section 4.5).

6. IE should appoint staff to implement the compliance audit regime (Section 4.3).

7. IE should produce manpower plans for the next decade, taking age profiles ofexisting staff and future staffing requirements into account (Section 4.2, 4.3.6,4.5).

8. IE should review the suitability of standards and procedures developed byconsultants for the Infrastructure Department and prioritise those that can beprepared for dissemination, learning the lessons acquired by the experience of theOperations and Mechanical Engineering functions in promulgating their safetymanagement documentation and obtaining ground level commitment (Section 4.2,4.5).

9. IE should complete the Corporate Standard on “Procurement and Contractors” asa matter of urgency, so that subsidiary Railway and Departmental Standards canbe developed and disseminated to improve the management of safety by IE overtheir contractors and sub-contractors (Section 4.3.8).

10. The railway Trade Unions should take action to prevent the blockage of safetyinitiatives by some staff who seek to couple the introduction of improved safetypractices with pay bargaining (Section 4.2).

11. IE should ensure that the PARS system of risk assessment is comprehensivelyrolled out and fully implemented by all Infrastructure supervisors as a normal partof their everyday work activities (Section 4.4.3).


IRMS


12. IE should develop a system for prioritising safety investment so that a robustmethodology exists when investment funds available become tighter - to bothprioritise safety projects themselves and to compare safety projects with other IEdesirable investment. This can be as relevant when the constraint is theavailability of human rather than financial resources (Section 8.2, 10).

13. IE should establish a way of evaluating safety culture and staff morale/attitudes ona regular ongoing basis (Section 4.4).

14. IE should engage with the RSA, the Department and other external parties to findways of more proactive co-operation without jeopardising the openness in incidentand accident investigation necessary to learn safety lessons (Section 4.3.10).

15. IE should review the working of the "mentor" system in the Operations function(Section 4.4.1).

16. IE should develop and implement an alcohol and drugs policy (this is not aprescriptive recommendation, but recommends that IE provide guidance tomanagement, supervision and staff as to what action can be taken whenappointing staff to safety critical posts, monitoring staff on duty and carrying outpost-incident tests) (Section 4.4.1).

17. IE should ensure a system is in place to provide prompt action following a hazardbeing reported by a Department when the corrective action is the responsibility ofanother Department (Section 4.4.1).

18. IE should develop an IE standard for determining the degree of both station andtrain passenger overcrowding that is acceptable for the maintenance of passengersafety, including provision for evacuating or safeguarding passengers in anemergency (Section 4.3.4).

19. IE should develop crisis management plan to provide an effective response to anymajor accident or incident (Section 4.3.7).

20. Both IE and the Department should maintain an action log for IRMS’recommendations that should be subject to regular review and update until allidentified actions are satisfactorily completed (Section 11).

21. IE should continue the development of a network wide risk model and to ensurethe required level of organisational commitment to the project (Section 8.2).

22. The Department should consider convening a high level seminar involving seniormanagers of IE, the Department and the Railway Safety Authority (RSA) to agreea comprehensive process for the request and approval of future fundingrequirements (Section 8.2).

23. The Department should continue to sponsor a comprehensive programme ofindependent audits into the future until IE demonstrates that it is fully in control ofthe implementation of the Railway Safety Programme (Section 7.4, 13.4).


IRMS


13.1.2 Infrastructure Department SMS Specific Issues

13.1.2.1 Standards

1. IE should develop a system of internal audits to monitor compliance withrequirements of the standards (Appendix II).

2. IE should develop a document control process (Appendix II).

3. IE should develop standards for modification and hand-over of safety criticalequipment (Appendix II).

13.1.2.2 Communications

1. IE should learn the reasons behind the successes achieved at Limerick Junctionand attempt to recreate these at Dublin and Athlone (Section 4.4.3).

2. IE should initiate a reliable and regular briefing process that facilitates two-waycommunication between managers and staff (Appendix II).

13.1.2.3 Safety Reviews

1. IE should implement a system of independent technical audit for all safety criticalsystems (Appendix II).

13.1.2.4 Procurement

1. The IE Procurement Department should adopt a system of project referencing atthe earliest stage. This project reference should be used on all correspondence anddocumentation by all departments involved (Appendix II).

2. The IE procurement lifecycle should be expanded to manage the initialdepartmental contact in a controlled manner, and should include the process ofgaining financial approval to proceed (Appendix II).

3. Key project roles and responsibilities should be established and recorded by IE(Appendix II).

13.1.2.5 Maintenance and Asset Management

1. IE should establish a planned maintenance regime for all safety critical work(Appendix II).

2. The work currently being undertaken by IE to develop a detailed asset databaseand infrastructure fault monitoring system should be completed as soon aspossible (Appendix II).

3. IE should place more emphasis on the replacement of worn equipment, especiallywhere major works have been deferred (Appendix II).

13.1.2.6 Safety Management Systems for Delays to Major Works

1. IE should complete the provision of robust documented Safety ManagementSystems for all lines where mini CTC or other major works have been delayed(Section 5.3).


IRMS


13.2 Infrastructure and Rolling Stock

13.2.1 Infrastructure Improvements

13.2.1.1 SET

1. IE should conduct an independent risk analysis to justify the decision to providemarker boards at controlled level crossings as an interim solution for insufficientbraking distances (Section 5.3).

2. IE should provide safety bays at user worked level crossings where sightingproblems exist (Section 5.3).

3. IE should refurbish the signalling infrastructure at Athenry at the earliestopportunity (Section 5.3).

4. IE should conduct an independent risk analysis for the proposed method ofrepairing the Heuston interlocking frame (Section 5.3).

5. IE should provide a fully documented SMS for all remaining mechanicalinterlockings awaiting checking and repair (Section 5.3).

6. IE should identify the means of getting the mini CTC project back on track as amatter of priority (Section 5.8).

7. IE should conduct an independent risk analysis to justify the course of actiontaken in relation to the potential safety critical failure associated with main colourlight signals (Section 7.2).

13.2.1.2 Permanent Way

1. IE should effect the replacement of rail defects revealed from ultrasonicinspection and badly drilled rail ends using the rail and fishplates now availableby cascade from relaying sites. It is important that this is done to eliminate thedefect backlog (Section 5.4).

2. IE should review the workload of the PWI (Appendix II).

3. IE should complete the tendering process for a fleet of modern ballast hoppers assoon as practicable (Section 5.4).

4. IE should initiate the procurement of a train capable of lifting the large quantity ofscrap produced by relaying activity (Section 5.4).

13.2.1.3 Structures

1. IE should quantitatively evaluate the risks that short or narrow platforms cause inthe context of wider risks being managed and apply appropriate controls to reducethem to ALARP levels (Section 5.5).

2. IE should review station footbridge parapets to determine those with gaps such asLongford or where the parapet height is insufficient and implement alterations toremove hazards (Section 5.5).

3. IE should review footbridges where the bottom member of the span offers awalkway to trespassers and implement anti-climb measures (Section 5.5).


IRMS


4. IE should produce a comprehensive plan for Claremorris station to allowplatforms to be rebuilt in the correct position following anticipated trackalterations (Section 5.5).

5. IE’s appointed consultants should provide Dublin DE with their Rosslare Strandcoastal monitoring information to enable Dublin DE to carryout safety of lineresponsibilities (Section 5.5).

6. IE should develop a structures major maintenance or renewal ‘proposal’ system sothat works with a priority insufficient to be included in the following year’sprogramme are held on a database for evaluation with other new priorities thefollowing year (Section 5.5).

7. IE should carry out annual inspections of all tunnels and report in a standardreport format (Section 5.5).

8. IE should identify all structures potentially vulnerable to scour action andundertake an engineering risk assessment of them. Develop a remedial worksprogramme resulting from that assessment (Section 5.5).

9. IE should develop a flood/scour management system to ensure safety of structuresat times of flood, including the conditions at which the track must be closed andthe conditions under which a track may be reopened (Section 5.5).

13.2.2 Electrification

1. IE should implement a range of remedial actions to address the safety ofmaintenance staff working on high voltage and traction supply equipment, bothequipment and management systems related (Section 5.6):

• as a short-term measure, take extra additional care in the new substations;

• consider urgent retro-fitting of interlocking on the new equipment;

• longer term, introduce a substation Permit to Work system;

• ensure for the future that those procuring equipment liaise with those who areto operate/maintain it.

2. IE should ensure that the new overhead line access equipment is taken into use,following staff training, at the earliest possible date (Section 5.6).

13.2.3 Rolling Stock

1. IE should conduct a study to optimise train evacuation signage and procedures forthe new Class 2900 DMUs (Section 6.6)

2. IE should monitor ongoing progress with the following items to ensure ongoingeffectiveness and robust implementation of the initiatives:

• rationalisation of maintenance documentation (Section 5.7);

• independent inspection on major maintenance and repairs (Section 5.7);

• specification of Safety Requirements and particularly the application ofCompany Standard No 6 and CME Technical Standard No 1 to theprocurement of the Class 2900 fleet (Section 5.7).


IRMS


13.3 Unreasonable Risks

1. IE should ensure that a realistic programme is put in place for the closing out ofsystem-wide unreasonable risks and it should closely review and monitor theseactions until they are fully completed (Section 7.2).

2. IE should implement a wide-ranging external regular safety review encompassingthe identification of unreasonable risks and comparison against relevant safetybenchmarks (Section 7.3).

3. IE should investigate the background to new unreasonable risk items 1 and 5 tounderstand how and why they arose and to minimise the potential for further suchoccurrences (Section 7.3).

4. IE should change its bridge raising procedures to avoid further occurrences ofunreasonable risk item 4 (Section 7.3).

5. IE should address the issues associated with poor visibility on platforms thatemploy Driver Only Operation CCTV (unreasonable risk item 8) as a matter ofurgency (Section 7.3).

13.4 Rail Safety Regulation

1. The Department should proceed with the making of the new Railway Safety Actwith the minimum of delay (Section 9.2.1).

2. The Department should press forward with other work in parallel with the primarylegislation so that all is ready together for implementation, in particular the:

• drafting and publication of appropriate safety standards (Section 9.3);

• recruitment of staff up to the authorised strength of the RSA (Section 9.1.1);

• establishment of the RSA in shadow format away from the Department(Section 9.1.1);

• drafting a formal MOU with the Health & Safety Authority, to cover theperiods both before and after the establishment of the RSA (Section 9.1.2).

13.5 The Way Forward

Given that this is the last in a programme of planned external audits into the safety ofthe Irish railway network, it is appropriate to consider the adequacy of the systemscurrently in place to assure the safety of the system into the future.

Whilst this audit has revealed far more substantial progress than for previous reports,it must be acknowledged that further major work is required before a self sustainingproactive safety culture is achieved. There is no doubt that there is a much betterunderstanding of what is needed to achieve this objective even if IE is struggling toget there. There is self evidently a shortage of people within IE who have thenecessary attributes in the area of management systems development. Only bytackling these management issues can IE become self sustaining when dealing with


IRMS


infrastructure issues. It needs a culture change that has commenced but is not yetfully in place.

Staff who have worked in more structured and systems orientated engineeringenvironments are generally more aware of the systematic safe working philosophythat must be applied to all activities. Those who have not been exposed through otheremployment, or dealing with high level matters, are less familiar with the need toadopt a systems approach to safety and infrastructure asset management. The broadbrush approach of sending most staff on core skills training (e.g. communications) isprobably a good start that will get all staff understanding a consistent approach ormessage where the skill or knowledge base is low. As that base improves moretargeted training can be developed.

The external assistance IE has gained from consultants has been in some casesapplying British solutions to British problems as opposed to those which would beappropriate and adequate for the IE context. An input of experience of railway assetmanagement from a practical as opposed to more theoretical perspective would alsobe beneficial. This would allow prioritisation of effort and allow the important workstreams to be taken forward quickly with a phased approach to those which are lessimportant at this stage.

IE could be described as in a state of change, although whether they will emergechanged is not certain at this point in time. If the funding tap were to be turned off, itis not certain what would happen. IE may then have time and effort to spend on itssoft issues, but there is a skill and knowledge gap that needs investment to close it. Inaddition, in order to continue to progress at all levels within the organisation, IE mustimprove the IR environment.

In summary, a sea change has taken place in safety management culture but this iscausing stress in management and staff. Given this status, and the large amount ofwork to be completed before a truly self sustaining safety culture is achieved, it issuggested that a final broad external audit be carried out on behalf of the RSA. Thisshould be undertaken once the RSA has been commenced its duties and after asuitable period of time has elapsed, possibly in 2002, in order to provide a benchmarkfor measurement of safety progress following this audit.


IRMS


14. REFERENCES

1. A Review of Railway Safety in Ireland, IRMS Report 2045.10, Issue 01, October1998.

2. Railway Safety Programme 1999 - 2003, IE, 1999.

3. A Review of Railway Safety in Ireland – Implementation Review, IRMS Report2081.01, Issue 03, March 2000.

4. A Review of Railway Safety in Ireland – Implementation Review: Summary ofRecommendations, IRMS Report 2081.02, Issue 01, June 2000.

5. Railway Inspectorate Human Resource Requirements. IRMS Report 7125.01,Issue 01, December 2000.

6. Signalling, Electrical and Telecommunications Technical Report”, MHA Report0948SET, Issue 01, March 2001.

7. Permanent Way Technical Report, MHA Report 0948PWY, Issue 01, March2001.

8. Structures Technical Report, MHA Report 0948STR, Issue 01, March 2001.

9. “Electrification Technical Report”, MHA Report 0948OLE, Issue 01, March2001.

10. Rolling Stock Technical Report, MHA Report 0948CME, Issue 01, March 2001.

11. IE Summary of Progress Against Previous IRMS Recommendations, November2000.

12. Infrastructure Adequacy Risk Assessment Report – Revised Risk Results, IRMSReport 2045.06, Issue 02, December 1998.

13. Infrastructure Adequacy Risk Assessment Report, IRMS Report 2045.06, Issue 01,October 1998.


IRMS

Report No: 7335.01Issue No: 03Date: April 2001

Appendix I

Listing of Sites Visited


IRMS

Report No: 7335.01Issue No: 03Date: April 2001 Page AI.1

Site / Line SET PWay Str. Elec CME

Dundalk to Dublin Connolly (Cab Ride) ü

Cork Yard ü ü ü

Cork to Cobh ü ü ü

Mallow Station and RR ü ü ü

Limerick Junction Station ü ü ü

Limerick station ü ü ü

Limerick Junction to Waterford ü

Waterford to Rosslare Strand ü ü

Barrow Bridge ü ü

Rosslare Strand ü ü

Rosslare Strand to Enniscorthy ü ü

Wexford South Gate Box ü

New Lane and Wexford LCs ü

Enniscorthy Signal Cabin ü

Wicklow Signal Cabin ü

Liffey Bridge and Junction (Freight) ü

Greystones to Bray inclusive (DART) ü ü

Sandycove to Glenageary (DART) ü

Porterstown and Clonsilla ü ü ü

Mullingar ü ü ü

Mullingar to Sligo (saloon) ü ü ü

Claremorris ü ü ü

Ballyhaunis Signal Cabin ü

Ballyhaunis Eircom Exchange ü

Athenry ü

Ballinasloe ü ü ü

Athlone Old Station ü

Connolly mini CTC and NMC ü ü

Pearse Station and RR ü

Bray, Greystone and Clonsilla RRs ü ü

Maynooth ECP ü

Inchicore Works ü

Heuston Carriage Depot ü

Fairview Depot ü


IRMS


Appendix II

Detailed Infrastructure Department SMSFindings


IRMS

Report No: 7335.01Issue No: 03Date: April 2001 Page AII.1

1 Summary of Audit

An audit of the Divisional Engineer’s (DE’s) office at Limerick Junctiondemonstrated that there was little change to report from the 1999 and 1998 visits,centred on the Divisional Engineer’s offices at Dublin and Athlone.

The areas of improvement and deterioration noted at Limerick Junction were mainlyas a result of differing local systems and procedures and not as a result of the newstandards or safety culture. The main area of concern was the lack of robustness in theproduction and maintenance of records.

In many cases there is an understanding at Assistant Divisional Engineer (ADE) levelof what a robust system would look like but resources and workload for IE-widecentral initiatives has resulted in slow progress of a local system implementation.

2 Budget and Resources

The budget levels are determined by the Chief Engineer in response to annual bids bythe DEs. The process is iterative with each DE in close and continuous discussionwith the Chief Engineer. Items relating to safety were usually authorised and the DEsare currently content with the level of funding being received.

For example, the Athlone DE had budget for 2001 (calendar year) which wasconfirmed on the 2 February 2001, a month after the period started. Despite the factthat the DE would have had a reasonably good idea of how much it was likely to be,and what items it would contain, it is undesirable from the point of view of resourceand work scheduling to be in the position of not having a confirmed budget, andtherefore physical works plan, some months before it should commence. Itemsrequiring a long lead time are always vulnerable to slippage in such circumstances.To some extent that was seen with works from 2000 programme still being completedduring February 2001.

With respect to permanent way, the overall level of staffing under the DEs for trackmaintenance has been enhanced and is proving to be adequate. However, theresources are still not used to best effect. The heavy requirements for the provision oflookout men, which is outwith the control of the permanent way Inspector (PWI) andoften at short notice, continue to be problematic in the effective allocation ofmanpower. The inspection regime is also wasteful of resource, in particular, wheretrack has been totally renewed. A reduction to one high quality inspection per weekby a patrol ganger is considered appropriate with the patrol ganger resource thenavailable for maintenance work for the remainder of time. It is understood that aproposal exists to move the patrol gangers into the mobile gangs for this reason.

With respect to SET, there is a definite increase in the budget and spend on SETengineering. The Divisional revenue budget for SET has increased due topostponement of the mini CTC project. The resources to cope with an increased spendare not available.


IRMS


3 Long Term Planning And Monitoring

In regard to Divisional SET engineering, the planning process is fairly rudimentary atpresent. It is effected by the Assistant SET, who has no dedicated resources for thistype of activity at his disposal. The only programme presented as evidence by theDivision is very short term, i.e. 1 year. In addition, Telecomms has embarked on theimplementation of Primavera P3 as a project planning tool. Detailed training hastaken place and it is now being used for new projects.

For permanent way, there is in place a structured 5-year plan for track renewal and theChief Engineer Infrastructure (CEI) has underwritten this.

A monthly report of specified works completed is sent to the CEI by the Divisions toenable monitoring of the physical programme works.

However, most medium to long term plans are driven by large new infrastructurerequirements and schemes.

4 Risk Assessment And Prioritisation Of Work

The new Priority Assessed Risk Survey (PARS) is based on a 5x5 matrix, for a simpleanalysis of the risks and prioritisation of work. It was reported to have been used onseveral occasions, though not yet uniformly across the IE divisions. For example, it isbeing used for safety inspections carried out on SET equipment. It is unfortunate thatindustrial relations issues are delaying this important safety advance. The initial workthat has been done indicates that PARS will be an effective tool for staff at all levels

SET have recently introduced a system of prioritisation on the interlockingrefurbishment project, using data on train movements combined with complexity ofthe interlocking concerned.

SET now use a documented Safety Management System (SMS) when it is consideredthat the infrastructure may degrade to the extent that it affects safety. This system hasbeen applied at Claremorris, Galway, Athenry and Ballinasloe, thus far. It is plannedto be systematically applied at other sites, particularly on all lines where there aredeferred works due to postponement of the mini CTC Project.

A documented SMS has been introduced for Heuston Resignalling andRationalisation to safely control degradation of the infrastructure during the projectprocess.

For permanent way, the basic foundation for effective maintenance is to have a robustinspection system that identifies and reports defects for attention. There is still no oneclear definition of what a patrol ganger should report other than section O.1 of theRule Book, and this is only a very brief resume.

For structures, the bridge inspection reports do not assess and prioritise risks ordefects using the 5x5 matrix or a full QRA. Each ADE operates their own simplethree or five step priority system. The capture, organisation and consequentprioritisation of defects varies from individual ADE to individual ADE. At LimerickJunction, for example, they are moving to a database for logging defects that allows a


IRMS


simple rating which has definitions for each priority rating. At some locations there isonly really a list of work required held on a summary sheet. Dublin DE operates agood Works Order system whereby the ADE issue a formal ‘Works Order’ which issigned off when completed.

Given the above, it is more difficult to determine how major work items that wouldneed to be included in annual work programmes are captured and included orcascaded to the following year.

Cost Benefit Analysis (CBA) was not applied initially for renewals arising from theIRMS recommendations [7]. There is no evidence that it is being used on a cross-functional basis, e.g. to compare the risk/benefit between a signalling project andpermanent way project. Whilst CBA is not carried out retrospectively, it is consideredto be a useful exercise in determining future priorities.

5 Engineering Systems, Standards, and Documentation

5.1 Introduction

With regard to Engineering Systems, little has changed since the last visit. Theprogress has been less than that had been anticipated on getting a structures databasein place at both DE level and IE-wide.

There has been considerable progress on drafting standards since the last audit in late1999. Certain of the issues identified at that time have been resolved, for example theneed for each document to have an owner. However, the system is as yet immature, asshown by the fact that no permanent way or SET standards have been issued to date.

At present, the draft standards are considered to contain too much information.However this is not a serious problem since excess information can be edited out atthe review stage.

The system being developed had a strong resemblance to the UK system of RailwayGroup Standards, Railtrack Line Standards, Contractor Company Standards and localwork instructions. However in the UK the working environment is very different witha fragmented industry related by contract and controlled by government regulationand inspection. In Ireland the railway industry is vertically integrated and the risks tobe addressed are different. There is recognition that the final documents must beappropriate to Irish conditions and the structure is being adapted to ensure that this isthe case.

The difficulties of identifying the target audience and the adoption of appropriatelanguage are now being addressed. There is recognition that this is key to havingstandards that are accessible and useful.

The process by which existing documentation and information is to be withdrawn andsuperseded by new standards is not yet developed. It is suggested that urgent attentionis given to this aspect

For example the gauging permanent way standards will at some stage be supersededbut much of the content is information and not mandatory. Any new gauging


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standard, containing only mandatory aspects, will only replace a portion of thepermanent way documents and the remaining information will need collectingelsewhere. Consideration should be given to the retention of a compendium of usefulinformation and data, perhaps based on the Maintenance of Way (MW) sheets. Itshould still exist in a controlled form and be referred to by individual standards. Thiswould be a document usable by all levels in the organisation.

Cross-functional standards remain an issue yet to be fully resolved but this is notconsidered to be a significant problem at this time.

5.2 Company Standards

The new IE Company Standard system (i.e. the system which sets out the structure,format and hierarchy of IE Company Standards) has been designed on a simplehierarchy having six levels:

1. Company Standards: the “Ten Commandments” of the IE Safety ManagementSystem. The Managing Director is the owner.

2. Railway Standards: those that apply across more than one department (forexample Operations and Infrastructure). Examples are the Rule Book, GeneralAppendix etc. It is possible for a cross-functional standard applicable toinfrastructure to be written by another department but subject to infrastructurereview before authorisation.

3. High Level Standards (Department or Discipline Standards): those that apply to adepartment. They may be specific to a discipline but some apply to more than onediscipline. The target audience for these is managers. None have been issued todate but 4 Infrastructure and 15 Permanent Way are in draft. Standards at thislevel are also being drafted for signalling, telecomms and structures. Thesedocuments specify department specific requirements that are mandatory on allstaff. They contain little technical information.

4. Procedure documents: those that are unique to the Infrastructure or any otherdepartment and are normally specific to one discipline. The target audience forthese is managers and inspectors. None have been issued to date but 12Infrastructure and 55 Permanent Way are in draft. These documents specifyDiscipline specific procedures that are mandatory on all staff. They containcomprehensive technical information appropriate for the target audience.

5. Work Instructions: those that are unique to a Discipline. The target audience forthese in permanent way is inspectors, gangers and permanent way operatives.None have been issued to date but in the case of permanent way, 37 are in draft.These documents specify discipline specific procedures that are mandatory on allstaff. They contain comprehensive technical information appropriate for the targetaudience.

6. Task Instructions: those that are unique to a discipline. For example, the targetaudience for these in permanent way is inspectors, gangers and permanent wayoperatives. None have been issued to date but 65 permanent way are in draft.


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These documents specify discipline specific methods of working that aremandatory on all staff. They contain little technical information.

Level 1 and 2 documents are written and approved by IE centrally. Level 3, 4, 5 and6 documents are developed and issued under the control of the Infrastructure ReviewGroup. Level 6 documents are written by specified groups of Divisional staff forreview by other Divisions and subsequent adoption by all. These are all in draft formand DEs are reviewing them for final implementation.

5.3 SET Engineering Systems, Standards And Documentation

5.3.1 Introduction of Documented Management Systems For Degraded Infrastructure

The system used for control of degraded infrastructure is of a good standard.

5.3.2 Production of Signalling Standards

These consist of 50 draft documents. There are 19 signalling currently awaiting issueand briefing. There are also 31 more signalling in draft form under review orawaiting review.

The current delay in issuing the standards appears to be due to the poor quality of thedrafts that had been sent for review.

They are well formatted but are not yet briefed in, due to the excessive number ofamendments required to them before application to IE infrastructure. The documentsborrow very heavily from Railtrack standards and are, therefore, unsuitable for directintroduction to the IE situation.

5.3.3 Production of Telecomms Standards

The department aspires to produce 53 telecomms standards by July 2001. At the timeof the audit, only 15 standards were available in draft form and the likely date forcompletion of the full suite of documents is now 2002. This late date is undesirable.

Digitised plans of all station areas are now available clearly showing cable routes andequipment locations.

During the office review an example of commissioning sheets was reviewed. Whilethe sheets were comprehensive in the detail captured during the commissioning tests,they lacked the details of the tester’s name, an approval signature and the date of thetesting.

The North Wall telecomms equipment repair shop contains a number of trainedEngineers, who demonstrated a good standard of record keeping including both faultand testing data.

5.3.4 Technical Training For Staff

Technical training is available for all staff. Some staff have not taken advantage ofthis essential safety process. This is partly the result of ongoing industrial relationsand HR difficulties, and must be resolved.


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The managers in charge of the staff concerned now feel that discipline has been veryseverely undermined as a result of the inability to resolve the dispute.

5.3.5 Development of Joint Signalling / Permanent Way Maintenance Routines

This initiative in its early stages but is already yielding excellent results, especially onthe Limerick Division.

5.3.6 Signalling, Telecomms and Electric Train Staff (ETS) Maintenance

Despite the lack of procedures, which are not yet available due to the delay in issuingagreed standards, local initiatives have been implemented, and maintenance is nowcarried out in accordance with technical training provided.

Where technical training has not been taken up by staff, the poor quality ofmaintenance is very apparent and warrants urgent action.

5.3.7 Safety Standards Applied Within Eircom Exchanges For ETS Infrastructure

A very successfully managed project to improve the standard of maintenance of ETSequipment has been introduced by SET.

5.3.8 Briefing Down and Understanding of Documents By Staff

There has been no briefing of SET technical standards since they have not yet beenissued.

5.4 Permanent Way Engineering Systems, Standards And Documentation

5.4.1 Permanent Way Progress to Date

The main body of standards are being written by external consultants and many of theconcerns expressed previously have been addressed. The suite has been prioritisedinto ten batches with the most safety critical standards being implemented first. Theconsultants have usefully rationalised Levels 2, 3 and 4 detailed above into PrinciplesLevel, System Level and Equipment Level as an aid to understanding.

A large number of standards are in draft and are currently in the review process. Thebatch one subjects have been reviewed and the consultants are revising the documentsaccordingly. It is seen by IRMS as vital to the credibility of the whole system toensure that first standards are of a high quality being readable, relevant, achievableand having IE ownership. As a result the issue of the first batch may be delayed fromprogramme and the current anticipated implementation is in early summer 2001.

Permanent way standards are in production to update and replace MW instructions.Progress to date on these has been mainly in gauging, track recording and ultrasonics.Some permanent way standards were issued late in 2000 bearing the word “draft” inthe header. It is understood that subsequently the status has been confirmed to beformal issue 1. The method of distribution was not fully controlled as per CompanyStandard number 9 because as yet there is no infrastructure document controller inplace. It is also understood that some permanent way standards may be superseded byinfrastructure standard over time.


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The external consultants have briefed some of the new draft standards to gangers andit is understood that feedback has been obtained from these potential users.

5.4.2 Level 6 Permanent Way Work Instructions

Personnel seconded from all levels in the organisation including mobile gangers andinspectors (the real end users) have produced these. The result is that there is a strongfeeling of ownership at ground level for the documents and they are accepted almostuniversally as relevant and useful.

It is difficult to decide if these documents are aimed at doing the work safely or doingthe work correctly. Ideally they should cover both. As they currently stand, they donot fully satisfy the requirements in either respect. However, with the strongwillingness and acceptance at ground level for them, it is agreed that they should beimplemented in their current form and experience gained in their use. From thisexperience the documents can be updated and amended as part of a cycle ofcontinuous improvement.

The Strategic Technical Review (ref. Permanent Way Technical Report [9]) ofpermanent way activity demonstrates whether the generic systems for permanent waymaintenance are present and adequate. With few exceptions those that exist are stilllacking not formally issued, and widespread knowledge among those who need toknow remains poor.

Since there is no system for the issue and control of documents, instructions,procedures, etc., staff work to a variety of documents and letters from the ChiefEngineer but they have no means of knowing if they are up to date. Since 1998 thesehave increased in number and there is widespread confusion about the status of many.The new permanent way standards are helping to consolidate the position and thesituation should improve as new infrastructure departmental standards start to beimplemented in summer 2001.

5.5 Structures Engineering Systems, Standards And Documentation

Within the civil engineering field (excluding permanent way) standards are beingproduced by at least three different groups, by IE internally and by two groups ofexternal consultants. All three appear to be adopting different format and approach tothe production of documents. Some are reflecting current practice e.g. I-STR-6102‘Bridge Inspections’ whereas other such as that concerned with tunnels are coveringentirely new subject matter where IE has previously not mandated requirements.Some documents draw heavily on the Railtrack approach. This is not always helpfulin a small integrated organisation such as IE. IE should be able to produce documentsthat mandate ‘how’ as well as ‘what’. This will make them more useful to the enduser. As risks are contained within a single organisation rather than widely contractedout as in Railtrack’s case there is opportunity to write documents in a direct mannerthat guides the end user as well as stipulating requirements to be adhered to. Thedocuments must be appropriate and reflect IE risks and working arrangements.

It is pleasing to see that the planned number of standards is an appropriately relativelysmall number and that hopefully they will reflect the most important aspects of thecivil engineering activity. However, the Index of Infrastructure Standards andProcedures document supplied (I-DEP-000v0-2) actually lists very few of the planned


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structures and bridges standards, and is therefore incomplete. None of the documentshave as yet been issued in a final form under a controlled document managementsystem. Some have been seen by DE staff for commenting upon, but not all. Thecycle of reworking and seeking fresh comments is very slow and none of the internalIE documents appear to have been sent back to DE staff for further comments.

A major concern is that there are common terms such as ‘inspection’, and‘examination’ used throughout these documents but the terms all have differentmeanings in different documents. This inconsistency will make using the documentsdifficult and lead to confusion of staff in the field resulting in practice being differentfrom that intended by the document owner/author. The term ‘safety impact work’was found in some authored documents which it is suggested should become an IEwide definition with consistent application across all IE activities if such a term is tobe used.

The ‘Management of Contractor’s’ suite of standards is reasonably well developed,but it needs a further document detailing site management. See section below on thirdparties and contractors.

5.6 Electrification Engineering Systems, Standards And Documentation

Work is proceeding by IE and external consultants on the identification and draftingof Standards and Procedures. Concerning the DART electrification, the relevantdocuments are the 4000 series (overhead catenary system: OCS) and 5000 series(electrical – ELE). Within each category, three sets of documents are being produced:

0. High Level Standards1. Procedures2. Work Instructions

In the OCS series, High Level Standards have not yet been seen, however the externalconsultants have produced as drafts the majority of the Procedures and WorkInstructions identified. The status of OCS documents as at 26/2/01 is shown inElectrification Technical Report (Ref. [11]).

Much of this documentation has drawn from the Siemens O&M material for theoriginal DART overhead line. It is at present being reviewed in the light of theequivalent material for the new Adtranz overhead line equipment on the extensions.

There are as yet no Electrical series documents available for review.

A revision of the Electrified Lines Working Instructions ‘Yellow Book’ has beenissued, as well as revised Isolation Documents which include the two DARTextensions. Within the document hierarchy of the Yellow Book, the followingDepartmental Procedures are now issued:

1. Operating Instructions for Overhead Line Equipment

2. Control Room Operating Instructions – Faults and Failures

3. Isolation / Working Instructions – Fairview Depot


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4. Control Room Operating Instructions for Signalpersons

5. Operating Instructions for EMU Drivers

6. Isolation Instructions – Substations and Switch-houses

Again, whilst the content of these documents is valuable, it is not clear how theseVolumes are integrated into the overall IE document structure and hierarchy.

6. Equipment Performance Information System

A system has been put in place using Microsoft Outlook for reporting of theSignalling faults. The lack of control of access to this system is a concern and therewas no visible training or briefing of its use. Within the divisions it was apparent,however, that the Outlook database was not being used fully, and there was still nosystem for recording failures.

The telecomms section has made major strides towards the management of failures.The Network Management Centre now includes a telecomms fault reporting desk,which utilises a direct internal telephone number (2888) and two dedicated operators.The fault desk completely manages all faults and tracks them for progress andcompletion, reporting back to the originator. The longer-term intention is to reviewthe collected data to formulate failure rate statistics from which to drive themaintenance regime. It is the intention that this system will be extended to includesignalling in the near future. This is proposed to be a temporary solution prior to theintroduction of IAMS.

Although there are systems in place to capture data on permanent way relatedincidents they are still not robust. This is a cultural as well as procedural issue.However, departmental recording of broken rails and fishplates now appears sound.

7. Human Resources And Training


Within the Divisions, recruitment of staff is being attempted but with little success.Much improved pay and conditions might improve the situation in the longer term.

Training needs are analysed by IE and staff are briefed prior to training courses. Thequality of the training received is monitored and reported upon.

Recruitment of staff is still a major problem within SET. The resource atHeadquarters for signal engineering has been improved by the secondment of externalconsultants to provide key support roles. The pool of expertise for this specialist typeof role is limited, not only in Ireland but elsewhere. SET has undertaken a process oftraining for all grades. The training given covers technical disciplines in addition toPersonal Track Safety (PTS), and is usually of a certified standard.

Training records are now maintained within the division as are plans of trainingrequirements. SET is currently completing a “Skills Register” to enable a more


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targeted approach to training and the identification of skills shortages. The registerwill eventually be used to prepare a set of competency requirements for all grades.

There is no evidence of supervisory training, apparently due to an on-going industrialrelations difficulty with a large group of supervisors.

Continuous Professional Development (CPD) as previously recommended has not yetbeen implemented.

7.2 Permanent Way

New pay and working arrangements were implemented for permanent way operativesin January 2001. These are intended to reduce the working week from a normal levelof 70 to 80 hours to 46. So far there has been little effect on actual hours workedbecause of the heavy workload of installing new CWR. The new higher rates meanthat staff are very willing to work overtime. The structure has created disparities withsupervisory staff and they are currently in negotiation to resolve the issue.

Examination of track patrolling records again showed that certain patrol gangerscontinue never to file a weekly report. It is important for safety that the underlyingreasons are identified and, where appropriate, staff are counselled or provided withtraining and assistance. In an organisation that requires its staff to read and understandcomplex rules and procedures and also to compose and write concise and accuratereports as a safety critical activity this remains an issue to be resolved.

It was positive to note that the industrial relations issues surrounding the introductionof new tampers has been resolved and the machines are being enthusiasticallywelcomed by staff. However, it was evident that there continue to be a range ofunderlying industrial relations problems concerning new working practices essential ifsafety is to be improved and maintained.

The workload of the PWI has changed little and still needs to be reviewed. He spendsat least one full day a week on basic clerical duties. To this work the current staff areunsuited, having normally come from a track worker background. Such staff weretaken on as labourers and have been promoted to inspector level. It is therefore nosurprise that many are not equipped for clerical work. Despite the introduction of newstaff at DE level, the PWI devotes a considerable amount of his time to renewalactivity for which he is not adequately resourced.

Training of the PWI’s staff in their duties is improved now that dedicated resource isin place on the Divisions. Employees are now given a range of basic training as amatter of course including PTS and safety plan briefings. It is regrettable to note thattrainees are not assessed for competence. There is no evidence that a training needsanalysis is carried out.

Maintenance of life expired track is now mainly undertaken by total renewal in newCWR. This gives a very good standard of finish but it is a concern that unless staffbegin to understand and implement the standards to work to, the track may be allowedto deteriorate. This could lead to a steady slow erosion of safety until it again reachesan unacceptable level.


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7.3 Structures

Within the Structures department, overall there appear to be more junior graduateengineers at Divisional level to support ADEs than at the previous visit. However theeffects of the economy and pay rates are causing staff retention problems in theDublin area. One ADE has lost 5 junior staff (some internally to North Wall) andgained 2 in the past 6 months. The DE Dublin is advertising for an additional ADEand private Parties Engineer to assist in the workload. This is to be welcomed andrecognises the disproportionately high workload that occurs within Dublin’s area.

Although practices vary between divisions, contract tradesmen are used widely forboth major and minor structures maintenance. As some appear to have long termrelationships with IE they are effectively an additional flexible resource to supplementthe sparse artisan resources available for structures maintenance. With the level ofnew works undertaken, there are still inadequate resources devoted to routineactivities such as installing handrails or de-vegetation. Working time at senior levelswithin IE appears to be very long with 6 days the norm. The ADEs role as productionmanagers for track renewals and both production and safety of line management forbridges imposes a huge workload on them.

There was no evidence of individual training needs analysis being undertaken withADEs and engineering staff. Training is generally provided without reference to theindividual. It appears often to be an IE wide training initiative i.e. communicationskills that is applied across the board. There is quite a lot of varied training beingundertaken at ADE and engineering support level. One ADE estimated his training atapprox. 15 days in the past year.

7.4 Electrification

7.4.1 General

Within the Electrification department there was at the time of the last audit anacceptance of the need to enhance both the quantity and calibre of IE staffing incertain areas of work. Since then, positive recruitment moves have been taken inrelation to both OCS and substation staffing.

However, there are continuing concerns about the level of success IE may expect inattracting new staff, owing to the booming Dublin economy and correspondingly highwages being offered in the private sector.

Considerable progress by the HR Department is apparent in the areas of recruitmentand re-training strategy. However, there is some way yet to go in the negotiations ofmore flexible rostering and working practices.

7.4.2 Substation Staff

IE has re-considered the staffing level necessary both to undertake the extramaintenance work-load imposed by the three new substations and two new switch-houses on the Greystones and Malahide extensions, and to provide cover for holidaysand sickness. As a result, an extra two electricians and two mates are to be recruited.This will enable 24-hour cover to be provided instead of the present 18 hour, and


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opens up the possibility of allocating two teams, to cover substations north and southof the river.

Adtranz have now completed the basic training of IE staff on the new substations; IEhowever remains concerned that there is an under-provision of training allowed for inthe contract, and has sought and processed a quotation from Adtranz for additionalmaintenance training.

7.4.3 Overhead Line Staff

Authority had been granted to take on 6 additional overhead linesmen, which wouldtake the total to 11. The posts were to have been advertised during December 1999,with interviews in January 2000.

At the current audit it was explained that, owing to continuing industrial relationsproblems, the programme outlined above had not been realised. However, the twolinesmen retained by ADtranz to maintain the two DART extensions have beeneffectively integrated into the IE teams, bringing the total of linesmen from 5 to 7.Also, the Technical Assistant’s work-load has been radically altered, and is nowfocused to 90% of his time on OCS matters, leaving a residual 10% for other dutiesbrought across from his former P Way job function.

Much progress has been made on the industrial relations front, in recognition both ofthe need to increase maintenance and wire renewal cover, and of the expansion ofelectrified services.

IE expect recruitment to commence within 2-3 months, and the new rosters to beimplemented by the end of 2001. They are hoping to recruit from outside the railwayas well as from inside.

Concerns were reported at the last audit about the level of responsibility shoulderedby the Technical Assistant. Although, as reported above, he has been relieved of mostof his non-OCS responsibilities, and he will be better supported through increasedstaffing levels, the technical and operational responsibility for the equipment(particularly when Competency Certification is introduced) should be vested at amore senior management level, with a recognised professional Electrical Engineeringqualification.

The overhead line staff have now had the opportunity to train on the new equipmentinstalled on the DART extensions, with the two ADtranz OCS staff retained tomaintain it. Although the new OCS is now formally taken over by IE, the acceptanceof operational and maintenance responsibility by the Division is dependent on asatisfactory transfer of data, drawings, calculations, test certificates, spares, specialtools, techniques and training. This is at present an outstanding action on theManager (Infrastructure).

7.4.4 Electrical Room Control Staff

Physical changes are at present being undertaken to the control room. These haveincreased the area of the room, which was previously rather cramped. A new longcurved control desk is now in place, at right angles to the former desk, and the


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lighting and decoration is at present being modified to suit the new layout. Telephoneinstruments, VDU screens and duckets for forms and files are still to be rationalised,but already the improvement in working environment is plain to see.

8. Management Of Contractors And Third Parties

A suite of 9 standards is being developed by external consultants which are each atvarious stages of detail, but none has been formally issued. DE staff are not aware oftheir content. Some are being trialed by Projects organisation. Some are related toprocurement and some to projects once the contract is let. There would appear to be astandard missing that details with the detailed site management requirements i.e.method statement requirements, separation of construction activity from trains etc.The management of contractors Standards do not appear to address external or 3rd

parties working outside the railway boundary (for a non-IE client) whose work mayimpact on the safety of the railway and railway staff.

There remains no dedicated resource at DE level for dealing with private parties, forexample members of the public, local politicians and local authorities. This isevidently a very significant workload and can divert the DE from more importantsafety of line activity. DE Dublin has recently advertised a post to fulfil this role inrecognition of the particular workload in the Dublin area.

Method statements for third parties undertaking works close to or under/over the trackare the norm. A very good example for the new road over bridge at Waterford wasseen. There is, however, still generally a lack of information about the management ofthe railway/construction interface in these statements, e.g. fence line dimensions,emergency contact arrangements etc.

SET have implemented the new corporate standard, and though it is still in its infancy,it is understood that further experience will be used to refine the process. Theycontinue to manage external contracts using consultants and this is proving aworkable arrangement, as evidenced at Clonsilla/Maynooth re-signalling where agood standard of installation was in evidence. Senior management is, however,concerned that they are losing some control of telecomms aspects of major projects,due to the proliferation of projects and contractors, and the lack of internal resource tocontinually police the day to day management. This points to a resourcing issue ratherthat a lack of desire to undertake such management activities. The recent changes tothe senior management structure should enhance the detailed control of any newworks, though telecomms may warrant further investigation.

An example demonstrating the continuing difficulties experienced by IE in ensuringsafe working amongst contractors was observed from the cab of the train whenapproaching Maynooth station. A contractor’s surveyor had set up the tripod of hisinstrument on the coping stone at the platform edge. It was therefore on the wrongside of the painted yellow line i.e. too close to the track. It would not have causedhim any difficulty to have been several metres back from the platform edge. The manonly moved after the driver had sounded his horn several times between 5 and 10seconds before the train passed him. In addition, it was not clear whether the man onthe opposite platform was the Lookout or not. If he was the Lookout, then he wasvery badly positioned with limited sighting due to the curvature of the track. If he


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was not the Lookout, then the surveyor was working in a manner that could haveresulted in him being struck by a train.

9. Safety Validation of Change

Company Standard No. 6 for the safety validation of changes only became effective inAugust 1999. It was noted that a Safety Case had been prepared for the installation ofthe new Westrace electronic interlocking system used on Clonsilla /Maynooth re-signalling, and that this was assessed by the SET professional head.

See also Section 6 of the main report related to the introduction of the Dart 8200EMUs.

10. Organisation

10.1 General

No progress has yet been achieved with the proposal to install additional resourcewith the DEs for safety, finance and human resource. However, a training resource atDivisional level is in place and operational.

It remains a concern that the Chief Engineer, DEs and ADEs appear to work very longhours on a regular basis. This is not sustainable and, in the long term, is prejudicial togood performance and safety.

There are several key staff, particularly at HQ level, whose experience is unique andwhose loss would create great difficulty. There was some evidence of successionplanning and this is an important advance.


The new Infrastructure division organisation provides clear management andprofessional reporting lines for SET divisions and headquarters groups. Professionalheads of each discipline, their authority and lines of responsibility are identified.However, no organisation charts or reporting lines were available for positions lowerthan Assistant Divisional Engineer.

Job descriptions (JD) and safety responsibility statements (SRS) have been written forsenior positions. Although some job descriptions have been prepared for thesignalling divisional staff they are still at a draft stage with negotiations still to takeplace with the unions for acceptance. It was noted that only one JD was providedwhich had been signed by both parties.

The telecomms group was extremely reluctant to prepare Job Descriptions and SafetyResponsibility Statements.

10.3 Permanent Way

In 1999 it was reported that at Divisional level the permanent way organisation hadbeen revised since summer 1998 to put the Assistant Divisional Engineers (ADEs) inthe line. The Division would have been divided into an area of responsibility for each


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ADE and he would then have directed the permanent way Inspectors (PWIs) for thatarea. It was also reported that implementation was proving difficult because of safetyvalidation and it now transpires that this proposal has not been implemented and isstill under consideration. Unfortunately no Divisional level organisation charts wereavailable to allow a full understanding of the proposals. Nonetheless the organisationis working adequately in practice. The proposals do not put the Chief Permanent WayInspector (CPWI) in the line with responsibility for PWIs and it is not clear whoresponds to him and how he reports.

As reported in 1999 the staffing levels under each PWI have been adjusted to takeaccount of track age and condition. However, no formal exercise of matchingresources to needs has been undertaken and staffing levels are still related to the 1978complement. The effect of this is that staff reduction benefit is still not being obtainedfrom the heavy investment in new track over many parts of the network.

Formal job descriptions for the key safety posts of DE and PWI are still not available.The draft is still in development but will place wide ranging responsibility on the DE.As a contemporaneous task it is important to confirm that the resultant personalworkload is identified and confirmed as achievable by an individual. Staff at the lowerlevels are still not reliably clear as to where safety of line responsibility lay.

Evidence of competency of all operators with respect to ultrasonic operator trainingwas provided.

10.4 Structures

ADEs have draft job descriptions which would give them safety of line responsibility.The SRS has been incorporated within the one document. Those JDs have not beenagreed or signed off by ADEs. There is a process of negotiation underway involvingADEs trade union representatives.

No competency assessment in the field of civil engineering or bridge management hasbeen carried out.

10.5 Electrification

There was a realisation at the time of the second audit that the IE establishment didnot include a ‘Head of Profession’ for Electrification. This caused concern in relationboth to the impending formalisation of electrical training, competency andcertification, and to the planned expansion of the electrified network and staffing.

There is however positive progress to report. An Electrification Engineer post is to beestablished, reporting through the DE to the CEI. This may initially be an outsourcedpost, and the effectiveness of the arrangement is to be monitored by an independentadvisor to the CEI. Reporting to the Electrification Engineer will be a PowerEngineer, an Overhead Line Engineer, and an Administrative Section (dealing withsuch subjects as Standards, Procedures, Training, Certification, Incident Investigation,Administration, etc.). This is a welcome move, which should be encouraged andmonitored.


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11. Procurement

During the head office audit a number of projects were reviewed to understand thecommon practices that are being adopted. One project (Heuston Stationredevelopment project) was then traced through the procurement lifecycle.

At the time of the audit, the Department was preparing its procedural structure. Thisis based on the CIE Group Procurement Policies and Procedures booklet. While thisbooklet is very high level, it provides good direction to the Department. Theprocedure structure is in the form of a flow chart, which is intended to assist the IEfunctional Departments in how to approach procurement in a structured and consistentmanner.

It was agreed during the audit that the procurement flowchart did not cover theconception of the project leading up to gaining board level financial authority.Therefore, it was agreed that the process should be expanded to cover the FULLprocurement lifecycle, which will also include project close-out.

One key aspect of the documentation reviewed, was the lack of traceability throughconsistent document referencing. It was found difficult to understand therelationships between the different sets of documents, which are prepared by differentIE departments. In addition, the document referencing becomes important as theProcurement Department is split over a number of sites with master records heldremotely.

The initial contact form IE departments for Procurement assistance comes innumerous ways, from e-mail to fax and letter. It is recommended that this initialprocess is formalised by the use of a company wide system, which will ensure that allrelevant information is captured in one place. This system should also enable theProcurement Department to issue a project control reference, which should be used onall correspondence and documentation.

A good system of supplier assessment exists for both project specific contractors andat the call-off contract level. This system is enhanced by scheduled supplier visits toaudit both quality and safety

At the stage when the Procurement Department take control of a project, they shouldclearly identify all roles and responsibilities. As it stands at the moment thisknowledge is held personally by the relevant procurement manager, and it is verydifficult for third parties to establish who the key contacts are.


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Appendix III

Status of Previously Identified UnreasonableRisks


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Report No: 7335.01Issue No: 03Date April 2001 Page AIII.1

The table below details the “unreasonable risks” highlighted in previous IRMS reports [1], [3].

Discipline Location Unreasonable Risk Explanation and Comment Original RiskMitigated?

Further ActionRequired?

Signalling Sligo Interlocking protruding fromlocking tray.

2001 comment. IE has completed repair work to effect theremoval of this as an unreasonable risk until November 2001when a re-test is due.

The Original timescale was not realistic due to the lack ofresources throughout the UK and beyond.

Yes All MechanicalInterlocking framesare beingsystematicallychecked throughoutIrish Rail.

Signalling Boyle Starting signal to Sligo (from downloop) stuck in the OFF (or proceed)position. This was due to signalarm catching on signal post fittings.

This type of tubular semaphore postshould be redesigned.

2001 comment. This signal was tested on site satisfactorily.The WSF was shown to be due to a worn plate which hadsubsequently been replaced,

IE has completed work to effect the removal of this as anunreasonable risk.

Yes No further signalsof this design willbe installed in IE.

Signalling Drumod Facing point lockbar damaged andrendered useless due to incorrectinstallation.

This type of mechanism should beredesigned. Some may requirereplacement by track circuit.

2001 comment. The immediate fault has been eliminated.

The redesign had not yet been completed by IE, though aprogramme had been put in place to ensure this risk wouldbe mitigated within 6 months.

This time-scale is deemed to be acceptable and hence thismay be removed as an unreasonable risk based on theproposed programme and timescale being met.

Yes See Comments.

Signalling Castlerea Wrongside failure of interlocking 2001 comment. IE has completed work to effect the removalof this as an unreasonable risk.

The Original timescale was not realistic due to the lack ofresources throughout the UK and beyond.

Yes All MechanicalInterlocking framesare beingsystematicallychecked throughoutIrish Rail

Signalling Wicklow Wrongside failure of signalindication (occurred after signallingalterations).

2001 comment. The wrongside failure was repairedsatisfactorily by IE.

Yes No


IRMS




Signalling RosslareStrand

Interlocking protruding fromlocking tray.

2001 comment. IE has completed work to effect the removalof this as an unreasonable risk.

The Original timescale was not realistic due to the lack ofresources throughout the British Isles and beyond.

Yes All MechanicalInterlocking framesare beingsystematicallychecked throughoutIrish Rail.

Signalling Longford Facing point lock failed gauge test. 2001 comment. This Facing Point Lock passed the safetycritical gauge test during the Feb 2001 Site visit.

Yes A special exercisehas been carriedout to check allsimilar cases

Signalling Allmechanicalfacing points

Special exercise to retest all facingpoint lock equipment in respect oflock notch width. Rectify whererequired.

2001 comment. The new gauge has been designed and willbe issued with appropriate instructions.

In the interim, as a means of risk mitigation, the frequency offacing points testing (including track gauge) would beincreased.

A 9-month timescale was agreed as acceptable to completethis programme.

Yes The completeremoval of this asan unreasonablerisk is conditionalupon the fullprogramme beingmet.

Signalling Heuston SB Lack of effective safetymanagement system to controldegraded interlocking.

2001 comment. A new documented SMS has been introducedand is being utilised together with the new control measuresbeing introduced.

At the time of the audit, some facilities had been signed outof use and the interlocking was causing serious concern.

Proposals for the safe management of the degradedinterlocking have been discussed within the SignalEngineer’s Group (SEG) and action agreed, as required bythe SMS.

Yes The documentedSMS used mitigatesthe presentlyidentified risks andmust continue to beused to control allemergent risks.


IRMS




Signalling ClaremorrisSB

Lack of effective safetymanagement system to controldegraded interlocking.

2001 comment. A new issue of the Claremorris SMS wasprovided during the site safety review.

A large proportion of the interlocking is now taken out of useand the degraded interlocking is being carefully managed.

Yes The documentedSMS used mitigatesthe presentlyidentified risks andmust continue to beused to control allemergent risks.

Signalling BarrowBridge

No facing point lock fitted on trackover swing bridge.

2001 comment. The demonstration of the locking which takesplace to put the bridge back in place leaves no doubt that thestructure will realign properly.

No.

Carefully managedin the interim.

Further design isrequired to provethe rails arecorrectly alignedprior to signallingof the route acrossthe bridge.

Signalling Locations,equipmentrooms(including TEpremises),andsignalboxes.

Cut back redundant wires,insulating and securing them so thatthere is no risk of wires coming intocontact with working circuitry.

2001 comment. Observations made indicate that goodprogress has been made on this item and signalling wiresinsulation has been undertaken by site inspections at Cork,Mallow and Pearse.

Yes On going task.


IRMS




Signalling Equipmentroomsincludingunderpart ofsignalboxes.

Take measures to ensure fire safetyand security for staff andcustomers.

Remove rubbish and all storedmaterials.

2001 comment. Under part of Mechanical Signal Cabinsinspected had been cleared of rubbish and fire hazards.

Rubbish and stored materials removed from mechanicalsignal cabins and most relay rooms.

Steel security doors are being fitted to the equipment areasof those signal cabins which will remain after the completionof mini-C.T.C.

Signal Cabin Equipment Room lighting and internalpainting is being upgraded and certain relay rooms whichhave been identified as being at risk of road vehicle damageare being provided with guard rails.

Yes

Timescale forcompletion givesno cause forconcern and thisitem may beremoved as anunreasonable risk.

On going task.


IRMS




2001 Update:Fireprotectionand detectionwithinequipmentrooms

New equipment rooms and REBs

Specifically at Clonsilla

2001 comment. Operational SET equipment exists within anew equipment room without any fire protection ordetection.

IE 2001 Comment:Fire extinguishesare now installedat Clonsilla.

All recentlycompletedequipment roomsbeing added to the‘safety criticalbuilding’ list.These locationswill be surveyedand upgraded ifnecessary tocomply with therecently adoptedsecurity and firesafety standardsfor such locations.

Short-term; FireExtinguishers havebeen arranged tobe installed.Longer-Term; FireDetection Systemhas been added toSafety BuildingsProject.

On going task.


IRMS




Signalling All controlledlevelcrossings.

Check braking distance ofprotecting signals, includingoverlaps and take appropriateaction.

Check road markings and takeappropriate action.

2001 comment. Crossings have been surveyed and actiondetermined

Yes - onceplanned action isimplemented

Provided allmarker boardshave beencommissioned.

On going task

Signalling Pole routes Remove redundant poles.

Ensure pole routes are in soundcondition.

2001 comment. A project manager is employed by IE tomanage a programme of pole route removals with the co-operation of Eircom.

Work is well underway in the recovery programme, currentlyongoing and to a sensible timescale.

Yes - once plannedaction isimplemented

Provided theproposedtimescales are met.

On going task

Signalling TelecomÉireann ETSinfrastructure

Ensure agreed code of practice ismet with regard to ETS equipment.

2001 comment. The code of practice is now in force and thisitem may be removed as an unreasonable risk.

Yes No.

Signalling Allmechanicalinterlockings

Full mechanical interlocking test atevery cabin.

2001 comment. The work of testing interlocking frames andcarrying out essential repairs is well underway.

The testing has been prioritised but the volume of repairs iscreating a very substantial workload and the programmetimescale is continuously in need of revision.

No

The Originaltimescale was notrealistic due to thelack of resourcesthroughout the UKand beyond.

A documented SMSis now required tocontrol the risksarising from anydelay to theprogramme.

Signalling Wicklow Design failing that could lead tosafety critical failure in colour lightsignals.

2001 comment. IE indicated that no action was proposed onthis item.

No risk assessment was used to determine whether thiscourse of action is safe.

No evidence of an audit having been carried out waspresented.

No

Original failedsignal has beenrepaired but nofurther action hasbeen taken forother signals

See comments.


IRMS




Signalling Facing PointsLocks

2 facing points failed gauge test dueto defective permanent way.

2001 comment. The new gauge has been designed and willbe issued with appropriate instruction .

In the interim, as a means of risk mitigation, the frequency offacing points testing (including track gauge) would beincreased.

A 9 month timescale was agreed as acceptable to completethis programme.

Yes

The completeremoval of this asan unreasonablerisk is conditionalupon the fullprogramme beingmet.

Completeprogramme ofpoints testing.

P-Way Liffey Bridge& Junctionarea

Very poor condition of permanentway over the lattice girder viaduct,results in little gauge retention andan unacceptably high risk ofderailment at a very vulnerablelocation.

2001 comment. Repair work completed and bridge nowplanned for partial reconstruction, possibly with embeddedrail system

Yes No

P-Way PorterstownLC

Very poor pair of insulated joints:the rail ends are badly matchedgiving rise to impact as a wheelpasses over. The joint is out ofsquare and the fishbolt holes havebeen incorrectly drilled.

Total track renewal in CWR has been undertaken since 1998.Level Crossing is also now a Strail with a good roadwaysurface. A new IBJ installed in concrete bearers with therunning on rail end supported. It is understood that this isstandard practice for new IBJs but is in contravention withMW17 that mandates joints to be centrally located betweensleepers. Such joints are also inappropriate for single lines.

2001 comment. IBJs now manufactured centrally for singlelines but offset for uni-directional use.

Yes No


IRMS




P-Way PorterstownLC toClonsilla

Large number of squat defectspresent. Many have been protectedby the installation of a pair offishplates with the back holesdrilled and bolted. However,several are very close to joints andthere are also many examples ofmultiple defects in single rails. Allthese together present a highlyundesirable situation. (the track isthe subject of a daily patrol).

Total track renewal in new CWR has eliminated the risk.

No further comment.

Yes No

P-Way Clonsilla There is a bull head crossoverwhose check rails are retainedsolely by conventional steel keys.With this arrangement there is arisk of the check becomingdisplaced with potential for aderailment in a passenger line.

The up line on the Dublin side ofClonsilla crossing has rails whichare peppered with squat defects,many are multiple within one railand adjacent to joints and thefishplates are thin and worn and arenot adequate for present day trafficand axleloads.

It was claimed that check rail security is not a feature of theBS drawings, which date from the 1920s, from which thelayout was manufactured. It is accepted that the crossoverwhen installed was correctly manufactured but the standardsof 80 years ago are no longer necessarily relevant to the risksof today.

2001 comment. Panlock keys have been installed that arevery difficult to dislodge accidentally. It is not consideredappropriate to install blocks and bolts.

Yes No

P-Way CulleenLevelCrossing

A joint was discovered that hadsettled very much more than theone opposite giving rise to a cross-level error of 20mm, equal to atwist of 1 in 135 over a 2.7mwheelbase (the draft immediateaction level is 1 in 150).

2001 comment. Site now totally renewed Yes No


IRMS




P-Way Lake LevelCrossing:PartialSleeperReplacement

Decaying sleepers result in gaugethat was very variable andmeasurements of 10 to 20mm widewere common. Because only about1 in 3 sleepers were being renewedit was not possible to bring the trackback to correct gauge and so newsleepers were being installedregularly 10mm wide. The railsection is very lightweight formodern day traffic and axleloads,with several locations being outwiththe maximum rail wear. Very manyexamples were noted on this curvedsection where the wheel flanges arestriking fishplates.

Total track renewal in new CWR has eliminated the risk.

No further comment.

Yes No

P-Way Longford Several joints were in poorcondition as a result of poor ballastconditions and sleepers becomingdecayed and split. One joint wasstaggered with a mixture of 92 and95lb rail sections: it is in a state ofcollapse, the sleepers beingunserviceable, founded on failedballast, supporting badly matchedrails with missing fishbolts.

2001 comment. Site inspection confirmed that morepermanent repairs have been carried out and the riskreduced to a tolerable level.

Yes No

P-Way ClaremorrisPermanentWay Section

Section has some 24 miles of 85lbtrack that has 268 class 2 ultrasonicdefects, mostly horizontal, upperfillet radius cracks.

2001 comment. 13½ miles out of 24 have now been relayedand the balance is in the programme for the coming year.

Partially.

Acceptablymanaged in theinterim.

Completion ofbalance ofprogramme.


IRMS




P-Way Castlerea toClaremorris(patchingbetween117¾ and118miles)

The sleepers were in very poorcondition and gauge was generally10 to 16mm wide with obviousdynamic movement of at least5mm.

2001 comment. Item is in the 2001 renewal programme. Partially.


Completion ofbalance ofprogramme.

P-Way Claremorris(56 points)

The timbers were decayed andsplitting, gauge being retained bytie bars. At one point the gauge was20mm wide with a single tie barwith signs that before its installationthere had been at least 20mmadditional movement under traffic.There is a high risk of failure of onetie bar, which is taking the whole ofthe gauge spreading force, and aderailment would be a likelyoutcome.

2001 comment. Switches and timbers have been renewed. Yes No

P-Way NavanBranch

Top and line throughout are verypoor and inadequate for the presentspeed limit of 40mph. Mainproblems arise from decayedsoftwood sleepers giving rise togauge variations and abysmalballast conditions making themaintenance of adequate top almostimpossible.

This route is not the subject of anyultrasonic rail flaw detection andthere is therefore a high risk ofunknown defects existing.

2001 comment. Branch is now the subject of a permanent25mph speed limit. All class 1 defects removed but someclass 2s remain. Additional manpower has been recruited.

Yes No


IRMS




P-Way Portlaoise A train loaded with new concretesleepers was observed departingfrom the depot. The sleepers werenot restrained on the flat bedwagons except by friction. The toplayer in particular appearedvulnerable to displacement intransit. It is recommended thatconsideration be given torestraining straps or similar.

2001 comment. It is understood that it is usual practice forsleepers to be restrained by straps along the top layer andthat it is not known why this was not the case with the trainthat was noted.

Yes IE to prevent re-occurrence.

P-Way Enfield Down loop is a mixture of1898/1900 94 flat bottom track andbull head of undetermined date.Many joints are wide, with boltholes very close to rail ends andbolts are missing. Decayed andindented sleepers were also noted inthe platform area.

Ultrasonic defects were notedwithin the station area, at least 11class 2s counted but there is noserviceable rail available forreplacement. A correlation with theDE’s list of defective rails wasunsuccessful and it was discoveredthat the list is not comprehensivedue to a computer or programmefault.

2001 comment. All track has been relayed. Yes No

P-Way Athenry Class one rail defect, requiringmandatory removal within 24hours, was still running without anyadditional controls 6 days afterdiscovery.

2001 comment. Class 1 defect removed. Yes No


IRMS




Electrification DART New OLE maintenance/repairaccess equipment & plant

2001 comment. Budget allocated, contract placed, deliverynow expected November 2001.

In progress.


See comments.

Electrification DART Incompatibility of two contact wiresections now in use. Risk ofmechanical failure at splices.

2001 comment. Risk being managed out by marking drumsetc., and introducing procedures.

In progress.

Acceptablymanaged in theInterim.

On going task.

Rolling Stock N/A Loss of Visibility to Driver:Unreliability of Class 201 wipermotors

2001 comment. It was confirmed that all locomotive hadbeen modified with the final locomotive completed inOctober 2000.

Yes No

Civils &Structures

3rd PartyWork -general

Control systems for private partieswork to be reviewed and newprocedures to be put in place.

The GNC consultants managing the Safety managementproject within IE Infrastructure have identified the area asone requiring a standard.

2001 comment. A series of nine standards have beenproduced. All are still in various stages of developmentalthough some are being trialed. There is a requirement foran additional standard dealing with construction sitemanagement. At DE level an informal approach continuesalthough the ADE have a good appreciation of mostrequirements and method statements are being increasinglyproduced.

In progress.


Issue and brief outStandards.


IRMS




Civils &Structures

DARTfootbridges

Parapet structures for all DARTfootbridges are to be exposed andinspected.

2001 comment. The Structural Engineer based at HQ hascarried out a survey of the DART footbridges that includedpartial removal of the cladding on parapets. The survey alsoexamined the welding where extensions were added to raisethe footbridge at the time of electrification. These bridgesare being replaced or reclad where replacement is notnecessary according to the Structures Engineer’sprogramme. The footbridges at Seapoint and Killineystations are taking longer to develop as the scheme must nowincorporate disabled access facilities.

Yes. Surveycomplete.

Carry out anyrepairs identifiedas necessary bysurvey.

Civils &Structures

DARTfootbridges

The methods of raising all DARTfootbridges are to be reviewed andstructural implications onfootbridges assessed.

See above comments As above. As above.

Civils &Structures

Cuttings andEmbankment- general

Assess stability of cuttings andembankments especially thosewhere slips have occurred and putin place programme for trimmingand stabilising.

2001 comment. External consultants have done a great dealof further work and refined the work options.Implementation of the works is subject to furtherconsideration by IE who will need to determine a reasonablebalance between works where necessary and a robustinspection and monitoring regime for the bulk of the asset.


Prioritise and carryout any repairsidentified asnecessary bysurvey.

Civils &Structures

CoastalDefences -general

Assess condition of coastaldefences and repair as required.

2001 comment. As above, external consultants have done agreat deal of further work and refined the work options.Implementation of the works is subject to furtherconsideration by IE who will need to determine a reasonablebalance between works where necessary and a robustinspection and monitoring regime for the bulk of the asset.Rosslare Strand requires special consideration and anaction plan putting in place quickly.


Prioritise and carryout any repairsidentified asnecessary bysurvey.


IRMS




Civils &Structures

Cast ironbridges -general

Increase frequency of inspection ofcast iron bridges.

The Chief Engineer Infrastructure has written to the DEsinstructing them to examine all cast iron bridges annually.

2001 comment. This has subsequently been amended to 6monthly. The 5 year programme for their removal is wellunderway

Yes. Inspectionsunderway.

Carry out anyrepairs identifiedas necessary byinspections.

Civils &Structures

Workshops -general

Increase tidiness of workshops andimprove standards for handlingpower tools.

2001 comment. No inspections of workshops wereundertaken as part of this visit.

Not audited.


On going task

Civils &Structures

Refuges -general

Remove all debris and obstructionsfrom tunnel and viaduct safetyrefuges.

Several tunnels were walked through and only minoramounts of debris found.

Yes On going task.

Refuges arerequired where notcurrently in placee.g. Cork tunnel.

Civils &Structures

ConnollyCTC

Fire safety at Dublin Connolly CTCto be reviewed and adequate safetyto be provided for staff in the eventof fire.

2001 comment. Major refurbishment is underway. The newfire escape staircase plans were seen and it was advised thatit had been ordered.

Underway.


No

Civils &Structures

Dublin -RosslareMain LineMP 92

Investigate suspected scour undertrack.

This site was not visited. DE Dublin advised that the sitewas visited by an engineer at low water to determine whetherthere was a problem with the foundation. No problems werefound.

No further comment.

Yes No

Civils &Structures

Dublin -RosslareMain LineMP 4.5 - 5.5

Investigate cause of track lateralmovement.

2001 comment. This site was not visited. Dublin DE advisedthat the track was dug out and drained, there is a rock outcrop at the location that may be contributing to the problem.As a control measure it is walked daily. A geo-technicalinvestigation was carried out to determine the underlyingcause.

Underway.


Furtherinvestigation isbeing undertakenas results are notconclusive


IRMS




Civils &Structures

Rosslare Enclose frame of Rosslare strandsignal box for security.

2001 comment. Frame now enclosed. Yes An IE wideprogramme ofupgrading signalboxes and othersafety criticalbuilding isunderway with thefirst group ofbuilding virtuallycomplete. The nextgroup will havework starting laterthis year.

Civils &Structures

Dublin-WexfordLineOverbridge99 (south ofSandycove):

Ensure that weight restriction isbeing observed or close bridge totraffic.

This bridge is on the Dublin-Wexford line at Dun Laoghaire.The site was visited and weight restriction signs observed.The bridge is planned for reconstruction in 2000. Indiscussion with the DE he advised that he has talked to thelocal police who are endeavouring to monitor the traffictravelling over it.

No further comment.

Underway


Bridge planned forreconstruction.

Civils &Structures

Dublin -WexfordLine 0/B 98

Prevent traffic accessing side spanuntil assessment can be carried out.

This bridge is on the Dublin-Wexford line at Dun Laoghaire.The site was visited and kerbing has been laid to preventroad vehicles using the side span. Until a longer term actionplan is decided upon this represents an adequate controlmeasure.

No further comment.

Underway.


Awaiting longerterm action plan.

Civils &Structures

Mullingar Review Bridge 387 to determinewhether it does contain cast irongirders and also provide adequateprotection to Sligo side footpathspan from road vehicle penetrationof the deck.

2001 comment. Athlone ADE confirms that it is cast iron andhas been added to the list of bridges to be reconstructed.Pot hole filled, but no deck protection provided.

Yes Bridge planned forreconstruction.


IRMS




Civils &Structures

ShannonRiver Bridge

Finish renewal of timber walkwayboards at Bridge 106 at Athlone(approx. 40%) complete to date.

Boards complete on walkways. Awaiting confirmation ofposition with respect to boards in five foot.

Yes All similarlocationsthroughout IEshould be restoredto a safe workingstandard

Civils &Structures

Lough AtaliaBridge

Renew timber walkway boards atBridge 171 Galway which arerotten and loose

Not inspected. Not Audited. All similarlocationsthroughout IEshould be restoredto a safe workingstandard

Civils &Structures

Ballinasloe Renew timber walkway boards atBridge 125 over the River Suckwhich are rotten and loose.

Complete. Yes All similarlocationsthroughout IEshould be restoredto a safe workingstandard

2001 Updateon WalkwayBoards

Missing UB 415A Cork - Cobh

Slippery UB 95 Suir viaduct, Cahir

Some walkway boards for staff access missing UB 415A andthose on UB 95 were extremely slippery when wet. Allsimilar locations throughout IE should be restored to a safeworking standard.

Systematic problem with maintenance of walking boards onunderbridges as evidenced by previous problem locations.

IE 2001 Comment:No boards missingon UB95. They areslippery when wetand antislipwalking materialhas been put inplace. With regardto UB415A this isthe old unusedDunkettle platformand not a bridge.It is not used and itwill be removed

All similarlocationsthroughout IEshould be restoredto a safe workingstandard


IRMS




Civils &Structures

Maynooth Close gap in footbridge railings attop of steps at station to prevent achild from falling through therailings.

Check for all similar footbridges asthat at Maynooth and close gaps onthose.

Complete.

Complete, there are none.

Yes

Yes

All similarlocationsthroughout IEshould be restoredto a safe condition

Civils &Structures

Bray Remove broken glazing fromcanopy roof at station which posesa risk to passengers who could bestruck by falling glass

Glazing replaced. Yes Review locationselsewhere.

2001 Updateon BrayGlazing

Many broken panes still in place. Glazing is being repeatedly broken. N/A Long termmitigation measureis required.


IRMS

Report No: 7335.01Issue No: 03Date April 2001

Appendix IV

New Unreasonable Risks Identified


IRMS

Report No: 7335.01Issue No: 03Date April 2001 Page AIV.1

No. Location Unreasonable Risk Explanation URRiskCat*

Groups atRisk **

Single Hazard orSystematic

ProposedTimescale forRectification

IE Response

P-Way

1. RosslareStrand

Weld installed onesleeper bay away fromfishplated joint inbullhead P&C,approximately 800mmapart.

Possible rail break andtrain derailment.

Minimum distance according toIE standards is 4500mm andgood European practice is forthree intermediate soundsupporting sleepers,approximately 1800mm.

(Mitigated by slow line speed)

1a Passengers.

Minor or majorinjury orpotentialfatality.

Single hazard 1 week The rail was replaced within one week.

Considered as low risk.

Electrification

2. DARTExtensions

Lack of safetyinterlocks for access tosubstation equipmenton DART Extensions.

Risk of shock or electrocution.

Existing enclosures areinterlocked to prevent accessunless power is de-energised.

1a IE staff andcontractors.


Systematic toDART extensionsubstations.

1 month Lockable Handles have been fitted to RectifierCubicle Doors. Key held by Traction Foreman.Safety Warning Sign fixed to door as an interimmitigation method.

Structures

3. UB 125Ballinasloe

Unsafe method ofscaffold dismantlingover water

Contract scaffoldersdismantling scaffolding wereworking over the redundantspan with single loose scaffoldplanks as walk way. High riskof falling in to river as theywere not secured to the bridge,were not wearing life jacketsand no safety boat was present.

3a Contractors


Single hazardalthough possiblyevidence of asystematic lack ofcontrol ofcontractors.

Site probablyclearedentirely bynow.

Systematicissue to beresolved.

The site was cleared on the same evening. TheContractors in question were not using a safesystem of work. The matter has been followed upwith them and method statements will besubmitted for their work in future.

4. UB 742Ballyhaunis

Unsafe method ofbridge raising

Bridge deck was being jackedup approx. 300mm and newbedstone of concrete cast while

2a Public

Minor or majorinjury or

Single hazardalthough possiblyevidence of a

1 week.

Systematicissue to be

This is not an unsafe method of raising thebridge. All loose materials were removed. Therewas scaffolding on each abutment. There wassingle line traffic through the road underneath,


IRMS



Groups atRisk **



IE Response

road vehicles and pedestrianspassed underneath.

potentialfatality.

systematic lack ofcontrol ofcontractors.

resolved and the footpath was scaffolded over. No memberof staff or the Public was placed in any dangerduring this work.

5. Close toBarbersTown levelcrossingnearClonsilla

Fencing erected tooclose to track

New post and wire fencetopped with barbed wireerected approx. 1m fromrunning edge. Effectivelyremoving the safe space forpeople to stand clear of trains

3a Staff andcontractors


Single hazard. 1 week. The distance from the fence to the running linevaries from 1.32m to 1.7m. This is beside aCCTV Level Crossing which gives warning ofapproaching trains. Limited Clearance Signs inplace. Moving back of fence to minimum of 2.1m.

6. Claremorrisstationplatform 2

Damaged platformcoping stones

Approx. 6 number very badlydamaged coping stones whichhave lost the front nose entirely

1a Passengers

Minor or majorinjury.

Single hazard 1 month This was on our programme and the work will becompleted by diverting from other works.

7. ApproachtoClaremorrisstation fromAthlone

Retaining Wallfoundation undermined

Low retaining wall foundationhas been undermined as a resultof excavation for track worksand not back filled. Possibletrain derailment if cutting slips.Low speed mitigates risk to adegree.

3a Passengers/Staff.

Minor or majorinjury.

Single hazard 1 month This is low risk . The foundation front wall wasexposed as part of the work at Claremorris butnot undermined. It is part of the planned work tohave this dealt with by end of April.

Operations

8. All stationswith long orcurvedplatformsthat employDOOCCTV

DOO CCTV andmirrors

Over 75% of the drivermonitors are unusable due tosunlight reflection problems,contrast settings and/or monitorpositioning. This makes itunsafe to close the train doorsand move off when the driver isunsighted. Station staffsometimes assist, but this is notguaranteed. Possibility of

2a Passengers

Potential minoror major injury,or fatality.

Systematic 1 month fortemporarymeasures.

Longer termsolution to beplanned.

Platform CCTV and mirrors are provided as anaid to the driver in observing the train doorwaysprior to closing the doors. All DOO CCTVrequirements are identified by the train operatingdepartments and solutions selected followingjoint site surveys and train trials.

A well known limitation of CRT displays is theirperformance degradation in direct sunlight. Thisis particularly evident at this time of the yearwhen the sun is low in the sky in the morningsand evenings. Outside of these periods, or in the


IRMS



Groups atRisk **



IE Response

trapping in doors or draggingincident.

absence of direct sunlight, the pictures areacceptable.

CCTV monitors, in this configuration, are widelyused on other administrations for this purpose.The responsibility rests with the train driver toascertain if the doorways are clear prior toclosing the doors and departing. Should it not bepossible to confirm visually, either directly of viathe platform equipment, assistance may be soughtfrom station staff or other confirmation obtained(such as the driver stepping onto the platformafter door closure and before departure).

In the context of the proposed increase in thenumber and length of DOO trains, a feasibilitystudy is now being conducted to consider theadoption of alternative technologies such as in-cab CCTV displays.

* unreasonable risk (Ur) Risks categorised as follows (e.g. 3a)

1. significant failures which violate Iarnród Éireann’s (IE) own ‘standards’, or;

2. significant failures where the IE ‘standard’ is considered inappropriate or unsuitable, or;

3. significant failures where no IE ‘standard’ currently exists.

AND

a. the failures have not been previously identified by IE, or;

b. inadequate temporary mitigation has been implemented to mitigate the failure, or;


IRMS


c. a long term solution has been planned and programmed within a reasonable timescales but the solution is considered inadequate, or;

d. an adequate long term solution has been proposed for which the timescales are too long, or;

e. the failure has system-wide implications which have not yet been investigated and control measures proposed.

** Passengers and/or

Public and/or

Staff and/or

Contractors



Appendix V

Review of Progress Against the RailwaySafety Programme 1999 - 2003


Report No: 7335.01Issue No: 03Date April 2001 Page AV.1

1. Introduction

A high level task force from the Department and IE prepared a prioritised safetyinvestment and implementation programme, based on recommendations from the1998 IRMS safety review [1] and other IE internal safety studies.

The annual planned investment expenditure, actual expenditure, planned programmeof physical works, and actual works completed is given below for each major elementof planned spending.

2. Infrastructure Discipline Spend

2.1 Permanent Way Renewals

1999 2000 2001 2002 2003 Total

Planned (£m) 42.0 40.0 39.0 33.0 33.0 187.0

Actual (£m) 41.1 44.3

Current plans (£m) 52.9 N/A N/A N/A

Miles planned 85 82 75 75 75 392

Miles achieved 88 84

Current miles planned 87 85 85 42917

(N/A = not available at present).

The original programme was to renew track at 75 miles per annum and this is nowbeing accelerated in view of the condition of the track. The objective is to have all theradial InterCity routes with full CWR by 2003. The unit cost per mile has increaseddue to construction inflation and new wage deals for permanent way staff.

2.2 Track Maintenance

1999 2000 2001 2002 2003 Total

Planned (£m) 5.0 5.0 3.0 2.0 2.0 17.0

Actual (£m) 5.7 4.6



As with track renewals, there has been an acceleration of expenditure in the earlyyears of the programme with a corresponding scaling down of costs in later years.

17 Including data for 1999/2000



2.3 Signalling, Electrical & Telecomms

1999 2000 2001 2002 2003 Total

Planned (£m) 5.6 8.1 4.9 4.4 4.4 27.4

Actual (£m) 4.3 5.6



The delays in the mini-CTC scheme caused lower spending in the initial years. Theincrease in work planned for 2001 is related to safety critical buildings (relay rooms,mechanical signal cabins, sub-stations, CTC control centre) and the work includessecurity, fire prevention and other physical upgrading which was underprovided for inthe original programme.

2.4 Heuston and Limerick Signalling/Terminals

1999 2000 2001 2002 2003 Total

Planned (£m) 1.0 5.0 6.0 3.0 - 15.0

Actual (£m) 1.5 6.1



The 2001 planned expenditure relates to Heuston station renewal only.

2.5 Electrification (DART)

1999 2000 2001 2002 2003 Total

Planned (£m) 1.0 0.2 0.2 0.2 0.2 1.8

Actual (£m) 0.2 0.4



There was a delay in delivery of the OHLE maintenance machine and work originallyplanned for 1999 will now be done in 2001.



2.6 Fencing

1999 2000 2001 2002 2003 Total

Planned (£m) 2.4 2.0 1.8 1.5 1.5 9.2

Actual (£m) 2.5 1.7


Fencing erected (miles):

- plan

- actual

- current

38

34

N/A

69

N/A

60

N/A

N/A

N/A

N/A

N/A

N/A


2.7 Structures (Bridges, Embankments etc)

1999 2000 2001 2002 2003 Total

Planned (£m) 4.0 7.1 7.1 7.0 7.0 32.2

Actual bridges (£m) 4.8 4.1

Actual cuttings &embankments (£m)

- 6.3

Current plans bridges (£m) 14.0

Current plans cuttings &embankments (£m)

15.0 N/A N/A N/A

Bridges renewed:

- plan

- actual

- current

24

41

N/A

17

N/A

25

N/A

N/A

N/A

N/A

N/A

N/A

Bridges painted:

- plan

- actual

- current

40

44

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A


Increased planned expenditure in 2001 is due to the inclusion of East Wall Bridge at£5.5m (the bridge has been the subject of numerous bridge-bashing incidents in recentyears) and work on cuttings and embankments as a result of a recently completed CarlBro Study.



2.8 Level Crossings

1999 2000 2001 2002 2003 Total

Planned (£m) 9.0 22.0 22.0 20.0 15.0 88.0

Actual (£m) 2.8 16.4


Crossings modernised:

- plan

- actual

- current

70

70

116

N/A

154

95

146

N/A18

116

N/A

602

N/A


The phasing of expenditure is lower than anticipated in the original programmebecause of difficulties reaching agreement with landowners. The 1999 programmeincludes the modernisation of 70 crossings, but these were lower cost modificationbecause of delays in getting agreement to modernise the more expensive levelcrossings.

2.9 Rolling Stock

1999 2000 2001 2002 2003 Total

Planned (£m) 0.6 0.3 0.3 0.3 0.3 1.8

Actual (£m) 0.6 0.3

Current plans (£m) 0.3 0.3 0.3 1.8

Expenditure is running as planned.

18 Further 103 under examination.



2.10 SMS (Training, Consultancy, Implementation Teams etc)

1999 2000 2001 2002 2003 Total

Planned (£m) 8.0 14.0 10.0 10.0 9.2 51.2

Actual (£m) 7.4 10.7


Training budget (£m) 3.5 5.3 6.1 4.5 4.4 23.8

Training man days:

- delivered

- planned

10,000

10,000

26,000

26,000 N/A N/A N/A N/A

Consultancy costs (£m):

- delivered

- planned

0.6

N/A

2.8

N/A

4.5

N/A N/A N/A N/A

The main SMS provisions covered the development of Corporate, Railway andDepartmental Standards, a significantly enhanced budget for training, thedevelopment of a safety performance database and a comprehensive system forimproved staff communication. The amount of training undertaken has increasedsignificantly and will be maintained. Heavy costs on consultants to deliver these newand revised standards have been incurred, which are reflected in the increasedconsultancy costs shown above.

2.11 Total (All Safety Investment Expenditure)

1999 2000 2001 2002 2003 Total

Planned (£m) 78.6 103.7 94.3 81.4 72.6 430.6

Actual (£m) 71.0 100.4

Current plans (£m) 135.0 130.0 130.0 556.4

The forecast increased expenditure in 2001 is mainly due to the accelerated spend ontrack renewals and on structures, with an additional £15m being attributed to essentialwork on embankment and cuttings not included in the original programme devised bythe Task Force, as a result of a more recent study.

3. Forecasts for 2002 and 2003

It is anticipated by IE that the 2002 and 2003 safety investment programmes will besimilar to the 2001 programme and will include ongoing work on cuttings andembankments. The track renewal work will continue at the highest level of 85 milesper annum (compared with the planned 75 miles), but track maintenance work as aresult will be scaled back. The planned budgets for delivery and implementation ofthe SMS will be similar to those over the past years. The development and deliveryof training will have a significant contribution to this budget, as will the utilisation ofconsultants.



IE estimate that an investment programme of about £130m per annum for each of theremaining two years of the programme will be necessary – an increase of over £50m ayear compared with the initial Task Force estimates.


IRMS


Appendix VI

Status of Previous IRMS Recommendations


IRMS

Report No: 7335.01Issue No: 03Date April 2001 Page AVI.1

The following table has been generated from a consolidation of all previous IRMS recommendations and the responses of both IE and the Department.Each of the previous IRMS recommendations was allocated a unique number, from 1 to 247 (plus an additional 8 Electrification references E3 to E10).However, many of these recommendations were effectively duplications of previous items. Such duplicated recommendations have been deleted fromthe following table.

ID Discipline IRMS Recommendation Reported Action Taken Reported Action Planned 2001 IRMS Audit Comments

1 Signalling,Communicationsand LevelCrossings

IE must ensure that rigorous measuresare taken to ensure the security and firesafety of its staff and safety criticalequipment in signal boxes;

160 buildings surveyed. Tenderprocedure. Project divided to dealwith first 80 on a priority basis.Work commenced 1/5/00.

1st phase complete Oct 00, Tendersfor second phase Nov 2000. Workon second 80 to commence Jan2001 and due for completion end2001.

New palisade fencing has been constructed atmany sites including relay room compoundsand Power Houses.

High security metal doors have now beenprovided at many sites for the doors to theunderpart of signal cabins.

Fire risk has been greatly reduced by theclearing of rubbish in the underpart ofmechanical signal cabins.


A detailed asset database andinfrastructure fault monitoring systemshould be developed by IE.

Specification developed. Tendersreceived for asset database. Bidsfor the provision of an AssetManagement System for allInfrastructure evaluated.

Proposal will be submitted to Boardfor approval on 4th October 2000.Phased implementation over 5years.

A new IT system, Infrastructure AssetManagement System, (IAMS) is underdevelopment but not ready forimplementation.

A feasibility paper on the IAMS system hasbeen produced.

Meanwhile, a telecomms faulting database isin use and being maintained at the ConnollyCTC.

Additionally, an interim system for themanagement of signalling failures is beingintroduced based upon the existing manualsystem (C25/2 reports) and MicrosoftOutlook.

3 Signalling,Communicationsand Level

IE should implement an interimrigorous safe working system for routesections for which the signalling is in

A system of hazard identificationand risk analysis was briefed tosupervisors. This approach will

System being introduced on allroutes. Further co-ordination underSRG, at Senior and Middle

IE has implemented a safety managementsystem for the route sections which have notbeen resignalled due to the imposed delay on


IRMS



Crossings particularly poor condition, untilessential investment takes place.

assist in the identification ofhazards and provide for prioritisedattention. PARS.

Management Level. investment in mini-CTC, Claremorris andHeuston .


Appropriate standards must bedeveloped for all aspects ofmaintenance, design installation,modification and subsequent hand-overof safety critical equipment. Thisshould include technicaldocumentation.

Specification developed. Tendersreceived for asset database. Bidsfor the provision of an AssetManagement System are beingevaluated. Contract with W.S.Atkins for StandardsDevelopment.

A contract is let with WS Atkins forthe development of standards in allthe elements mentioned.Completion is targeted for Oct.2001.

There are 19 standards under final review andin preparation to be briefed out.

There are 30 more in production and awaitingcompletion of review.


A planned maintenance regime withappropriate standards must beintroduced for all safety critical work.

The Asset Management Systemand development of standards willdemand these features anddevelopment of specifications isunderway.

see ID2 & ID 4 No planned maintenance regime has beenintroduced.


Appropriate training and certificationshould be provided for all staffengaged on safety critical work.

Signalling staff are continuing toattend training in the U.K.including, supervisory, technicaland operative grades. All coursesinclude competence assessmentand certification.

This approach will continue.Expressions of interest invited forfurther signalling training. Tenderprocess will be finalised before endof year

Staff are receiving technical training

Training plans are available at Divisionallevel.


A system of independent technicalaudit should be developed for all safetycritical systems.

Monitoring standard nowprepared. See ID2.

see ID2. External consultants are engaged to undertakeaudits.

The project manager for ETS now auditsEircom on a national basis.


There must be rigorous implementationof the practice of cutting backredundant wires, insulating andsecuring them so that there is no risk ofwires coming into contact withworking circuitry.

95% complete, a small number oflocations yet to be inspected.

Will be complete by year end. Redundant signalling wiring has now beenmade safe. The programme of insulating andsecuring signalling wiring appears nowcomplete.

Some minor work remains to tidy telecommswiring.

The practice of making redundant wiring safe


IRMS



is now part of SET engineering culture.


There should be a special exercise toreplace or remove all defective andworn signalling, electrical andtelecommunications equipment.

Special work-gang established,and program of replacement inhands. Resource problem.

Tender process commenced forextra resources.

A programme is in place to replace alldefective and worn mechanical equipment onthe Limerick Division. This work has beenprioritised in conjunction with the repair ofinterlocking frames.

On Dublin Division, the worn out assets arealso being replaced but on a separateprioritised basis often in conjunction with theP-Way engineer.

No such concerted effort was apparent on theAthlone Division.

There are resource problems affecting theoverall delivery of this item.


Specifically, all mechanicalinterlocking frames should be testedand repaired where necessary.

A contract placed with externalConsultants for examination andrepair of interlockings (prioritisedlist). Mitigation measures werenecessary, while awaitingreplacement.

Program continuing. A prioritised mechanical locking frame testand repair programme is being undertaken bycontract.

Mitigation measures are necessary whilstawaiting repairs.


Level crossing signs, road marking,sighting for road users and trains,communication and signal protectionshould be improved where necessary.

Signs and road markings onpublic roads with the exception ofyellow box markings, the functionof the local authority. Location ofsub-standard signalling have beenidentified, and temporary speedrestrictions and in some casespermanent speed restrictions havebeen applied to reduce train speedsappropriate to sighting distances.

AD Little report will guide actionon crossing prioritised for attention.Program on-going.

Locations of sub-standard signalling havebeen identified and temporary or permanentspeed restrictions imposed.

Some level crossings have been closed andothers converted to underpasses, thusproviding considerably improved safety.

Improved telephone facilities have beenprovided at a number of crossings.

Though action has been taken on roadmarking, no action has been taken on roadsigns, since these are deemed to be the


IRMS



responsibility of local authorities.


Iron gates level crossings should beprovided with safety bays.

Some Safety Bays have beenprovided.

Programme Continuing. Some safety bays have been provided.

A comprehensive programme, however, isrequired.


A safe and ergonomically soundworking environment should beprovided in all signal boxes.

Works programme in hands, workprioritised. Half will be completedthis year.

Half will be completed next year A programme is in hand for the refurbishmentof signal cabins, with very pleasing results.

Some further work requires to be done on theergonomics of the signal cabin layout.

14 P-Way The 11 major deficiencies noted shouldbe rectified without delay. This shouldpreferably be a long term solution,rather than a short term palliative. IEshould embark on an urgent studywhich examines the adequacy of thetrack structures.

All dealt with and risks mitigatedto acceptable standards.

All of the items will be renewedwith new materials as part of theSafety Programme in the 5-year and10 year programme.

Progress on the unreasonable risks is providedin Appendix III.

15 Structures A risk based bridge inspectionsprogramme should be introduced,underpinned by a planned maintenanceand/ or repair programme.

Bridge examination project (riskbased) expressions of interestreceived.

Progress to tender and selectionstage, Begin bridge examination byend of 2000.

Bridge examination project is a one offexercise to be carried out by externalconsultants. Once the cycle of inspections iscomplete there is no strategy for furtherexamination and condition monitoring.Presumably in the absence of an alternativeregime that described in MW41 will continue.Maintenance and repair process is stillhaphazard in places. Timetable has slippedand tenders are awaited at the end of February2001.

16 Structures Formal inspections and subsequentworks programmes should beintroduced for other structures.

Embankments, tunnels & seadefences completed.

Retaining walls with ID 15. Embankments, tunnels & sea defencescompleted. One off exercise undertaken byexternal consultants. There is no ongoingrequirement for inspection mandated as yet.Retaining walls, major gantries, otherstructures supporting the track or other


IRMS



infrastructure are now included in the scopeof this or the Bridge Examination Project. Butagain, as above, no ongoing regime iscurrently envisaged.

17 Structures Outside parties working on or near therailway must be better managed andshould be educated in railway risks.

Improved training in place. Aseries of documents identifying thecontrol requirements for pre-selection, selection, workingarrangements, also contractdocumentation reviewed, audit,are nearing completion. Someselected contracts are alreadyusing the new procedures.

Pilot projects using procedures willrun to year end.

Suite of 9 documents in various stages ofdevelopment and trialing. Problems stillevident. Sample of documents reviewed, someincomplete, all are draft. None appear toaddress third parties carrying out workadjacent to the railway e.g. new overlinebridge construction. All appear to apply tocontractors employed by IE for IE work.They are complex and will require muchbriefing to get working smoothly.

18 Electrification The overhead line access equipmentshould be replaced without delay.

Mitigation measures in place.Tender process complete. ToBoard for approval in October.

Manufacturer’s delivery of 12months after placing order.

In progress. Budget allocated, contract placed,delivery now expected November 2001.

19 Rolling Stock The significant risk associated withdefective windscreen wipers on Class201 diesel locomotives should beclosed out satisfactorily.

Modified wipers have been fittedto all Class 201 locomotives.Complete.

None. The previous audit identified that CME hadtaken three attempts to propose a robust andfunctional solution to the defective windscreenwiper issue with only one trial locomotive inthe field. The locomotive trial has beensuccessful and the complete fleet has beenmodified.

20 Rolling Stock A more detailed inspection of 15% ofthe fleet should be undertaken to assesscondition and maintenance quality.

An independent inspection of 15% of Rolling Stock has beencarried out by external consultants.Complete.

Measures to close out short termrecommendations in place, longterm recommendations to beconsidered and plan of action to beput in place.

It was confirmed that 15% of the fleet (bygeneric type) had been subject to a detailedinspection to assess condition andmaintenance quality. The inspection reporthad identified a number of inadequacies inmaintenance across all areas of the fleet.

The CME has been quick to address theinadequacies identified by tasking SectionalManagers to prepare a departmental action


IRMS



plan to address the issues within their area.

21 Rolling Stock A review should be undertaken of therelationship between OperationalInstructions and Rolling Stockdocumentation, bringing together all ofthe various "notes", etc.

Existing Documentation Manualsupdated to ensure that alldocuments are included.Maintenance Documentationtransferred from Main FrameComputer to Personal ComputerFloppy Discs. Complete.

All existing MaintenanceDocumentation to be transferred toa 'W' Drive and control systemsinstalled to ensure compliance withIS 9000 Standards

It was noted that the issues associated withacceptable integration of operators log sheetsand maintenance depot log books had beenconsidered and that it was a daily practiceinformation from drivers reports, operatorsdaily incident reports, and depot shift logbooks were collected to develop a dailypicture of activities in the field, programmeout of course maintenance and develop trendanalysis

22 Rolling Stock Rationalisation of the maintenancedocumentation should be undertaken toensure frequencies and examinationcontent are understood and controlled.

Complete. New documentation for Mk3 andMk 2 fleets to be developed withexternal assistance.

The CME has embarked on an exercise ofrationalising maintenance documentation withthe following initiatives:

• Development of examinations andmaintenance instructions into a formatsuitable for storage in a maintenanceinstruction database.

• Embellishment of examinations andmaintenance instructions withphotographic information showinglocations and explode views etc.

• Use of IT techniques to control the issueof documentation to the shop floor andprovide ‘hyperlinking’ of all relevantinformation required by the maintainer.

• Specifying these initiatives in thetechnical specifications for new rollingstock allowing direct integration of newinformation.

• Initiating the preparation of maintenancemanuals for (initially) MkIII coaches and


IRMS



Class 2600 & 2700 DMUs.

The initiatives are ongoing and progress isdeemed adequate. It is understood that oncethe proposed organisational changes to theTechnical Managers Department have beenratified and implemented responsibility for theproduction and co-ordination of thedocumentation will pass to the MaintenanceEngineers. Ongoing progress should bemonitored to ensure ongoing effectiveness andmaintenance of the initiatives.

23 Rolling Stock Independent inspections on majormaintenance and repairs be started.

An Independent Inspection ofMajor Maintenance (VehicleOverhauls) carried out.Completed

Measures to close out short termrecommendations in place, longterm recommendations to beconsidered and plan of action to beput in place.

It was noted that the CME had commissionedan audit (or independent inspection) of IEvehicles to establish the effectiveness ofoverhauls. The review identified a number oftechnical and process related issues.

24 Rolling Stock Requirements for the safetyspecification of new rolling stockshould be included within performancebased contracts.

This will apply - See ID 142.

A Safety Specification is nowincluded in all New VehiclesProcurement Contracts.Completed.

The Development and introductionof a Departmental VehicleAcceptance Standard. (No 11) isplanned to ensure that vehicles aremanufactured to the required SafetySpecifications.

It was noted that for the procurement of theClass 2900 DMU a detailed technicalspecification had been prepared that detailed anumber of safety related requirements. Inparticular detailing the requirements for thecontractor to supply appropriate and sufficientinformation to allow compliance withProcedure No. 6 and Technical Standard No. 1to be demonstrated.

It was noted that external consultants hadreviewed the documentation and thatappropriate Certificate of Approval (E Stage)had been obtained prior to the projectproceeding to the tender stage.

The development of the specificationsupported by the use of external consultants toprovide technical advice is seen as a positive


IRMS



step. This project is the first to beimplemented in compliance with TechnicalStandard No. 1 and Company Standard No. 6and should be monitored to ensure ongoingeffectiveness and compliance

26 SafetyManagementSystem

The Department, in conjunction withIE, should refine and agree the fundingof the additional costs necessary toimprove safety on the Ir£231 millionoutlined in [1].

Safety programme 1999 to 2003refers

Safety programme 1999 to 2003refers

Action ongoing – funding to be established onan annual basis against overall requirements ofthe RSP


IE should consider developing the riskmodel used by the Consultants for thisstudy to encompass a wider range ofhazards than those arising solely frominfrastructure and equipment failures,to include staff error, movement andnon-movement accidents andoccupational safety concerns.

Pilot Study begun by externalconsultants

Develop pilot study rationale onwider basis

Initial work started, momentum must now becontinued (see Section 10.2 of the report)


Revise the terms of reference of theCIE Safety Committee concerning itsauthorities and accountability andclarify the route by which CIEdecisions with safety implications arediscussed with or delegated to IE.

Completed Monitor and keep under review


Review the structure, resources andtechnical skills available, and theirdeployment, in all the engineeringfunctions, so that the achievement ofrobust maintenance standards cansupport the value of investment andupgrading of infrastructure.

Review in Place.

A Review has been carried out andAssistant Managers have beenintroduced into line managementto facilitate succession planning.Complete.

Additional Structure changes areunder consideration and plans toimplement these are at an advancedstage. All future changes inorganisation will be validated inaccordance with DepartmentalStandard no 3.

Implement Review.

Additional ADE and Private Parties Engineerat DE Dublin are being advertised.

A review of the structure, resources andtechnical skills available and their deploymenthas been undertaken in the infrastructurefunction.

A new organisational structure is being safetyvalidated and additional resources are being


IRMS



sought.

Thus far additional resources have beenprocured for the SET HQ organisation, butsevere difficulty is being experienced in theDivisions, due to lack of internal agreementand industrial relations difficulties.


Develop and document EngineeringStandards, Planned Maintenance &Inspection Programmes and equipmenttesting regimes.

See ID 4.

CME: Eight DepartmentalStandards have been developedfrom Company Standards andissued. Ten Equipment Standardshave been developed and issued.Complete

See ID 4.

CME: Develop with staffinvolvement and issue fifteenRolling Stock MaintenanceStandards.

See ID 4.


5 year plans should be prepared (with afurther 5 year outline estimate) for theinfrastructure investment necessary tomaintain a safe railway at the linespeeds required for optimum businessresults

5 year plan for Hard Issues. 5 yearplan for Soft issues.

Implement & Review. The original Railway Safety Plan is now outof date. The RSP needs constant review in thelight of experience and to become a rolling 5year programme updated annually.


Maintain resources available at localstation/depot management level for thecorrection of health and safety hazards,in conjunction with priorities agreedwith local supervisors and safetyrepresentatives.

£30,000 per District allocated toOperations Department in 1999,with £50,000 allocated for 2000and 2001.

Future annual budget allocations tobe made.

Operations implementation teams at Districtlevel using budget effectively.


Strengthen the arrangements for givingstaff feedback on their safetycomplaints and suggestions to improveconfidence of the staff in existingsystems.

Meetings Structure with SafetyReps. strengthened. SafetyRepresentative communicationreview. See ID 41 re briefinginitiative. Hazard Report formsdistributed.

CME: Safety Representatives meet

Draft proposals for SafetyRepresentative/Managementcommunication end Oct. See ID 41also

CME: Review existing hazardreporting procedures and follow upaction, update if required.

System implemented and operatingeffectively. IE should keep this issue underreview, especially at the interface betweenDepartments.


IRMS



with management during Toursand Inspection. (MonitoringStandard no 2). Formal Meetingsare held quarterly where Minutesare taken and issues not closed outduring local discussion are dealtwith. A newsletter has beenintroduced which includes Healthand Safety Issues. Complete.


Extend the provision of JobDescriptions and Safety ResponsibilityStatements to all safety criticalmanagement and supervisory posts andupdate these on a stipulated regularbasis.

Draft JD & SRS for managementsafety positions now ready forimplementation

CME: All Safety CriticalManagers and Supervisors havebeen provided with JobDescriptions / SafetyResponsibility Statements.Complete.

Target implementation year end.

CME: Carry out a review and makechanges if necessary.

Infrastructure Department ADEs have seenJD but not SRS. JD still subject to discussionand not signed off by staff.

Action complete for Operating and M&EDepartments.


Given the current standard of theexisting infrastructure and thefrequency of failures, undertake a riskassessment to identify the humanfactors risks associated with abnormalor degraded operating conditions (bothplanned and emergency).

Human factors proposed forinclusion in ERM development ofrisk model. Also, DistrictManagers and DivisionalEngineers to work jointly . See ID3.

CME: Measures that involverolling stock interface with trackhave been reviewed. Wheels andbogies are examined daily andduring Maintenance Examinations.Axles are ultrasonically test atplanned intervals. Complete.

Pilot Cork/Cobh line before end ofyear

CME: All Changes in plant,equipment, infrastructure andoperations will be validated inaccordance with DepartmentalStandards no 6

The pilot risk model does not address anetwork wide Human Factors assessment ofabnormal or degraded operating conditions.Action outstanding

36 SafetyManagement

Review the safety management ofcontractors' staff undertaking work on

No response provided No response provided


IRMS



System the IE system, clarifying IE andcontractor responsibilities and theireffective implementation.


Develop a system for integrating andprioritising safety objectives with otherkey business objectives, incorporatingsafety cost benefit analysis.

Pilot Study begun by ERM will bedeveloped to encompass. CBA ofdoor-locking investment, MKIIrolling stock.

ERM Pilot Study The CBA for the door locking investment is agood start. However, the pilot study referredto does not cover prioritisation betweenDepartments or between safety and otherbusiness investment. Action outstanding


Develop and install suitable computersoftware to maintain a full database ofaccidents and incidents that can bequickly and easily analysed for CIEand IE senior management, functionalmanagement and ground levelmanagers, supervisors, staff, and revisereporting instructions to include "nearmiss" data.

Synergi System installed.Training ongoing.

Progress monitor and review Much more work to be done before theSynergi system will be fully operational.


Develop and install a performance andfault database for all infrastructure androlling stock equipment.

See ID 5 & 4.

CME: A computerisedperformance and fault databasesystem (SAP) has been installed.Complete.

See ID 5 & 4.

CME: Set up a team in MechanicalEngineer to further develop thesystem with expert assistance.

The long term vision for the information tousers of the status of infrastructure assets andto plan for their maintenance is vested in theIAMS project,

This project is still in its infancy and notimescale for its introduction was producedduring this audit.

Due to the above factors, SET are nowextending the use of the manual Telecommsfault management system to include signallingusing the existing paper based reporting offaults.


Develop a programme to improvesafety culture and supervisory/staffcommitment to safety and audit its

Infrastructure Division, SafetyPlan. Training 4500 dayscompleted to end of Aug ,Briefing and Newsletter

It is proposed to audit the SafetyPlan and continue those initiatives.Supervisors Development

IE planning to seek external assistance to auditsafety culture.


IRMS



implementation. (IE) Development of consultativeexercise, example - workinstructions, SafetyRepresentative, Consultationprocess, and workshops.

CME: In addition to ISRSmonitoring requirements ADepartmental Monitoring Standardno 2 has been issued. OtherMeasures including: participationin the Safety Awards Scheme, AHealth and Safety Newsletter,Workshop Improvements andTraining Courses. Complete.

Programme.

CME: The use of an annualquestionnaire to assess progress willbe implemented with externalassistance.


Strengthen and consistently maintain asystem of briefing all staff at groundlevel on safety matters on a regularbasis by their supervisors/localmanagers, encouraging two-waycommunication and the upwardsprogressing of safety improvement.

Briefing arrangements- systembeing developed . Consultationexercise in progress for those whowill be involved in delivery ofbriefing exercises

CME: Informal Briefings takeplace daily.A requirement for Formal Briefingis included in DepartmentalStandard No 7 Training andCompetence. Complete.

Pilot Briefing Exercise due tocommence Oct. 2000 CME:Designated areas will be establishedin each work area where formalBriefings are to take place.

Communications training for supervisorsundertaken and briefing for Operations andM&E staff implemented. Action outstandingfor Infrastructure Department.


After carrying out a training needsanalysis, prepare individually tailoredtraining plans for all IE managementand supervisory staff, , which willincorporate the safety management andcommunication skills required, whichcan be costed.

Communication training forManagers and Supervisors hascommenced.

CME: A basic training needsanalysis of all staff and Managershas been carried out. Managersand Supervisors in safety criticalposts have Job Descriptions /

Further Courses Planned

CME: Accident and IncidentTraining of managers will becarried out this Year.The second module of the plannedSupervisory Training will alsocommence this year.Training in the uses of and

Infrastructure Department ADE's haveattended communications course but not hadtraining needs analysis.

Training needs analysis completed forOperations and M&E Departments.


IRMS



Safety Responsibility Statements.Training Requirements areincluded. Training hascommenced and a Training Co-ordinator has been appointed.Complete

reporting systems on SYNERGIComputer System will commenceshortly.


Supplement the regular existing ISRSsafety audits with compliance auditsagainst the requirements of the IE SMSissued 2.4.98 and IE operating rulesand engineering standards, throughoutthe organisation including groundlevel.

Audit tool 95% complete for initialuse in operations. Complianceaudit process developed for highand middle organisational levels.

To be extended. Compliance auditprocess for ground level underdevelopment.

Currently, lack of resources to complete theprocess and implement.


Implement a formal process (SafetyCase or Plan) for the management ofchange at the appropriate level ofdetail for all organisational andtechnical changes of significance-eitherto the existing system or new works.

Company Standards 3 and 6 onvalidation of change in force.

Monitor and review as required. Full implementation of relevant companystandards now required to complete action


Implement the recently approvedprocurement safety policies andperformance procedures as necessarycriteria in the selection of IEcontractors and suppliers andstrengthen the requirements forfeedback and audit.

Working to Oct 1998 procedures.Feedback and audit will beprovided for in contractordocumentation currently beingprepared see also ID17

See ID 17. See ID17.


Develop a performance basedprocurement process for allengineering equipment.

Internal IE Company Standard putin place.

CME: All new Rolling Stock isprocured using a performance-based process. Complete

Standard to be customised forInfrastructure.

CME: Introduce a DepartmentalStandard (No 11).- AcceptanceProcess for Design, Manufactureand Testing of Rolling Stock.

Full implementation of relevant companystandard now required to complete action.


IRMS




Develop and introduce a PerformanceAppraisal Process for all senior andmiddle managers, incorporating safetyperformance against targets whererelevant, and develop a simplifiedappraisal system against safetyobjectives.

Change Management Process inplace.

Plan to be developed. Nothing in place to date

48 Department ofPublic Enterprise

Strategic safety objectives should beset for IE in conjunction with the CIEand IE Boards, with a full awareness ofthe financial and service consequences.

No response provided. No response provided. This action is still outstanding on theDepartment.


Institute a Quality Assurance (QA)regime, such as ISO 9000, for allsystems and procedures that impact onsafety in all engineering functions.

See ID 4

CME: A computerised system forthe production and control ofMaintenance Documentation isbeing developed.

See ID 4.

CME: Ensure that the System is incompliance with IS 9000

See ID4. No clear intent by IE to introduceISO9000 certification requirement.


Establish regular research into staffmorale and the underlying reasons fortrends and changes, in respect of allactivities and grades of staff thatimpact on safety.

Complete. Recommendation reviewed Attitude surveys undertaken by HRDepartment but IR tensions meant thatoutcome was not considered representativeand of limited value. Further work required tocomplete action.


The pay and productivity structure,hours of duty and conditions of service,for staff grades that are safety critical,and outstanding issues between theTrade Unions and management onsafety discipline and techniques toensure public.

Agreement reached with 860 ofInfrastructure Rail Operative staff(50% +).

Further intensive negotiationsplanned. Implementation of RailOperative Staff over next 3 - 6months.

A programme of pay and productivity reviewsis ongoing.

52 Regulation ofRailway Safety

Strengthen the capabilities of thepresent sole Inspecting Officer, byrecruiting two more inspectors and onededicated administrative support

One additional RIO in place 9/99.Second RIO and full-timeadministrative person in place03/00.

Proposals made by external consultants forRSA staffing agreed by the Department butawaiting Department of Finance approval


IRMS



person now.


Reconsider the interpretation of thepublic safety clause in the SHW Act,or draft new legislation such thatinspection of public safety issues onrailways can be conducted with similarpowers to those available under theSHWA

Such powers to be provided for inthe railway safety regulation billcurrently in draft.

Action to be completed once new railwaysafety legislation passed


Make one Railway Inspectorate withinthe Department responsible formonitoring all railway safety issues,including those concerning employeesas well as passengers and the public.

Discussions with HAS regardingrationalisation of the current'overlap' of responsibilitiesbetween them and the RI ongoing.Associated MOU currently indraft.

Agreed MOU awaited – should be put in placeas a matter of priority.


Prepare a new mandate for the RailwayInspectorate from which its optimalsize, structure and position within theDepartment can be decided(Ultimatelythis will be dependent on newlegislation, but there will not be naturalphases en-route).

RI remit, powers and reportingarrangements proposed in draft ofrailway safety regulation bill.Independent consultants engagedto make HR recommendations interms of organisational size andstructure, required expertise, salarybands etc.

See ID 52.


Ensure that a programme of continuingprofessional development for the RIOsprovides the technical knowledgenecessary to understand and interpretmodern safety assessment andmanagement techniques, with theability for them to call uponindependent advice as and whennecessary.

Short-term needs of RIOs beingaddressed all having undergonetechnical and managerial training.A comprehensive trainingprogramme for all staff will bedeveloped with the establishmentof an independent Inspectorate.The independent HR studyaddressed the necessity for'bought-in' expertise and makesappropriate recommendations.

See ID 52.


IRMS




Require railway investment proposalsto include a statement of the safetyimplications.

This will be a requirement of allinvestment proposals submittedby IE to the DPE.

Action ongoing.


Revise existing railway safetylegislation to provide that which isrelevant to the late 20th century andbeyond.

New railway safety regulation indraft and proposed for enactmentin latter half of 2001. IE has beenasked in advance to take on boardthe safety case philosophy, whichis the core of the proposedlegislation.



Within such revised legislation, addressthe scope of New Works safetyassessment, including rolling stock,ensuring also that the duties andresponsibilities on the railway remainentirely clear. In particular, thelegislation should require IE to submita formal safety justification for anysignificant amendments or additions tothe network for RIO approval.

Within new legislationmethodology and scope ofapproval will be defined. It isenvisaged that the RI will standback from approval of moregeneric minor works but willrequire ongoing involvement inmajor projects. IE advised of thisposition.



Revise railway accident and dangerousoccurrence reporting legislation toensure common Reporting thresholdsbetween railway and other industries.

To be addressed in new railwaysafety regulation bill. Generalaccident reporting criteria andthresholds currently under review.



The Department should allocate thenecessary resources to achieve, withina reasonable time-frame, the necessaryrevision of railway safety legislation,including the introduction of therailway licensing procedure, demandedby EU Directives and described indetail in Section 9.3.

Additional resources provided (1AP in December 1999, 1 AP inOctober 2000 and 1 HEO inOctober 2000).

Action complete

62 Regulation of Government should nominate as soon The Minister is designated as the Action complete


IRMS



Railway Safety as possible an appropriate body to issueand manage Safety Certificates andLicences to railway undertakingsrequiring access to the Irish railwaynetwork.

licensing body for railwayundertakings under the EuropeanCommunities (Licensing ofRailway Undertakings).Regulations, 1999 and the CRIO isdesignated as the personresponsible for issuing safetycertificates under the EuropeanCommunities (Allocation ofRailway Infrastructure Capacityand Charging of InfrastructureFees) Regulations, 1999.


Railway undertakings wishing toobtain access to the Irish railwaynetwork should submit a Safety Caseor Plan to the Railway InfrastructureController.

New railway safety caselegislation envisages safety casesbeing submitted directly to anindependent RI rather than IE butwith evidence of adequatehandshake with the infrastructurecontrollers safety case



IE should submit approved SafetyCases or Plans to the Department (ornominated body) for acceptance andissue of Safety Certificates andLicences.

As above. Under the newlegislation, all safety cases will besubmitted directly to RI



Safety Cases or Plans should be limitedto a satisfactory demonstration of thesafety of the specific activity and routean its compatibility with IEinfrastructure and SMS.

Safety Cases will be required tocover all aspects of railwayoperations which impact on safety,including interfaces with otheroperators and agencies etc.



Safety Cases or Plans should beappraised against safety criteria agreedwith the Department for the nationalrailway system.

Acceptance criteria will bedeveloped prior to theestablishment of the independentRI. Guidelines for thedevelopment of safety cases are



IRMS



being developed and should bepublished early in 2001.


Safety Cases or Plans should addressrelevant safety issues concerningcompetence of personnel andorganisation and the applicant railwayundertaking's SMS, rolling stock,insurance and interface arrangementswith IE.

Safety Cases will be required tocover these aspects of railwayoperations.



The IE should be required to auditcompliance by the railway undertakingwith its Safety Case or Plan, and theDepartment (or nominated body)should have the powers to undertake itsown independent check audit, and torevoke an undertaking's SafetyCertificate and Licences in certainspecified circumstances.

The new legislation will require anoperator to have an independentexternal audit of its safety caseundertaken before the submissionof the SC to the RI. RI will alsohave audit and inspection powerswith follow-up enforcementpowers.



The Department should check that EUlegislation in the pipeline does notimpact on the proposals for safetyregulation of rail traffic that couldaccess the existing IE network.

DPE is represented on workingparties involved in thedevelopment of EU rail legislation.

Action complete

70 All InfrastructureDisciplines

Correction of infrastructure faultsneeding urgent remedial actiondiscovered during inspection.

All dealt with and risks mitigatedto acceptable standards.

To be dealt with as part of 5 yearand 10 year programme.

Action ongoing

71 Implementation Agreement between DPE, CIE, IE onAction Plans and responsibilities toimplement.

Safety programme 1999 to 2003 Ongoing The current relationship between IE and theregulator is not acceptable. A more co-operative environment is required to beestablished


Repair or renew infrastructure andassets where risks have beenestablished as unreasonable, and/or

PAR's Programme. Training in hand. DivisionalEngineer's and District Managers.

See Appendix III


IRMS



establish documented safe workingpractices until the necessary investmentcan be undertaken.

See ID 35.


Set up project teams to review anddevelop key areas of proposals andrecommendations.

Teams set up.

CME: A project team has been setup to implementrecommendations. A ProjectManager reports to the SteeringGroup and at Senior ManagementMeetings. Complete

Review Plans.

CME: Review resources and ensureadequacy to meet evolving needs.Review reporting and follow upaction process.

Teams to progress the IRMSrecommendations were implemented, but nodedicated overall co-ordinator was appointed.


External Audit of Action Plans. No response provided No response provided IE have engaged consultants to undertakeaudits of Departmental Safety Planimplementation. This action should berepeated on an annual basis


Evidence of best practice within SETwith respect to standards,documentation and training should bepromulgated throughout IE.

This will be taken on board. Though the format of the Standards beingproduced is good, the content is not acceptableand SET cannot be recommended as bestpractice in this respect.

No briefing of Standards has been possibledue to poor content


The timescale for the introduction ofthe new IT system is not acceptable,and an alternative should beimmediately explored.

Synergi is up and running.

Asset Data Base - See ID 2.

Develop Risk Model - See ID 208.

See ID 39 above.


The safety systems for the managementof degraded infrastructure are notrobust and should be improved.

See ID 4. A number of documented SMSs introduced bySET for the safe management of degradedinfrastructure were made available and siteinspections carried out.

This indicated that SET now had a system formanagement of degraded infrastructure.

123 Signalling, A solution for the design failing of the Design reviewed. Complete. A decision was taken at the SEG not to


IRMS



Communicationsand LevelCrossings

colour-light signal at Wicklow shouldbe approved and implemented withoutdelay.

implement any changes to the colour lightsignal design.

Engineering judgement was used to determinethis course of action. No risk assessment orother basis for it was produced in evidence ofthis being safe. This is not regarded asacceptable.


A methodology for a periodic jointPermanent Way/Signallingmaintenance routine should be agreedand implemented by the InfrastructureEngineer. This is now a matter of someurgency.

A tour of all Divisions explainingthe philosophy of Point care hastaken place. The Divisions arecommitted to deal with all Pointsin this way.

Methodology still underdevelopment but inspectionsprogressing.

The Athlone and Dublin Divisions performjoint inspections on the insulated joints andsome joint inspections of points had takenplace though no structure was evident.


A system of independent to IE audit forSET safety critical systems should bedeveloped.

Standards, Systems & AssetManagement role being developed.

Review type of audit required. No evidence of an audit regime was presented.


A monitored comprehensive actionplan is required for the replacement ofall SET assets.

5 year plan in preparation. No plans were provided.

On the Limerick Division, this work has beenlinked with the renewal of worn outmechanical signalling assets at the samelocations.

On the Dublin Division, the worn out assetsare also being replaced but on a separateprioritised basis often in conjunction with theP-Way engineer.

No such concerted effort was apparent on theAthlone Division.

127 Signalling,Communicationsand Level

The marker board solution forimproving braking distances should besubjected to risk assessment and anindependent safety assessment of this

Speed Restrictions in place. Notedand RIO consulted.

Marker Boards to be installed. No risk assessment was produced to supportthe proposed course of action.


IRMS



Crossings procedure is recommended.


In the light of mini CTC delays,renewal requirements should be re-appraised on the Galway line, togetherwith those other lines affected.

Requirements are currently beingassessed, materials sourced andrenewal program being developed.Progress delayed due to resources.

Progressing No plan was produced in evidence, thoughdocumented SMSs had been produced forindividual signal cabins and many items ofunsafe infrastructure signed out of use.

Progress is delayed due to lack of resources.


Procurement delays in obtaining newmaterials for renewals and maintenanceshould be resolved.

Availability of material hasimproved.

Staff have been recruited to ensure call offcontracts are in place and a dedicatedinfrastructure procurement resource is inplace.

Mechanical materials for Dublin are stilldelayed.


The Safety Management Systemshould, in particular, address all safetyissues arising during new works,degraded works or alterations toinfrastructure at these sites.

Noted and being addressed insystems and procedures currentlybeing developed. See ID17 also.

Heuston and Claremorris now havedocumented SMSs.


EirCom should seek professionaladvice on the safety critical standardsand procedures required for ETSequipment.

Eircom Advised. See ID 133. The code of practice is now available atexchanges for guidance on ETS maintenance.

Eircom are also now pursuing ISO9001accreditation.


An independent audit of EirComprocedures should be carried out.

ETS Project includes externalvalidation of Eircom practices(10% complete) commenced June2000.

2 year project. IE has recruited staff to perform audits ofEircom work on the railway infrastructure.


A record of all Safety Plan briefingsshould be maintained.

Documentation prepared andpresented to local management.Briefing information included inInternal Newsletter.

Plan Reviewed. Safety plan briefings are held by theDivisional Engineers.

135 Signalling, An appropriate system for recording of Refer to ID 2. See ID 39 above.


IRMS



Communicationsand LevelCrossings

signalling failures should be found andimplemented.

The temporary IT system (Outlook) is not yetnot in operation.


The recruitment of skilled staff shouldbe given the highest priority.

Managing Director has SpecialCommittee.

Recruitment Drive. IE is having enormous difficulty in this area.Problems due to wage structure and otherindustrial relations issues are blockingprogress.

A pay rate has still not been resolved whichwould enable the realistic recruitment ofskilled technical staff.


A Fire Warden with overallresponsibility for fire safety should beappointed at each site.

See ID 1. Immediately followingcompletion of works. This will bereviewed.

See ID 1. Management/monitoringsystems with consultants forproposals

No evidence was available to show movementon this issue.

139 P-Way The problems of lightweight andobsolete rails are being addressed bytotal track renewal. However, thereremain many locations that will not berenewed for several years and the safemanagement of the ageing trackinfrastructure is vital.

Noted and replacement ofdefective material is ongoing.

On-going Old and lightweight rails are being managedin a number of ways considered appropriate tothe perceived level of risk. Track renewal isproceeding apace and will eliminate theproblem during the coming three years.Temporary speed restrictions are imposed forthe highest risk locations so that the potentialconsequence of any incident is significantlyreduced. An increase in inspections, bothultrasonic and visual, is implemented so thatproblems can be identified at an early stage.Heavier locomotives are restricted from somelines that continue to have a large populationof lightweight rail. Proof of the effectivenessof these actions is the dramatic reduction inbroken rails during 2000, less than half incomparison with 1998.

140 P-Way The site inspections continue toidentify examples of defects which

See ID 3 & 4, and ID. 144. PWIs have had visits from staff with similarrailway experience to themselves from the UK


IRMS



would be quite unacceptable in the restof Europe, albeit the numbers havereduced. Staff are still used to workingwith poor track, particularly at stationsand passing loops.

employed by Jarvis for assistance with theidentification of problem spots.

141 P-Way The workload of the PWI has changedlittle and still needs to be reviewed. Hespends at least one full day a week onbasic clerical duties. To this work thePWI is unsuited.

Negotiation with Operative GradesSupervised by PAR's. Complete.

Negotiations commence in October2000 with PWIs.

This is part of the current negotiations withPWI staff representatives. Many PWIs nowhave Divisions entirely renewed in CWR andthis has led to a significant drop in theirworkload.

142 P-Way The fleet of plant available forpermanent way operations is still notadequate in two key respects: A fleet ofmodern ballast hoppers allowing staffto place stone where it is needed andobviate the need to plough.

Consultants appointed to Projectmanage the purchase andintroduction of suitable rollingstock/Road Rail vehicles to thesystem.

Tender stage completed by end ofNov. 2000. Delivery in 2002.

One new 08 tamper is now in service and asecond is set to join shortly. Tenders havebeen invited for the supply of a ballast hoppertrain with both central and side dischargechutes and modern control systems. A furthertendered requirement is for a train capable oflifting the large quantity of scrap produced byrelaying activity.

143 P-Way Training of the PWIs’ staff in theirduties remains at a low level. Newemployees are taken on and giveninitial safety training only. After this itis the responsibility of the PWI and hisgangers to train the new staff on thejob.

A number of training courses nowin place, including P.T.S.Lookout.- Person in charge ofPossession.- Small Plant &Equipment. - Basic PermanentWay Skills. Further courses willbe developed. Formal competenceassessment not yet in place.

Patrol ganger standard completeand will be introduced 0-6 monthstogether training needs analysis forpatrol gangers leading to qualityassurance

A trainer has been appointed for each divisionand the initial thrust is on basic P-Way issues.Testing of competence remains an IR issuewith no progress to date.

144 P-Way The lack of standards continues toleave staff unaware of what is correct.For example, on the basic subject ofthe overlap setting of adjustmentswitches there was a disparity ofresponses from senior staff.

Standards for P-Way are beingdeveloped by WS Atkins,concurrently with those forsignalling (see ID 4).

See ID 4. Standards progress is considerable andreported on in detail elsewhere.

145 P-Way Again the potential for confusion Included in the development of See ID 144. The issue of the positioning of an IBJ with


IRMS



includes the new, believed standard,IBJ arrangement with the joint beingpositioned over the face of the sleeperon the running on end. This isinappropriate for single lines and yet isin widespread use.

standards as outlined in ID 144. respect to adjacent sleepers has been resolved.

146 P-Way Maintenance of life expired track isnow mainly undertaken by totalrenewal in new CWR. This gives avery good standard of finish but it is aconcern that unless staff begin tounderstand the standards to work to thetrack may be allowed to deteriorate.

Workshop held to discuss thisissue. Standard 90% complete.

Complete standard. Initial contactswith UK training provider regardingprovision of training, no time framedecided

The training initiative will help to resolve thistogether with a systematic mechanisedmaintenance regime working on a 5-10 yearcycle. It is intended that the training focus on asmall number of critical items to get besteffect in the shortest time.

147 Structures Ensure that the scope of the bridgemanagement project includes morethan just bridges i.e. all significantstructures are listed and subject toexamination. Particular deficienciesnoted are that there is no engineeringexamination of tunnels.

All Tunnels, Infrastructureexamined 1999 by TunnelConsultants. See ID 2, 15 & 16.

See ID 2, 15 & 16. Inspection of tunnels, embankments, cuttingsand coastal/sea defences was a one offexercise. No plan or procedure in place forfuture inspection regime. Bridge Examinationproject now extended to cover all structurese.g. retaining walls, signal gantries etc.

148 Structures Those structures not included in thebridge management project shouldhave alternative management systemsdeveloped for them.

See ID 2, 15 & 16. See ID 2, 15 & 16. Nothing being put in place for tunnels,earthworks and coastal defences as yet.

149 Structures As part of the bridge managementproject the entire process of conditionmonitoring should be reviewed andappropriate changes made to improvethe quality of the process, theachievements of the standard and theuse of appropriate staff.

Asset Management system.Performance Incident InformationSystems Report 15/08/00. Bridgeexamination Project (risk based).Specification written. Expressionof interest invited.

Bridge examination Project afterselection process is complete willtake approximately 18months.

Bridge examination project (risk based).Specification written. Expression of interestinvited. Bridge management project will be aone off exercise. Recommendations for thefuture are not being sought.

150 Structures Revisit identification exercise andidentify possible structures that may

Revisited and records amendedwhere necessary.

Complete. Action complete.


IRMS



have been omitted during the initialexercise.

151 Structures Revise programme to reflect likelyreconstruction schedule.

39 cast iron bridges - Replacementprogram 5 years 1999 - 2003.Risk based approach.

18 completed by end of 2000 andremaining bridges are programmedfor replacement 2001, 2002 & 2003.

Action complete.

152 Structures Develop project management processto track project through itsimplementation.

Tracking system in place Tracking system will be updated aswork continues.

No real project management system apparentalthough tracking is undertaken by StructuresDesign Engineer. Split of responsibility withDEs makes this difficult.

153 Structures Determine what IE’s responsibilitiesfor ‘disused’ lines are and identify allof those lines.

Legal and property issuesinvolved. Responsibility for somebridges handed back to the localauthority. Repairs are carried outas required.

Proposal under consideration totake this matter forward.

Legal and property issues involved.Responsibility for some bridges handed backto the local authority. Repairs are carried outas required. Exercise to review recordsunderway although there are still concernsabout its robustness.

External consultants tasked with lookingthrough all known deeds and agreements todetermine what IE still have responsibility forprogrammed to complete that task by June2001. Unclear about how 100% coverage ofall lines has been achieved, for example howhave the lines that have no deeds beencovered?

154 Structures Identify the structures along the routesand instigate an appropriate inspectionand management regime for them.

See ID. 153. Inspection routine notyet in place, will be considered forinclusion in Asset ManagementSystem.

See ID 153. No inspections to date although Limerick JcnDE have done inspections on North Kerryroute on own initiative.

Structures will be identified as part ofexercise, inspection and management willfollow.

155 Structures IE should develop a comprehensivestrategy to reduce the incidents ofbridge strikes involving external parties

Instructions re-issued to divisionalstaff to report incidents of bridgestrikes to Gardai.

Awareness campaign planned. Articles in commercial press published. Butoverall strategy document still lacking.


IRMS



such as the Gardai in pursuingprosecutions of offending drivers, thehaulage industry bodies in awarenesscampaigns amongst drivers.

156 Structures A training and assessment packageshould be developed for staff such aspatrol gangers and PWIs to developcompetence in dealing with defineddamage levels to struck bridges.

A Standard now exists and hasbeen briefed. Training will follow.

See ID 143. Standard is still draft, not issued and hasweaknesses. No plans for competencetraining and assessment to inspect damage tobridges.

157 Structures Increased reporting of strikes should beenabled by fixing information plates tobridges with unique identification andtelephone number within IE to gettrains stopped as quickly as possible.

New sign to include thisinformation designed andapproved.

Planned Programme. Principle now in draft standard. Programmeof fixing plates now required, first one erectednear Greystones.

158 Structures Provide signal staff with instructionsabout what action to take when dealingwith a bridge strike.

Covered in Signalling instructions. Rule book is very brief and not adequate.

159 Structures Implement a programme of physicalworks to bridges, either protectionworks or raising decks whereappropriate.

Programme in place. On-going. Work is generally driven by relayingprogramme. Risk assessment exercise is nottransparently driving the programme.

160 Structures Embark on a comprehensivedevegetation programme of allstructures to allow effectiveexamination.

Has commenced. On-going. Very little progress seen on site visits.

161 Structures Provide ballast walls and handrailswhere track laying has created therequirement for improvements.

Done in conjunction with relaying. On-going. Some good progress although there are stillmany sites to be treated.

162 Structures Review parapet adequacy atoverbridges on a risk based approach toidentifying those requiring upgrading.

Complete. Some works have resulted but usually wherethe bridge was being reconstructed for otherreasons. Little physical progress.


IRMS



163 Structures Develop appropriate standards for theinspection of buildings which containengineering structures and implementthem.

See ID 1. No standards seen.

164 Structures Carry out a one-off inspection of allengineering structures within stationswhich the BMEs have responsibility.

Responsibility of ManagerInterCity

The architect intends letting a contract toundertake this during 2001.

165 Structures Agree and document the maintenanceresponsibility for the boundarybetween platform copings and the restof the surface.

Revised standard prepared,complete, will provide formaintenance responsibility.

Complete and Standard Issued. No standard seen or awareness of one. BMEsays that trip hazards are his responsibility.

166 Structures Repair all substandard platformcoping/surface joints to removetripping hazards.

Repairs in hand. PAR's Programme Many hazards seen during Jan/ Feb 2001 visits

167 Structures Give consideration to the role,capabilities and name of the IEpresence on site as part of the standardwriting process.

Will be included withdocumentation referred to in ID17.

See ID 17. No progress to date.

169 Structures Ensure that structures on disused,abandoned routes for which IE hasresponsibility are listed, examined andmanaged.

See IDs 153 and 154. See IDs 153 and 154. See IDs 153 and 154.

171 Structures Review Bridge 387 at Mullingar todetermine whether it does contain castiron girders.

Contains Cast iron. Bridge for Renewal in 2001. SeeID 172.

See ID 172.

172 Structures Provide adequate protection to Sligoside footpath span from road vehiclepenetration of the deck.

Reviewed with Local Authority. Deal with ID 171. No protection from footpath penetrationprovided although pot hole has been repaired

173 Structures Finish renewal of timber walkwayboards at Shannon River Bridge 106 atAthlone (approx. 40%) complete to

90% complete. Work ongoing as required. Walkways to sides of track repaired andcovered with mesh. However five-footwalkway still to be clarified


IRMS



date.

174 Structures Renew timber walkway boards at theLough Atalia Bridge 171 Galwaywhich are rotten and loose.

95% complete. Work ongoing as required. 95% complete Not inspected Jan/Feb 2001.

175 Structures Renew timber walkway boards at theBridge 125 over the River Suck atBallinasloe which are rotten and loose.

80% complete. Work ongoing as required. Rotten boards removed and boards fixed downfollowing painting, mesh laid to walkway.

176 Structures Close gap in footbridge railings at topof steps at Maynooth station to preventa child from falling through therailings.

This matter has been attended to,and similar foot-bridges inspected.

Will be included in FootbridgeInspection.

Action complete.

177 Structures Check for all similar footbridges as thatat Maynooth and close gaps on those.

Survey Complete. Work Progressed. Action complete.

178 Structures Remove broken glazing from canopyroof at Bray station which poses a riskto passengers who could be struck byfalling glass.

Complete. Approximately 10-15 cracked or broken panesstill in roof at time of Jan/Feb 2001 visit.Longer term plan to remove the entire canopy.

179 Electrification The operation and maintenancemanuals for the new DART extensionsrelating to OLE should be reviewed atthe next audit by the Consultants.

Still outstanding. Part of document reviewprocess.

180 Electrification The use or crimped rather than boltedconnections, and instructions for theiruse, should be reviewed at the nextaudit by the Consultants.

Existing system boltedconnections utilised, extensionscrimped connections utilised,

OCS staff to be trained in use ofhydraulic crimpers, when IRproblems are resolved.

Additional training and hand-over of specialisttools from contractors is planned.

181 Electrification Monitor the good progress now beingmade on the acquisition of overheadline access equipment.

SEE ID 18. SEE ID 18. In progress. Budget allocated, contract placed,delivery now expected November 2001

182 Electrification Urge the familiarisation of staff withthe new electrification equipmentinstalled on the Greystones and

See ID 234. See ID 234. In progress. Additional training andfamiliarisation to be undertaken in conjunctionwith the contractor, ADtranz


IRMS



Malahide DART extensions.

183 Electrification Discuss with the Railway Inspectoratethe safety implications of the load-measuring auto-reclose facilityinstalled on the 1500Vdc feeder circuitbreakers for the new DART extensions.

Not discussed as yet. Discuss with RIO. Scheme modified – reclosing not automatic.Action complete.

184 Electrification Discuss the procedure required tomanage out the risks arising from theinadvertent use of OLE splices andend-fittings which may beincompatible with one or other of thetwo contact wire cross-sections now inuse on DART.

At the moment, the equipmentused on the extensions, and theequipment used on the existingsystem is stored at two separatelocations.

This matter is under further review. In progress. Risk being managed out bymarking drums etc., and introducingprocedures.

185 Electrification Urge the Contractor for theelectrification equipment on the newextensions to remedy exposed liveterminals in the motorised isolatormechanism boxes.

Noted. No progress. Considered low risk but will receiveattention in due course.

In progress. Contractor to confirm whetheroperational access necessary.

186 Electrification Continue to work towards theestablishment and maintenance offormal training, competencyassessment and certification proceduresfor electrical operations staff, andconsider the need for a nominated'Head of Profession' for theelectrification system.

Preparation of standards, is welladvanced, 90% complete. Formaltraining, and certification will beaddressed when gangs increase,and IR. Problems resolved. Headof Profession issue not yetfinalised.

Will continue to progress. Head of Profession now recognised and willbe appointed.

High level standards still awaited.

187 Electrification The following new risk has beenidentified and must be managed - useof load-measuring auto-reclose onExtensions feeder circuit breakers.

See ID 183. See ID 183. Scheme modified – reclosing not automatic.Action complete.

188 Rolling Stock It is recommended that a further reviewis undertaken after a further 6 monthsperiod to audit in detail the

To be arranged. No further progress.


IRMS



implementation of the complete suiteof Company procedures (anddeveloped Departmental procedures)and to monitor the progress inaddressing original auditrecommendations.

189 Rolling Stock Due cognisance should be taken byCME to the implementation of thevarious recommendations detailedwithin the main body of this report andin particular: Project reporting by theIRMS Project Manager should beenhanced to discuss threats and risks.Benchmarking of configuration statusis a key issue and a strategy (or actionplan) needs to be developed. The safetyvalidation regime (for bothorganisational changes and engineeringchanges) needs to be considered atsome length within CME. Completionof the safety justification supportingthe refurbishment of Craven carriages.Completion of the secondary doorlocking risk assessment.

All changes are validated usingDepartmental Standards. IncludingChanges in Plant, Equipment,Infrastructure and Operations,standard no 6. Changes inOrganisation are validated usingdepartmental Standard no 3. Theuse of Craven Coaching Stock willbe phased out with theintroduction of new vehicles,maintenance activities will reflectusage. Independent RiskAssessment of Mk 2 complete.

Maintenance of Craven Stock is tobe monitored. Mk 2 SecondaryDoor locking report is to bediscussed by the SRG. Pendingdecision, maintenance to continuewith existing practice of lockreplacement every General Repairand daily checks and inspections.

The risk assessment to ascertain the safetybenefits of fitting secondary locking onMark II coaches has been completed byexternal consultants. The risk assessmentshowed a marginal cost benefit of fittingsecondary locking (a cost benefit ratio of 1.02over a 10-year life). It is understood that thisassessment (together with the rolling stockplan) will be presented to the IE board forconsideration.

The CME (in conjunction with the ‘business’)has prepared a coaching stock plan whichdetails a proposed increase in rolling stock upto 2005 including:

• An overall increase of coaching stock toapproximately 600 vehicles by 2005.

• Withdrawal of all Craven Coaches by2003.

• Withdrawal of MkII Coaches by 2005.

• Aspiration to replace withdrawn stock bydisplaced MkIII coaches from the UK.

190 Rolling Stock Particular attention should be focusedon the validation of the management ofmaintenance and related other activitiesand the development and verificationof safety within the ongoing rolling

Existing Documentation Manualsupdated to ensure that alldocuments are included.Maintenance Documentationtransferred from Main Frame

All existing MaintenanceDocumentation will be transferredto the 'W' Drive and control systemsinstalled to ensure compliance withIS 9000 Standards.

A detailed inspection of the condition andmaintenance quality of 320 vehicles has beenundertaken by external consultants. A numberof inadequacies in maintenance across allareas was identified, however the inspectors


IRMS



stock procurement activities. Computer to Personal ComputerFloppy Discs. Complete.

did not regard any of the inadequaciesidentified as being safety critical. The CMEhas been quick to address the inadequaciesidentified by tasking each sectional managerto prepare a departmental action plan toaddress the issues within their area. Theissues identified in the main have beenaddressed on the vehicles although some workis still ongoing. Where it has been necessaryto make changes to maintenancedocumentation this has been (or is being)undertaken.

Significant steps have been taken to rationalisemaintenance documentation.

191 Rolling Stock CME should take particular duecognisance of the need to prioritise thedevelopment of a robust and coherentsafety management system and theimplementation of the appropriatesystems and support within thedepartment.

A Safety Management System isin place and DepartmentalStandards 1 to 10 (1 - 8 issued)will ensure that requirements areaddressed. In addition theMechanical Engineering 2000Strategic and Safety Plans aredesigned to begin deliver on thisrecommendation. Complete.

The CME has made considerable efforts in thedevelopment and implementation of a safetyculture underpinned by the ongoingdevelopment (and implementation) ofdepartmental procedures, Strategic and SafetyPlans etc.


The need for administrative support tothe railway inspectors is reiterated andstrengthened.

Full time administrative personassigned in March 2000.

Action complete.


Facilities for the CRIO to call upexternal assistance need to bedeveloped.

Addressed in independent HRstudy with recommendations onappropriate budgetary allocation.Approval to be sought before year-end to proceed with establishmentof RI office.

Action complete.

197 Department of The CRIO needs to consider potential Proposals received and contract Action ongoing.


IRMS



Public Enterprise guidance to parallel new legislation. placement imminent for drafting ofSC guidance to be completed03/01. Terms of Reference draftfor proposals on drafting oftechnical guidance with contractplacement envisaged 01/01. Intentto have both documents publishedin advance of railway safetylegislation and possible need forfurther guidance recognised.


Efforts must continue by word anddeed to convince all staff that safetymatters and that unsafe actions orconditions will not condoned orignored in future.

All personal involved in incidents/accidents are interviewed.Organisation response underlinedin induction training See ID 122regarding unsafe conditions.

CME: Meetings with SafetyRepresentatives are in place withformal minutes and close out ofconcerns. Standard no 7 Includesprovision for staff briefing. The2000 Strategic Plan also includesmeasures to achieve this objective.

Unsafe acts and conditions will behighlighted in Infrastructurenewsletter and safety briefings.Ongoing survey of unsafeconditions is core to the AssetManagement System.

On going task.


Where necessary, special efforts basedon best practice within the companyshould be applied to improve attitudeand morale. (e.g. Dublin area asopposed to rural areas).

Communication of Safety Plan.Communicating the success ofultrasonic test team in IarnródSafety awards. Country wide gangvisits to collate ground levelconcerns regarding safety.

Formalisation of the briefingprogram. Development of userfriendly materials. Relaunch ofInfrastructure informationnewsletter. Brief the positiveimplications of the new dealcovering pay and conditions ofservice for a section of P-Way staff

Good progress in Operations and M&EDepartments.


It must be ensured that sufficient staffare available to implement these safetyprogrammes without a few having towork excessively long hours. The

External resources are at presentassisting in activities that need tobe progressed in the short term. Arecruitment drive has commenced

Continually review. Management of consultants in InfrastructureDepartment has been a problem but revised in-house management arrangements are now inplace.


IRMS



resources implied here include themanagement of external contractors orconsultants, as well as in-house safetyenhancement programmes.

and new structures are underconsideration.Departmental Standards no 8Procurement and Contractors hasbeen issued and will begin to makeand impact on the management ofContractors and Consultants.Contracting and outsourcing isused when appropriate andnecessary.


Consideration needs to be given torationalising, and where appropriatearranging delegation of parts, of theworkload of technical professional staff(e.g. DEs & bridge examinations).

Consultants employed. Continue to employ Consultants towork.

No change as yet to bridge inspection methodsand staffing specifically.


Every effort must be sustained torecruit and retain suitably qualifiedstaff at all levels

In addition to the recruitment driveDepartmental Standard no 7includes measures to achieve theseobjectives.

See Section 4 of the main report.


The formal examination and recordingof competence in safety-criticalactivities needs to be adopted (but it isnoted this issue is within currentindustrial relations difficulties)

Over 50%of infrastructure staffhave accepted proposals whichinclude formal examination andcompetence assessment for SafetyCritical activities.

Project to identify safety criticalroles next three months

See Section 4 of the main report.


A culture of intolerance towardsunauthorised intrusion on the railwayshould be encouraged.

Fencing program & Publicity andAction by Staff.

Continue Fencing Programme,Publicity and Action by Staff.

Much new fencing observed during Jan-Feb2001 visit.


As a particular issue, there is a need toensure that the standards and quality ofthe work of Eircom on the safety-vitalETS equipment are adequate andappropriate.

This is included as one element inthe ETS project

See ID 133. See ID 133.


IRMS




Most importantly, technicaldepartments must themselves scrutinisetheir assets to determine where elsethan the locations identified by IRMScomparable conditions exist.

PAR's Programme See ID 122 &ID 35.

PAR's Programme See ID 122 & ID35.

See ID 122 & 35. PARS system not yet fullyimplemented.


Funds need to be directed to signallingand p-way assets already sub-standardbut still in use because of the delays tomini CTC.

Funds provided in 2000. See ID129.

Funds to be provided in 2001. Funds awaited.


The actual implementation programmeof mini CTC needs to be planned, e.g.by a 'safety case' approach, to minimiserisk before and during change.

See ID 200. Mini CTC postponed.

227 Structures A system to cascade serviceable trackcomponents from relaying sites tolesser lines is needed.

Plan is prepared. Per plan. Underway.

231 Structures Lines of demarcation (e.g. between P-Way and Structures) need to be agreedto avoid misunderstanding leading toomission of action (e.g. at platformedges).

See ID 165. See ID 165.

235 Rolling Stock Customise corporate standards so theyare relevant and practical in thedepartment.

Company Standards 1 to 8 havebeen departmentalised and issued.Complete.

Departmental Standard no 9Document Control is in draft formand will be issued shortly.

Departmental Standard No. 9 ‘DocumentControl’ formally issued.

236 Rolling Stock Systematically analyse the safety issuesraised by the refurbishment of theCraven carriages.

A plan has been developed for thereplacement of Craven carriagesby new Vehicles.

No further comment.

237 Rolling Stock Complete a formal risk assessment ofthe secondary door locking proposal.

Completed. Recommendations to be discussedat Steering Group Level.

Action complete.

238 SafetyManagement

An adequately resourced centralservice is needed to better co-ordinate

Project Manager in place.Departmental structures in place

Ongoing co-ordination anddissemination of best practice.

IRMS believe that the top-level co-ordinationrequires full time attention, and Safety


IRMS



System safety standards and initiatives. and SRG co-ordinate supportinggroup led by Safety Department toimplement.

Department requires more resources tomanage the initiative.


Facilitate the spread of good practice inone department for the guidance ofothers.

Safety Review group support teamunder project Manager.

Ongoing review.


Provide central monitoring andauditing of the progress of the safetymanagement arrangements.

Safety department monitoring anddeveloping audit tool which is95% complete.

Extend implementation.


No doubt IE and the trades unions wishto resolve the present industrialrelations issues for a range of reasons,but within this report it must bereiterated that some safety initiativesare being delayed or stifled by thepresent impasse.

See ID 51.

CME: Industrial Relations is not ablock at present on Safety Issues inMechanical Engineering.

(I) Month of Nov. 200 set aside tomeet with Trade Unions on alloutstanding items. (2) Review ofIndustrial Relations in IarnródÉireann by Labour RelationsCommission to convene Oct. 2000.

CME: Progress with all Safetyrelated Issues.

High level meeting with Trade Unions tookplace but some issues not able to be resolvedat this level. Operations negotiations haveresolved some issues but the use of radios forshunting and the use of the PARS system forInfrastructure supervisors are examples ofoutstanding issues.

E3 Electrification Prove voltage testing devices beforeand after each verification

N/A N/A Implemented and added into procedures.Action complete.

E4 Electrification Log in and out of substations withControl

N/A N/A Implemented. Action complete.

E5 Electrification Prove OLE sections dead beforeearthing

N/A N/A In progress. New testing devices procured, andprocedure introduced. To be added intoprocedures.

E6 Electrification Use ‘Caution Notices’ at locked-offpoints of isolation

N/A N/A Notices procured and in use. Procedureimplemented. Action complete.

E7 Electrification Provide delineation of safe workinglimits at Depot centre walkway forhalf-road isolations

N/A N/A Depot Procedures (Vol 3) have been revised tocater for contractors. Action complete.

E8 Electrification Use multiple padlocking facility on N/A N/A Implemented, and Depot Procedures revised.


IRMS



Depot OLE lock-off boxes Action complete.

E9 Electrification Provide and use ‘open door keyrelease’ interlock key on Depothigh-level access gantry

N/A N/A Agreed unnecessary as E8 implemented.Action complete.

E10 Electrification Add ‘limits of isolation’ graphics toDART signalling mimics

N/A N/A In progress. Awaiting new signalling mimic.


IRMS


Appendix VII

Detailed Risk Assessment Results


IRMS

Report No: 7335.01Issue No: 03Date April 2001 Page AVII.1

It should be noted when reviewing the information in this Appendix that not all lines werereassessed in the 2000 when compared with the 1998 audit and where this is the case thevalues are shown to be the same.

Sub-Section

Route Contribution to TotalAccident Freq

Predicted AccidentFrequency(per year)

Mean Time BetweenAccident(years)

Year 01 00 98 01 00 98 01 00 9829 Connolly -

Mullingar12.68% 10.96% 12.73% 0.85 1.03 1.27 1.2 0.97 0.79

25 Athlone -Claremorris

12.19% 8.28% 7.79% 0.82 0.78 0.78 1.2 1.3 1.3

24 Athenry - Galway 9.48% 3.49% 3.28% 0.64 0.33 0.33 1.6 3.0 3.016 Mallow -Tralee 8.74% 8.81% 8.29% 0.59 0.83 0.83 1.7 1.2 1.29 Heuston -

Cherryville Junction5.17% 7.14% 6.72% 0.35 0.67 0.67 2.9 1.5 1.5

36 Limerick -Waterford

5.04% 3.87% 3.64% 0.34 0.36 0.36 2.9 2.8 2.8

31 Carrick on Shannon– Sligo

4.45% 2.64% 2.48% 0.30 0.25 0.25 3.3 4.0 4.0

30 Mullingar - Carrickon Shannon

4.34% 2.32% 3.81% 0.29 0.22 0.38 3.4 4.5 2.6

8 Kilkenny –Waterford

3.99% 2.96% 2.79% 0.27 0.28 0.28 3.7 3.6 3.6

3 Bray - Arklow 3.98% 3.61% 3.40% 0.27 0.34 0.34 3.7 2.9 2.9

Table AVII.1: Line Subsection – Contribution to Total Railway Train AccidentFrequency

Sub-Section

Route Contribution to TotalCollective Risk

Collective Risk(Equivalent Fatalities

per year)

Mean Time BetweenEquivalent Fatalities

(years)Year 01 00 98 01 00 98 01 00 98

24 Athenry - Galway 13.2% 4.0% 3.7% 0.60 0.29 0.29 1.7 3.4 3.425 Athlone -

Claremorris11.5% 8.2% 7.5% 0.52 0.59 0.59 1.9 1.7 1.7

29 Connolly -Mullingar

8.3% 5.4% 7.1% 0.38 0.38 0.56 2.6 2.6 1.8

9 Heuston -Cherryville Junction

8.3% 10.1% 9.3% 0.38 0.72 0.72 2.6 1.4 1.4

12 Ballybrophy –Limerick Jcn

7.0% 16.8% 15.4% 0.32 1.2 1.2 3.1 0.83 0.83

11 Portarlington –Ballybrophy

6.2% 6.0% 7.3% 0.28 0.43 0.57 3.6 2.3 1.8

13 Limerick Jcn –Mallow

6.2% 8.4% 7.7% 0.28 0.60 0.60 3.6 1.7 1.7

34 Howth Jcn –Drogheda

6.2% 5.6% 7.6% 0.28 0.40 0.59 3.6 2.5 1.7

3 Bray – Arklow 5.3% 3.5% 3.2% 0.24 0.25 0.25 4.2 4.0 4.07 Cherryville Jcn -

Kilkenny4.2% 3.1% 2.8% 0.19 0.22 0.22 5.3 4.5 4.5

Table AVII.2: Line Section –Contribution to Total Railway Collective Risk


IRMS


Sub-Section

Route Yr. P-Way Signal Interlocking Points TrainDetect

01 0.01% 0.33% 0.05% 99.42% 0.09%00 0.64% 0.76% 0.19% 97.99% 0.18%

24 Athenry - Galway

98 0.64% 0.76% 0.19% 97.99% 0.18%01 2.01% 10.59% 2.47% 82.13% 1.47%00 30.94% 9.75% 4.33% 51.55% 1.08%

25 Athlone - Claremorris

98 30.94% 9.75% 4.33% 51.55% 1.08%01 0.16% 33.88% 4.27% 48.85% 9.56%00 1.36% 45.87% 4.40% 28.28% 10.35%

29 Connolly - Mullingar

98 10.77% 38.60% 17.33% 19.46% 7.12%01 0.17% 13.94% 3.37% 48.13% 30.68%00 0.97% 42.39% 17.07% 22.27% 14.20%

9 Heuston - CherryvilleJunction

98 0.97% 42.39% 17.07% 22.27% 14.20%01 0.00% 41.96% 4.04% 30.07% 20.92%00 1.74% 50.06% 12.38% 23.58% 10.20%

12 Ballybrophy –Limerick Jcn

98 1.74% 50.06% 12.38% 23.58% 10.20%01 0.38% 25.12% 1.27% 48.45% 20.90%00 3.85% 35.15% 14.20% 32.05% 11.64%

11 Portarlington –Ballybrophy

98 2.90% 44.06% 10.67% 31.29% 8.75%01 0.55% 26.14% 3.00% 37.12% 31.25%00 2.65% 39.41% 10.07% 35.38% 10.96%

13 Limerick Jcn –Mallow

98 2.65% 39.41% 10.07% 35.38% 10.96%01 0.28% 9.99% 0.51% 35.21% 49.79%00 1.96% 48.70% 1.50% 17.16% 24.27%

34 Howth Jcn – Drogheda

98 1.32% 65.51% 1.01% 11.54% 16.32%01 0.00% 15.95% 4.12% 77.61% 1.47%00 4.03% 13.41% 7.28% 72.00% 1.08%

3 Bray – Arklow

98 4.03% 13.41% 7.28% 72.00% 1.08%01 0.37% 20.18% 5.46% 63.62% 7.79%00 2.69% 21.34% 10.00% 57.01% 4.79%

7 Cherryville Jcn -Kilkenny

98 2.69% 21.34% 10.00% 57.01% 4.79%

Table AVII.3: Equipment Type –Contribution to 10 Sub-sections with HighestCollective Risk


IRMS


Route Sub-Section

Reasons for Changes inRisk

Predicted Train AccidentFrequency (per year)

Passenger CollectiveRisk (EF per year)

Passenger IndividualRisk (EF per year)

01 00 98 01 00 98 01 00 98

Connolly –Mullingar

29 Change from jointed trackto CWR –decrease inpassenger nos. and increasein train service freq

0.85 1.03 1.27 0.38 0.38 0.56 1 in6,000

1 in6,400

1 in4,500

Bray – Arklow 3 Infrastructureimprovements

0.27 0.34 0.34 0.24 0.25 0.25 1 in6,800

1 in6,300

1 in6,300

Athlone –Claremorris

25 Degraded condition ofmechanical points –population decrease andfreq. of train serviceincrease

0.82 0.78 0.78 0.52 0.59 0.59 1 in7,500

1 in8,100

1 in8,100

Cherryville -Kilkenny

7 Infrastructureimprovements

0.23 0.31 0.31 0.19 0.22 0.22 1 in11,100

1 in9,200

1 in9,200

Waterford -Rosslare Europort


0. 09 0.10 0.20 0.02 0.02 0.47 1 in11,600

1 in10,900

1 in5,400

Athenry – Galway 24 Degraded condition ofmechanical points

0.67 0.33 0.33 0.60 0.29 0.29 1 in14,100

1 in27,400

1 in27,400

Limerick Jcn –Waterford


0.34 0.36 0.36 0.16 0.17 0.17 1 in15,500

1 in14,400

1 in14,400

Howth Jcn -Drogheda


0.14 0.48 0.54 0.28 0.40 0.59 1 in24,000

1 in12,200

1 in8,200

Portarlington –Ballybrophy


0.12 0.20 0.23 0.28 0.43 0.57 1 in28,900

1 in17,000

1 in12,700

Mallow – Tralee 16 Infrastructureimprovements

0.59 0.83 0.83 0.18 0.27 0.27 1 in29,500

1 in23,000

1 in23,000

Kilkenny –Waterford


0.27 0.28 0.28 0.09 0.10 0.10 1 in33,900

1 in30,200

1 in30,200

Mullingar –Carrick onShannon

30 Change from jointed trackto CWR – degradedcondition of mechanicalpoints and interlocking

0.29 0.22 0.38 0.14 0.11 0.22 1 in34,000

1 in45,900

1 in23,200

Total 4.98 5.51 5.85 3.21 3.36 4.3 N/A N/A N/A

Table AVII.4: Sub-Sections with Passenger Individual Risks Greater Than 1 in40,000