Recommendation Date
Recipient Name
KiwiRail
Text
There were 2 safety issues identified with the Wellington maintenance depot processes:
- there were no individual task instructions on how each job was to be done
- there was no check sheet associated with each task to record that important steps and checks for the task had been completed.
Instead, the depot relied on the knowledge of the depot staff to complete each task satisfactorily.
These shortcomings in maintenance control could be indicators of other safety issues within the wider maintenance system at the Wellington maintenance depot.
On 13 August 2013 the Commission recommended that the Chief Executive of KiwiRail urgently address this safety issue by ensuring that at the Wellington maintenance depot, and other maintenance depots under KiwiRail control:
- maintenance is undertaken in accordance with good railway engineering practice
- manufacturers’ inspection, repair and maintenance instructions are documented and followed
- safety-critical components are identified and documented
- work instructions are issued for maintaining all equipment
- work on safety-critical components is signed off by someone other than the person responsible for carrying out the maintenance work
- all maintenance work is recorded.
- there were no individual task instructions on how each job was to be done
- there was no check sheet associated with each task to record that important steps and checks for the task had been completed.
Instead, the depot relied on the knowledge of the depot staff to complete each task satisfactorily.
These shortcomings in maintenance control could be indicators of other safety issues within the wider maintenance system at the Wellington maintenance depot.
On 13 August 2013 the Commission recommended that the Chief Executive of KiwiRail urgently address this safety issue by ensuring that at the Wellington maintenance depot, and other maintenance depots under KiwiRail control:
- maintenance is undertaken in accordance with good railway engineering practice
- manufacturers’ inspection, repair and maintenance instructions are documented and followed
- safety-critical components are identified and documented
- work instructions are issued for maintaining all equipment
- work on safety-critical components is signed off by someone other than the person responsible for carrying out the maintenance work
- all maintenance work is recorded.
Reply Text
As a consequence of the derailment and our internal investigation the following actions have already been completed by the Wellington EMU [electric multiple unit] depot management:
1. Manufacturers' inspection, repair and maintenance instructions are documented and followed
Engineers audited the Ganz Mavag manufacturers' documentation on Friday 16 August to establish what information and/or references are required in documentation and work instructions
2. Safety critical components are identified and documented
Staff notice #24 has been issued to detail the safety critical jobs and the information is also in poster form around the depot.
3. Work instructions are issued for maintaining all equipment
Based on the audit of the Ganz manufacturers' documentation, work instructions for the Ganz fleet are being developed starting with the safety critical tasks. There are not currently work instructions for repairs.
4. Work on safety-critical components is signed off by someone other than the maintainer
Safety-critical tasks are now identified and individually checked and signed off by an appropriately qualified staff member who has not completed the job. Requirement for a counter-sign has been added to the work sheets.
5. All maintenance is recorded
SAP is used to record all maintenance and that data was supplied to TAIC [the Transport Accident Investigation Commission] during the investigation.
The TAIC preliminary report has also made a much more general recommendation that Maintenance is undertaken in accordance with good railway engineering practice. This is already the case as much as can be practicably expected within the profile of the railway fleet. It is unclear to us at this stage that it would be practical to, for example create detailed work instructions for locomotives that are in some cases several decades old. In some cases the assets will end their operational life before such a task could be completed. However, we will put in place a review of this and where it is practical to put this in place – we will. Where it is not we will instead put in place the best practical mitigation.
1. Manufacturers' inspection, repair and maintenance instructions are documented and followed
Engineers audited the Ganz Mavag manufacturers' documentation on Friday 16 August to establish what information and/or references are required in documentation and work instructions
2. Safety critical components are identified and documented
Staff notice #24 has been issued to detail the safety critical jobs and the information is also in poster form around the depot.
3. Work instructions are issued for maintaining all equipment
Based on the audit of the Ganz manufacturers' documentation, work instructions for the Ganz fleet are being developed starting with the safety critical tasks. There are not currently work instructions for repairs.
4. Work on safety-critical components is signed off by someone other than the maintainer
Safety-critical tasks are now identified and individually checked and signed off by an appropriately qualified staff member who has not completed the job. Requirement for a counter-sign has been added to the work sheets.
5. All maintenance is recorded
SAP is used to record all maintenance and that data was supplied to TAIC [the Transport Accident Investigation Commission] during the investigation.
The TAIC preliminary report has also made a much more general recommendation that Maintenance is undertaken in accordance with good railway engineering practice. This is already the case as much as can be practicably expected within the profile of the railway fleet. It is unclear to us at this stage that it would be practical to, for example create detailed work instructions for locomotives that are in some cases several decades old. In some cases the assets will end their operational life before such a task could be completed. However, we will put in place a review of this and where it is practical to put this in place – we will. Where it is not we will instead put in place the best practical mitigation.
Related Investigation(s)