Saturday, 25 January 2014

Transport Minister asks SMRT for update on rail incidents in January 2014, conveys concern

Minister 'disappointed' over train disruptions
Lui Tuck Yew wants operator to get back to him on spate of breakdowns
By Royston Sim, The Straits Times, 24 Jan 2014

A RECENT spate of train disruptions has left Transport Minister Lui Tuck Yew disappointed and concerned, and he told SMRT so yesterday.

He asked the rail operator's chiefs to get to the bottom of the breakdowns, check how it dealt with affected commuters, and let him know next week the outcome of their investigations and the actions taken.

"I share the frustrations of train commuters affected by these incidents, and I empathise with them on the anxiety and uncertainty that they may experience," he said yesterday, following the latest breakdown on Wednesday night.

"I am also very concerned about SMRT's service recovery efforts, particularly in reaching out to affected commuters promptly and keeping them updated during these incidents."

There have been several incidents recently. Among them:
- On Wednesday night, an error by a train driver led to an hour-long disruption on the East-West Line.
- On Monday morning, a signal fault caused a train to stall and affected 19,000 North-South Line commuters during the rush hour.
- And on Jan 11, some commuters had to get off their train and walk on the tracks after a section of the track between Kranji and Yew Tee stations lost traction power.
Mr Lui was briefed on ongoing investigations when he met SMRT chief executive Desmond Kuek and senior management yesterday.

He urged them to identify the root causes quickly and determine if the incidents resulted from technical or procedural shortcomings.

In a statement, the Transport Ministry said Mr Kuek assured Mr Lui that SMRT would do its best to step up checks to minimise service disruptions and improve its response to such incidents.

SMRT spokesman Patrick Nathan said last night that the company will focus on reducing its shortcomings to make the system safer and more reliable.

Wednesday's breakdown occurred after a train driver went past a signal point without authorisation at 10.12pm.

Another SMRT spokesman, Ms Alina Boey, said his action caused safety measures to kick in, disrupting service between Tanah Merah and Pasir Ris stations.

Engineers were sent to rectify the fault and free shuttle buses were provided to affected commuters.

The engineers had to be satisfied that everything was in order before service could resume.

Service resumed at 11.19pm. Ms Boey apologised to all the affected passengers.

She said SMRT viewed any breach of operational protocol seriously and the driver - who is experienced - faces disciplinary action.


I share the frustrations of train commuters affected by these incidents, and I empathise with them

on the anxiety and uncertainty that they may experience. I am also very concerned about SMRT's service recovery efforts, particularly in reaching out to affected commuters promptly and keeping them updated during these incidents.

* Train disruptions due to human error and equipment failure
By Royston Sim, The Straits Times, 30 Jan 2014

RAIL operator SMRT yesterday explained the causes of three recent disruptions on its train lines, saying two were due to human error, and the third, equipment failure.

It had been asked by Transport Minister Lui Tuck Yew a week ago to furnish an update on its investigations into the delays on the North-South and East- West lines.

In the most recent incident, on Jan 22, the "oversight and non-compliance" of a train captain caused an hour-long disruption near Tanah Merah. The driver has been taken to task for not following a signal light on the track between the Expo and Tanah Merah stations, said SMRT spokesman Alina Boey.

Because of his action, train service had to be suspended while SMRT engineers checked that the network was working safely.

The Straits Times understands the driver failed to stop and wait for authorisation to drive on, when he got to the junction connecting the Changi extension to the East-West Line to Tanah Merah.

Trains that pass signal points without authorisation could potentially damage the tracks.

When that happened, SMRT locked down the track as part of its standard safety procedure and checked for damage to the area.

In the second incident, a technician failed to close two circuit breakers after a routine nightly service of a train. This caused the train's battery to drain to a level that automatically triggered a safety mechanism to prevent it from moving further.

The train stalled between Yio Chu Kang and Ang Mo Kio stations at 8.11am on Jan 20. SMRT used the train behind to push the stalled train to Ang Mo Kio, where passengers began alighting at 8.54am. Some 19,000 commuters were affected.

Ms Boey said the technician at fault has also been taken to task and pre-launch train checks will be supervised more thoroughly.

The third disruption, on Jan 11, occurred when a damaged cable caused a train to stall between Kranji and Yew Tee stations, so commuters had to get out and walk on the tracks to the station platform.

The cable, worn out by chafing against an installation bracket, cut off the power supply between the two stations.

Ms Boey said the cable has been repaired, and system-wide checks show there are no other points that might be worn out.

SMRT is also putting in place a condition monitoring system, she said.

Meanwhile, a track fault delayed train service on the North- South Line last night. SMRT is investigating why trains that passed a point on the tracks were switched to manual mode.

This restricts them to a speed of 18kmh, which led to longer journeys for commuters travelling between Ang Mo Kio and Marina Bay both ways.

Human error, equipment failure not root causes

SMRT has said that human error and equipment failure caused three recent train disruptions ("Train disruptions due to human error and equipment failure"; last Thursday).

A train driver and a technician have been "taken to task".

The operator also said that pre-launch checks will be supervised more thoroughly and a condition monitoring system will be put in place.

However, human error and equipment failure are not root causes of the train disruptions.

The more fundamental question is whether the systems regulating the train drivers, technicians and equipment are robust enough to prevent human error and equipment failure that can result in service disruptions.

Humans are prone to lapses and errors. When such lapses can result in severe consequences, procedural checks and engineering controls are necessary.

Periodic audits of these controls and processes are also necessary to ensure the reliability of these systems. Were these controls in place prior to the train disruptions?

In terms of the violation of procedures, humans have a tendency to break rules when it is perceived to be justified.

Some possible causes of violation include the lack of understanding of the rationale for the procedures, the lack of management and supervisor emphasis on compliance, fatigue, production pressure, peer pressure and group norm, and unrealistic procedures that do not match reality.

Were these factors considered during the investigation of the train disruptions?

To effectively prevent future disruptions, it is important to understand the work conditions that provoke human error and violations. These are the root causes that must be eradicated.

Goh Yang Miang
ST Forum, 3 Feb 2014

How SMRT mitigates risks of human error, equipment failure

SMRT thanks Mr Goh Yang Miang for his letter ("Train disruptions: Human error, equipment failure not root causes"; Monday).

We agree that a systematic approach to address track and train faults is needed to ensure the safety and reliability of the MRT system.

We do have a system of procedural checks, engineering controls and periodic audits in place, but we acknowledge that improvements can be made.

Each investigation we conduct looks into the root causes, a number of which have been carefully listed in Mr Goh's letter.

We assure him that beyond these investigations, we make it a priority to ensure that our systems and processes are robust enough to mitigate the risks of human error and equipment failure.

To mitigate the risk of human error in operations and maintenance, we intend to reinforce human factor training for all our staff.

We will also enhance staff engagement to bring about an open reporting culture among our workforce, and to better understand why errors are committed by staff.

To mitigate the risk of equipment failure, we have started moving our maintenance regime beyond corrective and preventive maintenance to include predictive maintenance.

We have implemented monitoring and tracking systems and processes to help identify potential technical issues before they cause service disruptions.

A traditional preventive maintenance regime relies on fixed inspection intervals to detect impending material failures.

With new sensor technology implemented on service trains, we can now collect data on

track conditions and predict required maintenance interventions in a timelier manner.

We have installed some sensors on our tracks and trains to enable early detection of track and train faults. There has been some early success.

To guide us in our journey towards excellence in rail engineering, we will adopt the ISO 55001 standard to benchmark our technical competencies, engineering systems and processes in managing rail infrastructure and assets.

We have also recently formed a technical advisory panel, comprising local and international experts, to help us raise our operational performance standards.

Regardless of whether it is human error or equipment failure, the management in SMRT Trains accepts responsibility for incidents of service disruptions, and we are committed to delivering safe and reliable train services to all our commuters.

We appreciate the patience and understanding of our commuters while we work hard to nurse our rail network back to good health.

Lee Ling Wee
Executive Vice-President,
SMRT Trains
ST Forum, 6 Feb 2014

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