A Report Prepared by International Risk Management ... · PDF fileA Report Prepared by International Risk Management Services On Behalf of The Department of Public Enterprise IRMS

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

IRMSIRMSIRMSIRMS

International Risk

M anagem ent Services

International Risk Management Services (UK) LtdSuite 8.01, 8 Exchange QuayManchester M5 3EJUKTel: +(44) 161 958 8803 Report No: 0948PWYFax: +(44) 161 958 8888 Issue No: 01E-mail: [email protected] Date: March 2001

A Review of Railway Safety in

Ireland - Second Implementation

Review

Permanent Way Technical Report

In Association with:

MHA Systems Limited

MHAMHAMHAMHA

Holmes Davies

Holmes Davies Partnership

PB Power Ltd.

A Review of Railway Safety in Ireland - Second Implementation Review of Permanent Way IRMS

Report No: 0948PWYIssue No: 01Date: March 2001 Page 1

Document History

Issue Author Date Reason for issue and comments

0A D Holmes 01/03/01 Initial Draft

0B D Holmes 04/05/01 Technical Reports collated to provide information toIE Auditees

01 D Holmes 10/05/01 Formal Issue



Distribution Control Sheet

Version Date Compiled By Checked By Authorised By

01 10/05/01 D Holmes G Topham A Pickett

File Name: Print date:

Distribution List

Name From To Comments

IRMS

1 copy each to:

AJ Smith 01 C

P Cheeseman 01 C

ADF Pickett 01 C

The Department of Public Enterprise

E Burke 01 C

C = Current Version ()



CONTENTS

1. INTRODUCTION 3

1.1 General 3

1.2 Objectives and Scope 4

2. INFRASTRUCTURE METHODOLOGY 5

3. AUDIT RESULTS 6

3.1 Head Office Audit 6

3.2 Site Visits 13

3.3 Infrastructure Adequacy Score Sheets 23

3.4 Case Study 23

3.5 Miscellaneous 23

4. CONCLUSIONS 25

4.1 Way Forward 25

5. RECOMMENDATIONS 26

6. REFERENCES 27

APPENDIX I TECHNICAL REVIEW SUMMARY

APPENDIX II INFRASTRUCTURE ADEQUACY SCORE SHEETS

1. INTRODUCTION

1.1 General

As commissioned by the Department of Public Enterprise (DPE), a railway safetystudy of Iarnrod Eireann (IE) was carried out by IRMS and its partner consultantsduring 1998 with the objective of carrying out a strategic review of all aspects ofsafety of the IE railway system. Within the scope of this study a number of genericareas were reviewed. This document describes issues relating to the Permanent Way



and aims to provide guidance and objective review of work performed by IarnrodEireann

The review of the Permanent Way was led by auditors from Holmes Davies (HD),with the findings of the original audit documented in the formal IRMS Report[1] andsubsequently presented to DPE.

A key recommendation from the final report was that the external audits of the ActionPlan are carried out, after 6 months and 18 months. In accordance with thisrecommendation the ‘6 month’ audit of the Permanent Way was conducted by HD inNovember 1999. The findings of this audit were presented to the DPE undercover ofan IRMS Implementation Review Report[2].

The ‘18 month’ audit of the Permanent Way was conducted by HD during Januaryand February 2001, and the findings of this audit were presented to the DPEundercover of an IRMS Second Implementation Review Report[3]

This is one of a suite of documents describing the technical detail of the SecondImplementation Review of Iarnrod Eirean.

1.2 Objectives and Scope

The purpose of the audit was primarily to the check and monitor progress made by IE,and in particular the Permanent Way Department against the recommendations for thePermanent Way, detailed in the IRMS Report[2].

The objective was to produce an informed opinion of the safety adequacy of IEinfrastructure and systems for the permanent way department allowing directcomparison with the 1998 and 1999 studies.



2. INFRASTRUCTURE METHODOLOGY

The study comprised a number of office audits and site inspections completed over athree month period from December 2000 to February 2001.

The site inspections were all undertaken accompanied by IE representatives and thelocations were a mixture of unreasonable risks sites identified in 1998 and 1999, otherrisk sites identified in 1998 and 1999 and a sample of new sites selected by IE andIRMS. Defects were discussed on site with IE representatives and any itemsconsidered to be high risk had remedial or mitigating measures discussed on site. Anumber of photographs were taken as back up evidence to the inspection reports. Theinspection reports were provided to IE in draft form to ensure that they were factuallycorrect.

The office audits comprised the gathering of information and evidence from aprotocol that had been given to the auditees in advance to allow adequate preparation.The audit reports were provided to IE in draft form to ensure that they were factuallycorrect. Scoring for the audits was on a system consistent with that used in both 1998and 1999.



3. AUDIT RESULTS

3.1 Head Office Audit

An audit of Infrastructure head office at North Wall was conducted as previously.There was very little change with the notable exception of ultrasonic operator trainingwhere evidence was presented of competence for all the operators.

3.1.1 Audit Questionnaire

An audit of the Divisional Engineer’s office at Limerick Junction demonstrated thatthere was also little change to report from the 1999 and 1998 centred on theDivisional Engineer’s offices at Dublin and Athlone.

The areas of improvement and worsenment noted at Limerick Junction were mainly asa 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 for the track inspection process. Local goodpractice was identified in the fields of gauging, track renewal and CWR maintenance.Full information on scoring and risk assessment is contained in the Technical Auditquestionnaire sheets.

3.1.2 Budget and resources

The overall level of staffing under the DEs for track maintenance has been enhancedand is proving to be adequate. However, the resources are still not used to best effect.The heavy requirements for the provision of lookoutmen, which is outwith the controlof the PWI and often at short notice, continue to be problematic in the effectiveallocation of manpower. The inspection regime is also wasteful of resource inparticular where track has been totally renewed. A reduction to one high qualityinspection per week is considered appropriate with the patrol ganger resourceavailable 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.

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.

3.1.3 Long term planning and monitoring

There is in place a structured 5-year plan for track renewal and the Chief Engineer hasunderwritten this.

3.1.4 Risk assessment and prioritisation of work

The new PARS system, based on a 5X5 matrix, for a simple analysis of the risks andprioritisation of work is being well received. It is unfortunate that industrial relationsissues are delaying this very important safety advance. The initial work that has beendone indicates that PARS will be an effective tool for staff at all levels.



The basic foundation for effective maintenance of permanent way 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 the rulebook and this is only a very brief resume.

3.1.5 Infrastructure and rolling stock improvements

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 be available to effect replacement of ultrasonic defects and badlydrilled rail ends by cascade from relaying sites. There was much evidence that thiswas now being achieved and it is important to continue in order to eliminate the defectbacklog.

The site inspections identified very few examples of defects that would beunacceptable in the rest of Europe and this is a positive improvement. Station yardareas remain the locations with most problems and this has been recognised andresource diverted to reach resolution. The lack of adequate and understood standardsavailable to staff on the ground still makes objective judgements difficult.

The fleet of plant available for permanent way operations is still not adequate in twokey respects:

1. A fleet of modern ballast hoppers allowing staff to place stone where it is neededand obviate the need to plough

2. Materials handling equipment to allow the removal of scrap and serviceablematerial from the lineside for sale or reuse

As reported in 1999 the problems arising from this inadequacy have increased withthe new level of track renewal.

3.1.6 Engineering systems, standards and documentation

3.1.6.1 System Design

The standard system has been designed on a simple hierarchy having six levels:

Company Standards. The “ten commandments” of the IE Safety Management System.The Managing Director ids the owner

Railway Standards. Those that apply across more than one department (for exampleOperations and Infrastructure). Examples are the Rule Book, General Appendix etc. Itis possible for a cross functional standard applicable to infrastructure to be written byanother department but subject to infrastructure review before authorisation.

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 to datebut 4 Infrastructure and 15 PW are in draft. Standards at this level are also beingdrafted for signalling, telecomms and structures. These documents specify departmentspecific requirements that are mandatory on all staff. They contain little technicalinformation.



Procedure documents that are unique to the Infrastructure or any other Departmentand are normally specific to one Discipline. The target audience for these is managersand inspectors. None have been issued to date but 12 Infrastructure and 55 PW are indraft. These documents specify Discipline specific procedures that are mandatory onall staff. They contain comprehensive technical information appropriate for the targetaudience.

Work Instructions that are unique to a Discipline. The target audience for these in PWis inspectors, gangers and PW operatives. None have been issued to date but 37 PWare in draft. These documents specify Discipline specific procedures that aremandatory on all staff. They contain comprehensive technical information appropriatefor the target audience.

Task Instructions that are unique to a Discipline. The target audience for these in PWis inspectors, gangers and PW operatives. None have been issued to date but 65 PWare in draft. These documents specify discipline specific methods of working that aremandatory on all staff. They contain little technical information.

Level 1and 2 documents are written and approved by IE centrally.

Level 3, 4, 5 and 6 documents are developed and issued under the control of theinfrastructure review group.

Level 6 documents are written by specified groups of Divisional staff for review byother Divisions and subsequent adoption by all. These are all in draft form and DEsare reviewing them for final implementation.

3.1.6.2 Progress to date

The main body of standards is being written by WS Atkins and many of the concernsexpressed previously have been addressed. The suite has been prioritised into tenbatches with the most safety critical standards being implemented first. WS Atkinshave usefully rationalised levels 2, 3 and 4 detailed above into Principles, Systemlevel 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 Atkins are revising the documentsaccordingly. It is seen as vital to the credibility of the whole system to ensure that firststandards are of a high quality being readable, relevant, achievable and having IEownership. As a result the issue of the first batch may be delayed from programmeand the current anticipated implementation is in early summer 2001.

PW standards are in production to update and replace MW instructions. Progress todate on these has been mainly confined to gauging, track recording and ultrasonics.Some PW standards were issued late in 2000 bearing the word “draft” in the header. Itis understood that subsequently the status has been confirmed to be formal issue 1.The method of distribution was not fully controlled as per company standard number9 because as yet there is no infrastructure document controller in place. It is alsounderstood that some PW standards may be superseded by infrastructure standardover time.

Ray Bland (Gibb) has briefed some of the new draft standards to gangers and it isunderstood that feedback has been obtained from these potential users.



3.1.6.3 Commentary

There has been considerable progress on drafting standards since the last audit visit inlate 1999. Certain of the issues identified at that time have been resolved, for examplethe need for each document to have an owner. However, the system is as yet immatureand just 12 PW standards have been issued to date.

At present the draft standards contain too much information but this is not a badfeature, editing out can be at 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 Britain the working environment is very different witha fragmented industry related by contract and controlled by government regulation andinspection. In Ireland the railway industry is vertically integrated and the risks to beaddressed are different. There is a 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 PW standards will at some stage besuperseded but much of the content is information and not mandatory. Any newgauging standard, containing only mandatory aspects, will only replace a portion ofthe PW documents and this will be very difficult to manage.

Consideration should be given to the retention of a compendium of useful informationand data, perhaps based on the MW sheets. It could still exist in a controlled form andbe referred to by individual standards. This would be a document usable by all levelsin 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.

3.1.6.4 PW Work (Task) 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. As they currently stand they do not fully satisfy requirements ineither respect. However with the strong willingness and acceptance at ground level forthem it is accepted that they should be implemented in their current form andexperience is gained in their use. From this experience the documents can be updatedand amended as part of a cycle of continuous improvement.



The Strategic Technical Review of permanent way activity demonstrates whether thegeneric systems for permanent way maintenance are present and adequate. With fewexceptions those that exist are still lacking in formality and widespread knowledgeamong those who need to know remains poor.

There is still no system for the issue and control of documents, instructions,procedures etc. related to the permanent way. Staff work to a variety of documentsand letters from the Chief Engineer but they have no means of knowing if they are upto date. Since 1998 these have increased in number and there is widespread confusionabout the status of many. The new PW standards are helping to consolidate theposition and the situation should improve as new infrastructure departmentalstandards start to be implemented in summer 2001.

As in 1998 and 1999 at several locations the track gauge was checked at toes ofswitches. This is a critical area if the signalling equipment is to function correctly.Many were found to be wide to gauge by up to 15 mm, which would be totallyunacceptable on other high quality railway administrations. Signalling detection washowever more reliably 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 fangs and poor designs of soleplate. It isrecommended that this problem continue be the subject of a cross functional workinggroup.

3.1.7 Safety culture and occupational safety

Safety briefings are held but only at a yearly frequency where the annual safety plan ispresented and explained. The briefing is by the Divisional Engineer in person to all hisstaff. It would appear that the current heavy workload, a lack of training and potentialindustrial relations problems prevents safety briefings being held any more frequently.

The use of method statements to assist in the management of safety is a positiveadvance. As yet these appear to be confined to the larger sites where externalcontractors are involved. The issue and implementation of task instructions will helpwith normal day to day activities.

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 experienced engineers, competent in their sphereof activity remain in the Iarnrod Eireann industry. It was pleasing to note that theactual conditions on the ground in many locations had improved significantly and fewremain unacceptable. It was also pleasing that there was immediate recognition andacceptance of unacceptable conditions when discovered.

The one item of concern surrounded the unacceptably short piece of rail, onlyapproximately 800mm from weld to joint, recently installed at Rosslare Strand. Therules for minimum rail lengths (4500mm) appear to be well known at all levels in theorganisation and yet some staff appear to have been willing to put in the trackknowingly a grossly deficient section. It is understood that the defect has beenrectified and that staff briefings have been undertaken but this remains an indicationthat the safety culture still has some distance to go before it is ingrained.



Staff continue to work in hazardous conditions on the trackside with relativelyprimitive protection arrangements. The fact that staff numbers have increased and thata higher proportion are relatively inexperienced must have increased the risk.

3.1.8 Accident and equipment performance information systems

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.

3.1.9 Human resources and training

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 hors 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 helped with whatmay be an embarrassing personal problem. In an organisation that requires its staff toread and understand complex rules and procedures and also to compose and writeconcise and accurate reports as a safety critical activity this remains a issue to beresolved.

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 he is unsuited,having normally come from a track worker background. Such staff were taken on aslabourers and have been promoted through the ranks to inspector level. It should be nosurprise that many are not equipped for clerical work. Despite the introduction of newstaff at DE level he devotes a considerable amount of his time to renewal activity forwhich he is not adequately resourced.

Training of the PWIs’ 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 due to industrial relations problems. There isno evidence that a training needs analysis has been 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 the standards to work to the track may be allowed to deteriorate.This could lead to a steady slow erosion of safety until it again reaches anunacceptable level.



3.1.10 Management of contractors and third parties

There remains no dedicated resource at DE level for dealing with outside 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.

3.1.11 Control of the Introduction of New Works, Plant and Equipment and/or Safety CaseRegulations

See comments on the case study in 5.7.

3.1.12 Organisation (including: job descriptions, safety responsibility statements,competency, etc.)

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 eachADE 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 is still under consideration.Unfortunately no Divisional level organisation charts were available to allow a fullunderstanding of the proposals. Nonetheless the organisation is working in practice.The proposals do not put Chief Permanent Way Inspector (CPWI) in the line withresponsibility for PWIs and it is not clear who responds to him and how he reports.

No progress has yet been achieved with the proposal to install additional resource withthe 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 is in the long term prejudicial togood performance and safety.

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.

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



3.2 Site Visits

Cork Yard (Passenger)

The overall impression was good. The main line S&C inspected was relatively new,that is 10 years or less, and had been installed to a good standard. Top and line wereacceptable for the speed of trains. In the sidings and locomotive depot older materialhad been the subject of considerable maintenance attention. Many components hadbeen renewed, in particular timbers and a good proportion had been reballasted.

Through the main platforms CWR had been installed in 2000. This was checked dueto the sharp radius, confirmed as approximately 180m by telephone. CWR at thisradius is unusual and normally undesirable because of the risk of buckling in hotweather and pulling inwards in cold. However, because the station has an overall roofand the track is restrained within platform faces the risk is considered to be controlled.Particular attention had been paid to track to platform dimensions and these had beenrecorded for future maintenance and monitoring.

There were no noteworthy areas of risk identified.

Cork to Cobh (Passenger)

The great majority of the route was laid with 87lb bullhead jointed track supported onsoftwood sleepers. A number of bolts were missing and it was claimed thatreplacement was difficult due to the need to undertake rail adjusting at the same time.Generally the deficient joints still retained three bolts out of four.

2001 risk factor 3X6=18

Throughout a considerable amount of maintenance had been very recently undertakenwith evidence of tamping and rail end straightening very visible. The results of thiswork were generally of a good standard but at many locations the track had been leftwith an inadequate ballast profile and this will require rectification before the onset ofhot weather. The risk rating is only applicable if the ballast levels are not made upbefore the onset of hot weather.


Between Myrtlehill level crossing and Cork there was a sharp reverse curve andadjacent to the up track was a drop to the street below. Over a length of approximately80 metres there was a drop of some 3m onto paved surfaces. The drop was directlyadjacent to the track, varying from approximately 0.5 to 2m from sleeper end. A wallto retain the ballast was in place and the top was approximately 100mm above thelevel of the cess, an ideal tripping hazard.


Between approximately 167½ and 168 miles on the down line the rails are worn sothin that flanges are striking the fishplates in places. It was reported that this strip wasdue for renewal in CWR in the current year. Although fishplate striking is a beyondtolerance condition the low speeds (50mph), the fact that the problem is only justbeginning and forthcoming renewal mean that the risk is considered to be tolerable.

Between Fota and Carrigaloe there was a considerable amount of lineside scrap albeitin long lengths not susceptible to vandalism. This was considered noteworthy becauseno scrap producing activity was reported to have taken place for many years. This is



indicative of the lack of capability for scrap recovery identified at previousinspections.

On the Cobh branch line itself the quality of cant and alignment was poor in somelocations. However, the low permissible speed means that this is not considered to bea risk. The quality of joint maintenance was also below that seen between Cork andGlounthaune but was again considered adequate for current speeds.

At Cobh station it was noted that there were two category two ultrasonic rail defects inthe track, one a single squat the other two squats. It was discovered that they had beenidentified some 7 weeks previously and the instructions state that such defects shouldbe removed in 6 weeks or controls put in place. It was confirmed that the risk wasbeing managed by additional controls coupled with a 25mph PSR. The defects wereboth in “crank” rails, being transitions from bullhead to flat bottom sections.Replacement rails had been fabricated and were newly delivered to site and awaitedinstallation shortly. The defects were correlated with the DE defective rail database atLimerick Junction at the subsequent audit visit.

It was noted that a crossover at the Glounthaune end of Cobh station was of bullheadconstruction with two check rails secured only by keys. Each check had a singlePanlock and three conventional keys but because no facing moves are made bypassenger trains and the speed is 25mph the risk is considered tolerable.

At Harpers Island a long timber bridge was inspected. The track is sharply curved andwith a high installed cant. This was measured across the up line and varied from105mm to 130mm, gauge was also variable up to 20mm wide. There is obviousdifficulty in maintaining the cross level at the transition from long timber toconventional cross sleeper track and this was worst at the Cork end where a twist ofapproximately 1 in 200 over 5m was measured. It was reported that this structure wasdue for complete renewal in the current year. The risks are currently being managedby the imposition of a 25mph TSR.


At Glounthaune the up line has a poor joint in the middle of the platform. The six footjoint is low and dipped with a sharp alignment fault on the approach side. All bolts aretight and in place in the joint. The low speed of trains, a 50mph PSR applies, isconsidered to control the risk to a tolerable level.

Mallow Station (Passenger)

Several category three ultrasonic defects were observed in the running lines. Althoughnot critical for removal the opportunity was taken to record their presence and this wascorrelated with the DE defective rail database at Limerick Junction at the subsequentaudit visit.

At the Cork end of the station there is a crossover installed toe to toe with a lead intothe container sidings and loop platform face (568 and 567A points). All are fullystrengthened and welded into the adjacent main line CWR. Between the toes on thesix foot rail there is an insulated joint that was in poor condition. The joint had pulledapart and on the running off leg only one bolt was insitu but of the wrong thindiameter and of a normal tensile strength instead of the required high tensile.Rectification will be very difficult because of the proximity of the S&C. Currently thejoint is protected by a 25mph TSR imposed for footbridge construction but when this



is removed the joint will deteriorate rapidly. However, even if the joint fails it isunlikely to pull apart because of the proximity of fixed S&C. The risk factor has beencalculated on the basis of the current restricted speed. Should the joint remain in thiscondition at full line speed then the risk factor would increase to 32.


Limerick Junction Station (Passenger)

At the Dublin end of the station is a flat crossing intersection of the Dublin to Corkline with the Limerick to Waterford line. The crossings are short angle diamondscomprising full depth manganese steel castings of Edgar Allen manufacture. Speed islimited to 25mph in all directions. One crossing was noted to have a crack thatemanated from the foot at a change in casting section. The crack was approximately100mm in length and was the subject of daily visual inspection. Manganese steel isnot susceptible to brittle fracture and quite long cracks can be tolerated with low ratesof propagation. It is considered that the low speed and daily examination reduce thehazards from this cracked crossing to a tolerable level.

Limerick station (Passenger)

In the track to platform three there is a facing bullhead lead which has check rails notsecured other than by keys. All keys were conventional wood design. Speed is low butthe likelihood of a derailment due to a displaced check is high.


Waterford to Rosslare Strand (Passenger)

Waterford station has a sharply curved platform at the Limerick end. Track is bullheadrails on softwood timber sleepers and there has been considerable refurbishmentactivity in the recent past. The site has been resleepered and reballasted and the checkrail has also been renewed. The work has been completed to a good standard and norisks were identified.

There is a road overbridge also at the Limerick end where the ballast conditions arepoor with heavy clay contamination, probably as a result of road construction activity.This is leading to difficulty in maintaining a satisfactory top and some remedial workwill be required in the coming years to maintain safety. The S&C is 92lb flat bottomon softwood and is nearing the end of its economic life before major refurbishment orrenewal becomes necessary. There was some evidence of gauge push of the order of10 – 15mm. At present no significant risk exists with the current 25mph permanentspeed restriction but it is recommended that a regular review be made of the rate ofdeterioration.

Between Waterford and Barrow Bridge several strips with inadequate ballast profileswere noted. It would appear that these may be of long standing however, it isrecommended that the profiles are made up before the onset of hot weather.


Barrow Bridge is a multi span lattice girder structure with one swinging span. Track is85lb flat bottom rail supported on softwood timber sleepers that sit in transversetroughs supported on longitudinal girders. Some of these rails are approachingminimum acceptable depth with wheel flanges striking fishplates in a few isolatedlocations. The site is the subject of ongoing remedial and maintenance work. To



facilitate bridge work the rails have been cut into lengths supported by 9 sleepers andtwo bolts inserted in four hole fishplates for ease of removal. The permanent speedrestriction is believed to be 25mph. Upon completion of the bridge work the rails arebeing replaced by longer lengths of good quality 92lb flat bottom and the end result issatisfactory. It was noted that the gap between the rails on the fixed and moving spanswas of the order of 30 to 35mm on a day with temperatures at around freezing point. Itis understood that in summer this gap can close up to almost nothing. For this reasonalone the current speed is considered correct. Derailment confinement is provided byexternal guard rails of inverted channel section. No significant risks were identified.

A subsequent road visit was made to Barrow Bridge on a Sunday when underprotection of a T3 possession published in the weekly circular. It was noted that sitesecurity was poor. The entrance gates were wide open with no staff present and accessto the track by unauthorised persons would have been a simple matter. It was alsonoted that a van had been parked and left unattended foul of the line. Although thiswas within the possession it is not considered to be good practice.


On from Barrow Bridge to Rosslare Strand the overwhelming majority of trackcomprises bullhead rails supported on softwood sleepers. The line was constructed inthe early 1900s and the rails are mostly original. Despite their age they have beenmaintained to a high standard. Joints were uniformly good and there was muchevidence of appropriate maintenance work such as joint shimming, lubrication andpacking. There were few defective sleepers noted and much evidence of effectiveplanned patching. The off track features were also good with well trimmed hedges andbanks affording excellent sighting for both train crew and track staff. Fencing wasnoted to be good and it was reported that the line was constructed with cess drains thathave been maintained in good working order. Overall there was an impression of aline being maintained to a very high standard indeed. Between Carrowanree levelcrossing and Rathumney level crossing a strip was inspected on a curve ofapproximately 500m radius. The high rail had been recently turned for sidewear aftersome 64 years of traffic. Defective sleepers had been renewed and fishplates replacedwith the deep skirted type. The end result was a very good piece of bullhead track;gauge varied from correct to +8 but was mainly better than +4; the joints were wellpacked and presented a very good vertical running surface.

At Wellington Bridge station a bullhead lead was inspected at the Rosslare extremity.The rail section was a mixture of 87 and 95lb in generally good condition. Timberswere softwood. The check rails were only secured by conventional steel keys andfacing moves at line speed (50mph) were possible. The concern about such check railretention have been highlighted previously and this example with conventional steelkeys, noted for a tendency to become dislodged in cold weather, should be addressedas soon as practicable.


Rosslare Strand (Passenger)

The lead from the Waterford line was examined. It comprises bullhead rails onsoftwood timbers. Gauge is 1603 at the toes and remains close to design along theturnout leg, the widest recording being +8 at a location of slight sidewear. Theflangeways at the switch heels are undesirably tight, approximately 23mm (left hand



half set) and 22mm (right hand half set). At this dimension the backs of wheelsets runalong the switches and force the gap out but there is no real risk of derailment.Signalling equipment will however be the subject of unnecessary vibration and it isrecommended that this be addressed. The check rails are secured only by keys butthese were all of the Panlock design and therefore almost impossible to dislodgeaccidentally. It is considered that this mitigation managed the risk to a tolerable levelat the low permanent speed of 25mph.

At the harbour end there is another bullhead lead. This is adjacent to a newly installedCWR strip and the opportunity has been taken to undertake mid life refurbishment.The timbers have been renewed, the ballast has been replaced and all the jointswelded. The result is a very good and well packed lead that should last for aconsiderable time to come with current traffic levels. There were however twoundesirable features. The crossing vee legs had been welded to the adjacent plain linebut the next joints were only 2m away and the rail between weld and joint wassupported by only 3 sleepers. This is contrary to IE standards but would be acceptableon other European administrations. This feature is not therefore considered to be anintolerable risk. Adjacent to the switch toes there were four timbers with asignificantly deficient ballast profile and this should be rectified before the onset ofhot weather.


At the Wexford end there was another bullhead lead and adjacent to this a rail hadrecently been replaced due to it being defective. A new piece had been site welded inbut at one end the weld was in the next bed from a fishplated joint, barely 800mmaway. This is in complete contravention of IE standards and would not be acceptableon other administrations. It is surprising that the team of track welders were willing toinstall a weld in such a vulnerable location. The main mitigation is the low speed of25mph but nonetheless such a breach of both good practice and IE standards makesthis an unreasonable risk. The defect was immediately acknowledged by theDivisional Engineer to be outwith IE standards and assurance was obtained that itwould be rectified to a very short timescale.


Subsequent to the inspections this defect was confirmed as removed in week ending18th February and the DE provided copies of correspondence to relevant staff toreiterate the IE standard and the means by which derogation could be sought.

Rosslare Strand to Enniscorthy (Passenger)

In the first half mile out of Rosslare Strand towards Felthouse Junction there was astrip that had been very recently renewed in CWR. There were a number of shortpieces of rail and other scrap awaiting removal, ideal ammunition for vandals. Thelocation is relatively remote and well away from a centre of population and so thevandal risk might be considered low. However, there was a road rail excavator stabledon site during the track renewal that had been vandalised and destroyed by fire. It isrecommended that the scrap be removed as soon as practicable.


A subsequent visit was made to Wexford on a Sunday when the track was not underthe protection of a published T3 possession. It is recognised that public access to the



track is a fact of life but some further undesirable features were noted. Vandals hadplaced ballast on the rail head. Although very unlikely to cause a derailment the lackof success may tempt them to use heavier items in an attempt to cause damage. Thearea was noted to be very tidy and totally free of railway derived scrap and this iscommendable. Public car parking is permitted directly adjacent to the running line andsome vehicles were noted close to structure gauge. The 5mph PSR is a suitablecontrol to prevent incident but subsequent disruption could be significant. At thestation end of the quay is a public main road crossing adjacent to a T-junction andcontrolled by traffic lights. It was noted that driver discipline in keeping the yellowbox clear was very poor. Approximately 3 chains on the station side is a furthercrossing to a small yard. This crossing is unprotected and appears to be used both byIE staff and public. Several vehicles were noted to block the crossing whilst waiting togain access to the adjacent main road. Again the 5mph PSR should be a suitablecontrol to prevent incident but it is recommended that this crossing be reviewed forsafety of users.


At Enniscorthy there is a bridge over the River Slaney. Track support is by longtimbers sitting between two rail bearer I section girders. There are no transoms toretain gauge and it would be very difficult to install them. However the long timbershave been well packed off the girders and gauge as measured was generally very goodindeed, only one point being at +8mm. The timbers were in fair to good condition. Itis understood that this structure will be reconstructed in the current year concurrentwith adjacent track renewal. It is not considered that any significant risk exists fromthe track system.

Liffey Bridge and Junction (Freight)

This is the site previously identified as an unreasonable risk due to problems withgauge retention on long timbers and the risk of derailment at the adjacent junction.The risk was partly mitigated in 1999.

The Vossloh fastening system on the long timbers was standing up to traffic very well.Gauge on the down line varied from 0 to +16 but virtually no dynamic movement wasnoted during the passage of a freight train. The up line is better, mostly ±2 but ±5 atworst. Again there appears to be little dynamic movement.

The adjacent junction comprised 92lb flat bottom rail on decayed softwood timberswith an ineffective fastening system on badly degraded ballast. As now inspectedsome 90+% of the timbers have been replaced with new hardwood, the fastenings areall Vossloh and the ballast has been renewed. Evidence that the whole was wellpacked was provided by a freight train and the one poor feature was a few workingjoints that could be rectified by replacement fishplates. Overall it is considered thatthe risk has been reduced to a tolerable level.

Greystones to Bray inclusive (DART)

Greystones has recently become the southern limit of the DART suburbanelectrification system. As part of this work there have been some track upgrading.There is a lead at the Dublin end comprising 50kg flatbottom rails on BR standardvertical baseplates supported on what appeared to be softwood timbers. As part of theelectrification scheme there has been an element of signalling work and some new



insulated block joints (IBJs) have been installed. Two have been installed of the toesof this lead in an undesirable fashion. The switch fronts have been cut back and weldsinstalled only one bay from the toes. This may lead to difficulty in maintaining a goodalignment and will cause problems when replacement switches are required. The IBJsare some 3.4m from the welds, again in contravention of IE standards that state aminimum of 4.5m. However, the rails between weld and IBJ are supported on 5 soundand well packed timbers and there is not considered to be any risk.

Between Greystones and Bray the track comprises 54kg flat bottom rails laid onVossloh concrete sleepers on a good ballast bed. Throughout there is a very good cesswalkway surfaced with chippings to facilitate any emergency egress from trains onthis remote and exposed section of line. Where appropriate guard rails have also beeninstalled in the five foot way and should a derailment occur then the train would beconstrained on the formation with very little risk of falling off the cliff.

No significant risks were identified on this section.

Sandycove to Glenageary (DART)

This location was identified as having a risk factor of 24 in 1998 mitigated to 12 in2000. The down line is in the process of renewal with CWR laid on hardwoodsleepers supported by new ballast. The site is currently running with jointed servicerails under protection of a 25mph TSR. The renewed track will eliminate the risk andit is reported that both line are due to be completed over the coming two years.

Porterstown and Clonsilla (Passenger)

It was noted that the previously identified high risk sites at Porterstown LevelCrossing and between Porterstown and Clonsilla have been rectified.

Mullingar (Passenger)

There remains some bull head S&C without blocks and bolts retaining the check rails.One check has been dealt with but two facing crossing noses are still only protected byan unsecured check. The installation of additional “Panlock” keys in the check hasreduced the risk of the check being displaced. 44 points, facing double junction 13mmwide at toes and 15mm wide in the belly. 50A points, facing double slip 6mm wide(facing point lock test failed). This poor gauge is unlikely to lead to derailmentproblems but is no doubt a significant contributory factor in the difficulty ofmaintaining the facing point locks. The whole layout is still waiting remodelling butthis continues to be delayed by mini CTC problems.

1999 risk factor 24 2001 risk factor 4X6=24

Mullingar to Edgeworthstown (Passenger)

All jointed track has been eliminated by renewal with concrete sleepered CWRincluding the 1998 high risk site at Lake level crossing. The general standard ofinstallation is first class. Top and line are to a very high standard and mostlycompliant ballast shoulders have been created. Scrap, albeit in long lengths, remainingthroughout the strip from the works is the single blemish.

Edgeworthstown (Passenger)

Double track loops, both flat bottom 95A fang bolted jointed track. Elsewhere in theyard appropriate maintenance has controlled the risk of derailment to a tolerable level.



Rail remains on site for renewal in near future as per 1999 notes. The whole layout isalso still awaiting remodelling but this continues to be delayed by mini CTCproblems.

1999 risk factor 24 2001 risk factor tolerable

Longford (Passenger)

The switch and crossing layouts are very much as observed in 1998 and 1999 but withimprovement to the defects. Gauge at the toes of 10 points 10mm wide and generalgauge in turnout 12 to 15 mm wide; gauge at the toes to 13 points 13mm wide. Aswith Edgesworthstown above the derailment risk problems associated with thislocation have been managed down to a tolerable level. The main remedial measuresadopted have been the installation of all missing fishbolts, regular tightening offishbolts, manual reballasting of the worst wet joints, joint shimming. The wholelayout is also still awaiting remodelling but this continues to be delayed by mini CTCproblems.


Longford to Dromod (Passenger)

As noted above jointed track has been eliminated by renewal with concrete sleeperedCWR. The general standard of installation continues to be very good. Top and line areto a very high standard and mostly compliant ballast shoulders have been created.Again large quantities of scrap remain throughout the strip from the works and this isconsidered to be a hazard that is not being controlled effectively. The risk ofderailment at any one strip is low but cumulatively the scrap across the network willproduce an unacceptably high addition to overall risk

Dromod (Passenger)

It was noted in the 1998 inspections that a lead at the Dublin end of Dromod stationhad an unusual and unsatisfactory locking bar arrangement. This was inspected againon this visit and was found to be improved but not fully resolved.

In the down side loop there are the remains of a bullhead lead that formerly gaveaccess to a siding. The timbers are decaying to a very poor state together with thesleepers in a short piece of adjacent plain line. Although not yet a derailment risk thisis a location that will require considerable maintenance input if mini CTC is delayedfor much longer.

There is new P&C material on site waiting installation with mini CTC and thiscomprises flatbottom ironwork and jarrah hardwood timbers. The timbers havesuffered from exposure to sunlight and drying winds and many have warpedconsiderably. Experience with such timbers is that they will remain warped wheninstalled and cross level will be permanently variable. It is recommended that jarrahtimbers are stored covered.

On a goods warehouse there was a limited clearance safety notice faded almost toindistinction. It is recommended that this be replaced.

Boyle (Passenger)

It was noted in the 1998 inspections that the ballast and track component conditions atBoyle were poor and in need of remedial maintenance. This inspection revealed that



the necessary holding work had been effectively undertaken using a strategy similar toLongford with the additional use of tie bars to maintain gauge. As a result the risk hasbeen reduced to a tolerable level. This layout is also still awaiting remodelling and thiscontinues to be delayed by mini CTC problems.


Sligo (Passenger)

At the Dublin end there is a lead comprising bullhead rails on softwood timbers that isnear to the end of its useful life. The timbers are becoming decayed, the ballast is poorand degraded and the joints difficult to pack. There is also an unsecured check rail butthis has been retained by panlock keys and the 10mph speed reduces derailmentconsequence to a low level. Gauge varies from 16mm wide at the toes to 20mm wideat the worst point. Replacement P&C is on site waiting installation but is the subjectof more mini CTC blight.

1999 risk factor not applicable 2001 risk factor 4X5=20

19B points are of 90lb bullhead material. Gauge is very variable from 12mm wide atthe toes, 20mm wide in the belly and slightly tight at the crossing. The widest gaugewas controlled by a tie bar.

17B points are of 92lb flatbottom material and form a facing connection to the Quaybranch. Gauge is 17mm wide at the toes and between 7 and 19mm wide in the turnout.Adjacent plain line is up to 26mm wide with sidewear.

14A points are of 92lb flatbottom material and form a half a crossover for trainspropelling out of the arrival platform. Gauge is 20mm wide at the toes.


The quay branch comprises flatbottom jointed track on softwood sleepers that wasinstalled as serviceable a few years ago. The track has a very sharp radius for the firstfew lengths and this is an area that had given concern in the 1998 inspections.Although the gauge remains very variable and up to 30mm wide at the worstmeasured point considerable maintenance activity has reduced the risk of derailmentto a tolerable level. The main remedial measures have been the insertion of newsleepers or tie bars.


The platform tracks were identified in 1998 as being in very poor condition, inparticular the departure line. Both platforms have been renewed with concretesleepered CWR and the risk has been eliminated.

1998 risk factor 16 2001 risk factor eliminated

The general standard of installation of new CWR is very good but there are tworegular detracting aspects. The first is that scrap remains on site after the works arecompleted with no adequate means of removal. The second is that many sites wereflooded with ballast up to rail level. Whist not a safety issue in itself the ballast givespoor underfoot conditions for the patrol ganger and prevents him from inspecting thefastenings.

Claremorris (Passenger)



In 1998 an unreasonable risk was identified at this location, then incorrectly identifiedas 54 points as a result of information given on site. The actual location is 56 pointsand these were again examined. Since 1998 a considerable amount of effectivemaintenance has been carried out and all the poorest timbers in the area between andadjacent to the crossings have been renewed. Although the ballast conditions anddrainage are still far from good there has been some improvement and joint packingshould be longer lasting. The risk has consequently been reduced in line with thatessential for a layout due for renewal in the near future. Gauge is still variable in thecrossover (used by all trains departing towards Dublin) and is generally 10 to 15mmwide however, although several tie bars are still in place, dynamic movement appearsminimal. Derailment damage was noted and this was reported to have occurred lastOctober. A barytes wagon used for carrying spoil from track excavations had come togrief and the mode of derailment was stated to be flange climb resulting fromextremely eccentric wagon loading and poor joints. The damage to the timbers fromthe derailment was much reduced because of the retimbering that had recently beencarried out.


The facing lead to Athenry, actually 54 points (line currently disused) was identifiedas a risk in the 1998 inspections. At that time one switch half set had been repaired bywelding with less than satisfactory results. Now the offending switch and stock havebeen replaced and the risk eliminated.

1998 risk factor 16 2001 risk eliminated

Ballinasloe (Passenger)

The bridge over the River Suck comprises longitudinal timbers and was identified in1999 as a location of high risk. The main problem was with some poor joints at theAthlone end that were working and moving longitudinally under traffic. This has nowbeen eliminated.


A short stretch of plain line, about 100 yards in length, between the bridge and thelead at the start of the loop was also identified in 1999 as being in poor condition.Minor maintenance work has tightened up the joints and fangs and the risk has beenreduced to a tolerable level.

1999 risk factor 24 2001 risk tolerable

Athlone Old Station (Passenger)

The track through the old platform gave cause for concern in the 1998 and 1999 insections even at the low authorised speed of 25mph. Components were 95lb flatbottom rail dating from 1902 supported on softwood sleepers by soleplates and fangbolts. The worst features have now been rectified by means of a track lift, selectivesleeper replacement and packing. The risk has now been eliminated.




3.3 Infrastructure Adequacy Score Sheets

See table in appendix II.

3.4 Case Study

The case study selected was the introduction of the Alstom class 8200 DART EMUs.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:

• Gauging and clearances

• Track forces

• Derailment resistance

The audit demonstrated that the risks involved in the introduction of the new trainswas either controlled or confirmed to be no worse than current stock. The main area ofdeficiency concerned the lack of standards against which compliance could beassessed. Notwithstanding this good 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 have 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.

Independent consultants provided confirmation of compliance to specification or ofacceptability. It would appear that they had undertaken a role similar to that of a VAB(Vehicle Acceptance Body) in the UK.

Compliance with company standard number 6, which came into force mid waythrough the procurement process, has been the intention and this project has provideda valuable learning exercise in its implementation. The identification and mitigation ofrisks, not undertaken before in a structured way, has been a key element in theintroduction of these trains.

3.5 Miscellaneous

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. The standard of installation hasbeen high marred only by the lack of resource to remove scrap and excessive ballaston some sites due to inadequate regulating equipment.

Some trialing of the PARS system to assist in the prioritisation of work andassessment of risks has been undertaken but as yet this is immature. There areindustrial relations problems currently preventing full implementation. Withexperience PARS should prove a useful tool.

New standards have not yet been issued in the permanent way department and so thereis no progress to report on implementation. The development process for the new



standards appears more focused than before and the fast tracking of key standardscovering high risk areas is to be commended.

Mini CTC delays are still causing considerable problems to permanent waymaintenance staff. Old station yard layouts are having to be kept going well beyondthe desirable time limit. It is fortunate that good progress on the installation of CWRhas released maintenance resource on some Inspector’s divisions to deal with theseongoing problems.

Although the existence of lineside scrap has been commented upon previously thelarge track renewal programme has made the problem worse by an order ofmagnitude. Although most of the material is in long lengths not usually susceptible tovandalism there are nevertheless many small items that make ideal ammunition formiscreants. It is recommended that IE procure the resource to deal with this growingproblem.



4. CONCLUSIONS

4.1 Way Forward

IE have made very substantial progress since 1998 and the speed of improvement hasincreased since the last audit is late 1999. The hard issues of life expired infrastructureare being tackled effectively and the result should be a reliable and maintainablerailway.

Safety is becoming more ingrained in the culture. It is pleasing to be able to report thatthe safety implications identified on site inspections are now immediately recognisedas problems by IE staff and the need for mitigation is understood.

It may be appropriate for IE to seek advice and help in the further development ofstandards and in the implementation of a system of internal check from bodies used toworking in an environment where such systems are mature. There is also a lack ofstaff resource to brief in and perpetuate the new standards.



5. RECOMMENDATIONS

It is recommended that the key areas for development in the permanent waydepartment are:

• Resolution of IR problems

• Development and implementation of standards that are appropriate andeffective for IE needs

• A system of internal check to monitor compliance with requirements of thestandards

• A document control process

• A reliable and regular briefing process that facilitates two-way communicationbetween managers and staff.

• Competence assessment of staff to give confidence that people are equipped tosucceed

• Clear job descriptions and safety responsibility statements

• Matching of resources to needs, both in terms of manpower and plant

Specific recommendations are made below.

• IE should effect the replacement of rail defects revealed from ultrasonicinspection and badly drilled rail ends using the rail and fishplates nowavailable by cascade from relaying sites. It is important that this is done toeliminate the defect backlog.

• IE should review the workload of the PWI

• IE should complete the tendering process for a fleet of modern ballast hoppersas soon as practicable

• IE should initiate the procurement of a train capable of lifting the largequantity of scrap produced by relaying activities.



6. REFERENCES

[1] A Review of Railway Safety in Ireland, IRMS Report 2045.10, dated10 October 1999.

[2] Implementation Review, IRMS Report 2081.01, Issue 03, dated March 2000.[3] Second Implementation Review, IRMS Report 7335.01, Issue 03, dated April 2001.


Report No: 0948PWYIssue No: 01Date: March 2001

Appendix I

Technical Review Summary



Divisional Engineer - Technical Self Check Procedures

No formal system in place for the DE to check compliance with technical requirementswithin his own organisation. No significant change in this item since summer 1998.

Instructions To Local Staff

No formal instruction distribution and control system is in place. No significant change inthis item since summer 1998.

Cab Riding

There is a clear requirement for PW Inspectors to undertake footplate inspections butcompliance is variable. The requirement for the DE to undertake footplate inspections isless clear and compliance is also variable. No significant change in this item sincesummer 1998.

Track Inspection: Divisional Engineer

Track walking requirements not clearly understood and compliance is low. Inspection carrequirements understood and compliance good. No significant change in this item sincesummer 1998.

Track Inspection: PW Inspectors

Requirements clearly understood but availability of auditable records is variable. Nofollow up process. This is an activity that demands complete and accurate records butthese are not reliably available. No significant change in this item since summer 1999.

Track Inspection: Patrol Gangers

Requirements clearly understood but availability of auditable records is variable. DEAthlone PWIs records of coverage complete but standard variable, DE Limerick Junctionhas a slight shortfall and standard again variable. No follow up process. This is an activitythat demands complete and accurate records but these are not reliably available. Nosignificant change in this item since summer 1999.

Track Recording Coach

Urgent action timescales now widely known but compliance poor except for twist faults.Comparison, recording and follow up processes not robust. No significant change in thisitem since summer 1999.

C.W.R. Maintenance

DE Limerick Junction has a register of CWR for recent installations but correlation withstressing records not in place. No formal system for recording and rectifying disturbance.No significant change in this item since summer 1999 except for the existence of aregister.

Hot Weather Precautions – Track

Large are of risk with no systems or processes in place. Ballast deficiencies identified onsite inspections confirm the office findings. No significant change in this item sincesummer 1998.



Ultrasonic Examination Of Rails

Frequency of examinations now widely understood but no robust process to ensurecompliance, however records showed coverage generally compliant. No significantchange in this item since summer 1998.

Ultrasonic Examination Of Rails Testing Equipment, Training & Performance

All operators now trained and certificated and other risks generally well controlled.Significant improvement in this category.

Defective / Broken Rails, Broken Fishplates, Derailments And Track Buckle Reporting

Database of broken rails and fishplates much more credible than previously withreporting discipline much improved. Other incidents less reliably reported. No significantchange in this item since summer 1998 except for some improved reporting.

Defective Or Broken Rails Procedure

Defective rail management and record keeping generally compliant with standards. Nosignificant change in this item since summer 1999.

Welders Competency - Alumino Thermic

Welders currently trained and certificated. Records of weld installations good butcorrelation with ultrasonic inspections not possible. No significant change in this itemsince summer 1998.

Structural Clearances

DE Limerick had good records of all structures within structure gauge. Significantimprovement in this category.

Track Renewal And Design

DE Limerick had good drawing office and site systems in place. No significant change inthis item since summer 1998.

Rail Sidewear (Plain Line)

Management of this aspect is not demonstrably robust. No significant change in this itemsince summer 1998.

Raising / Removing Temporary Speed Restrictions

An area of risk with little formal control. No significant change in this item since summer1998.

Non Ballasted Track On Bridges

An area of risk with little formal control. No significant change in this item since summer1998.

PWI structures responsibilities

Commented on in structures report.



Appendix II

Infrastructure Adequacy Score Sheets



SUMMARY OF PRELIMINARY RISK FACTORS L X C = H

NEW AND PREVIOUS UNREASONABLE RISKS ARE SHOWN IN ITALICS WITH ANY ORIGINAL HAZARD RATING IN BRACKETS. THEREMAINING RISKS IDENTIFIED IN 1998 AND 1999 ALSO HAVE THE ORIGINAL HAZARD RATING IN BRACKETS.

New risks identified in 2001 are marked with an asterisk (*).

Location or route section Likelihood Consequence Hazard

Cork to Cobh general track component conditions (Passenger)* 3 6 18

Cork to Cobh ballast adequacy (Passenger)* 3 6 18

Cork to Myrtlehill, lack of fence (Passenger)* 4 6 24

Harpers Bridge (Passenger)* 4 4 16

Mallow (Passenger)* 4 4 16

Limerick station (Passenger)* 4 4 16

Waterford to Barrow Bridge ballast adequacy (Passenger)* 3 6 18

Barrow Bridge site entrance (Passenger)* 3 6 18

Wellington Bridge (Passenger)* 4 6 24

Rosslare Strand, harbour end (Passenger)* (Subsequently removed w/e 18/2/01) 4 4 16

Rosslare Strand Wexford end (Passenger)* 4 4 16

Rosslare Strand track renewal strip (Passenger)* 4 6 24

Wexford Quay, open crossing (Passenger)* 5 4 20

Sandycove to Glenageary (work in progress to eliminate risk) (DART) 0 0 0(24)



Location or route section Likelihood Consequence Hazard

(Liffey Bridge) (Freight /Passenger) 0 0 0 (32)

Liffey Bridge Junction (Freight /Passenger) (Switches & crossings) 0 0 0(32)

Porterstown Level Crossing (Passenger) 0 0 0 (32)

Porterstown to Clonsilla (Passenger) 0 0 0(32)

Mullingar (Passenger) 4 6 24(24)

Lake Level Crossing (Passenger) 0 0 0(32)

Edgeworthstown (Passenger) 0 0 0(24)

Mullingar to Longford (Passenger) 0 0 0(16)

Longford (Passenger) (collapsed joints) 0 0 0(30)

Boyle (Passenger) 0 0 0(24)

Sligo P&C at Collooney end (Passenger)* 4 5 20

Sligo Quay Branch (Freight) 0 0 0(24)

Sligo Station approach P&C (Passenger) 4 4 16(24)

Sligo Station (Passenger) 0 0 0(24)

Claremorris 56 points (previously referred to as 54 points in error) (Passenger) 3 5 15(30)

Claremorris 54 points facing lead to Athenry (Passenger) 0 0 0(16)

Ballinasloe (Passenger) (River Suck bridge)* 0 0 0(18)

Ballinasloe (Passenger) (plain line)* 0 0 0(24)

Athlone (old) Station (Passenger) 0 0 0(24)



Documents

A Report Prepared by International Risk Management ... · PDF fileA Report Prepared by International Risk Management Services On Behalf of The Department of Public Enterprise IRMS