Getting on track: Secretary for Environment, Transport & Works Dr Sarah Liao says KCRC management should speed up the development of an integrated asset-management system.

Secretary for Environment, Transport & Works Dr Sarah Liao says the Kowloon-Canton Railway Corporation should improve its inspections and overhaul procedures, and staff training, to enhance crack-detection effectiveness.

It should also develop an integrated asset-management system, she stressed.

Announcing the Government's assessment of the East Rail's underframe equipment-mounting problem today, Dr Liao said the scope of the KCRC's investigation was comprehensive and it had taken a scientific approach in identifying the root causes of the incident.

The Government accepts the KCRC's explanation that excessive vertical vibration trains experienced was one of the dominant causes. It led to the material fatigue that caused cracks to appear in the underframe equipment.

"This excessive vertical vibration was caused by a combination of three factors, namely, the undulation pattern on the rail top of a particular batch of rails with a longitudinal pitch of 3.1m and a vertical profile of less than 1 mm, the train speed of 70-90 kph,  and the natural frequency of 7-9 Hz of the car body," Dr Liao said.

"The inferior quality of welding at the equipment brackets, for example, poor welding fusion, could be another dominant cause of the fleet-wide problem."

Maintenance regime examined

While KCRC's day-to-day maintenance practices are consistent with those railways practise internationally, the Government's expert team also examined its maintenance regime to find out why maintenance activities missed the cracks on the compressor, and those that appeared fleet-wide. 

The team concluded the hairline cracks were unlikely to have been identified within the limits of visual inspection and prevailing conditions for maintenance inspection and underframe overhaul.

"However, during overhaul of the equipment, when the equipment is removed from the train, the paint is removed and inspection takes place in the workshop under good lighting, it is reasonable to expect that workshop staff should notice if large cracks are present although the equipment overhaul procedure does not specifically point the staff to inspect for cracks.

"We consider that the corporation should improve its procedures for inspections and overhauls, and staff training to enhance the effectiveness of cracks detection."

Dr Liao said KCRC management should also develop a formal and integrated asset-management system. This will enable KCRC to more effectively detect and prevent recurrence of major fleet-wide problems which require immediate and massive efforts from all parties, she added.

Government's recommendations

Dr Liao said the Government made 18 recommendations to the KCRC for improvement as it attached great importance to railway safety and reliability. They include:

* enhancing crack identification and management during maintenance;

* ongoing monitoring of the trains' and tracks' conditions; and

* expediting the development of a formal and fully integrated asset-management system.

The Railway Inspectorate will monitor the KCRC's implementation of the required improvement measures and require the corporation to regularly report the work progress, Dr Liao added.

Separately, Government-appointed Review Panel on the Reporting of East Rail Incidents submitted its report to Dr Liao this morning.

The panel said there was a matrix of relevant inter-related factors set against a rather special set of circumstances surrounding the East Rail incidents which led to the inadequacy of communication from the KCRC to the Government.

The panel considered those who had responsibility, including the Acting Chief Executive Officer, Senior Director - Transport, Safety & Quality Manager (SQM) and Safety & Quality Manager (Acting), during the time under review should learn a lesson, although it did not hold any one staff member responsible.

More communication needed

It said the corporation should have been more sensitive and alert to the need for more communication throughout the process. It should have communicated more even if they considered the incident to be an issue of perceived public safety and not of real public safety.

The panel also pointed out that if the Railway Inspectorate had been alerted promptly, they could have carried out their duty at the earliest opportunity and have promptly assessed the issue of public safety regarding the continued operation of the affected trains.

It said the corporation's best safety assurances with respect to their own railway operation are not acceptable to the public unless and until they are separately assessed by an independent monitor, in this case the Railway Inspectorate.

If the corporation does not share the relevant information, the Government cannot be in a position to discharge its role.

Inspectorate could be more proactive

If the Railway Inspectorate were be more proactive, the two-way communication between the corporation and the Government would be different.

The panel pointed out that there were four arrangements that limited the communication flow:

* the existing code of practice agreed between the Government and the corporation for the conduct of investigation of incidents;

* the line of reporting of the SQM within the corporation;

* the interface between the corporation and the Railway Inspectorate; and 

* and the corporation's culture.

Noting there is a need to improve the existing code of practice agreed between the Government and the corporation for the conduct of investigations of incidents, the panel said the corporation's Safety & Quality Division's role and responsibilities could be improved and given more independence from the operation division.

Follow-up actions

Appreciating the panel's work, Dr Liao said the Government places great importance on railway-incident notification as transparency is needed for the public to monitor whether the measures adopted are appropriate.

"We are glad the Review Panel has identified areas for improvement to the notification procedures and processes. The Government will follow up the panel's recommendations," Dr Liao said.

The Government agreed that SQM should be given more independence so that he/she could provide an independent source of opinion to advise the Chief Executive Officer in judging matters of safety and quality.

She said the Railway Inspectorate will enhance its contact with the corporation when following up railway incidents, adding both parties will keep records of the information exchanged.

The secretary reiterated the Government is committed to improving the incident notification system because there will be more new railways in future.

When asked whether any KCRC staff will be disciplined, Dr Liao said it was up to the corporation to decide.