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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: 0948OLEFax: +(44) 161 958 8888 Issue No: 01E-mail: [email protected] Date: March 2001

A Review of Railway Safety in

Ireland - Second Implementation

Review

Electrification 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 Electrification IRMS

Report No: 0948OLEIssue No: 01Date: March 2001 Page i

Document History

Issue Author Date Reason for issue and comments

0A L Brunton 01/03/01 Initial Draft

0B L Brunton 04/05/01 Technical Reports collated to provide information toIE Auditees

01 L Brunton 10/05/01 Formal Issue


Report No: 0948OLEIssue No: 01Date: March 2001 Page ii

Distribution Control Sheet

Version Date Compiled By Checked By Authorised By

01 10/05/2001 L Brunton 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 ()


Report No: 0948OLEIssue No: 01Date: March 2001 Page iii

CONTENTS

1. INTRODUCTION 4

1.1 General 4

1.2 Objectives and Scope 4

2. AUDIT RESULTS 6

2.1 Head Office Audit 6

2.2 Site Visits 12

2.3 Systems 12

2.4 Procedures 15

2.5 Progress on Previous OLE Issues 18

3. CONCLUSIONS 20

3.1 Way Forward 20

4. REFERENCES 21

APPENDIX I PROGRESS ON PREVIOUS UNREASONABLE RISKS


Report No: 0948OLEIssue No: 01Date : March 2001 Page 4

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

Parsons Brinckerhoff (PB) Power (as PB Merz and McLellan Ltd) was retained byIRMS to provide technical and electrical operational input into the Electrificationaspects of the Safety Study of Irish Rail (IE) undertaken during May 1998.

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 Electrification by PB was conducted inNovember 1999. The findings of this audit were presented to the DPE undercover ofan IRMS Implementation Review Report[2].

The ‘18 month’ audit of Electrification was conducted by PB during January andFebruary 2001, and the findings of this audit were presented to the DPE undercover ofan 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 particularly on IE’s traction electrification system against the recommendationsfor Electrification, detailed in the IRMS Report [2].

The scope of PB’s work continues to be centred on IE’s traction electrification system.This was restricted to the 1982 1500 V dc electrified suburban system operatingbetween Howth and Bray at the time of the November 1999 audit, although extensionsat both ends, to Malahide and Graystones, had been constructed and were awaitingfull commissioning. Since that time, these extensions have been completed andhanded over to IE, and are in public service. The electrification system under auditreview comprises the electrified track itself, the Depot at Fairview, the tractionsubstations and track paralleling switch-houses, and the associated Electrical ControlRoom (ECR) at Connolly Station. The detail of this equipment and the associatedmaintenance, operation and safety documentation surveyed covers:

• Traction Substation and Switch-house installations



• 1500 V dc overhead line equipment (OLE)

• Traction return current track bonding

• Depot OLE safety and interlocking system

• ECR Supervisory Control (SCADA) and procedures



2. AUDIT RESULTS

2.1 Head Office Audit

2.1.1 Engineering systems, standards and documentation*;

Work is proceeding by IE and Consultants on the identification and drafting ofStandards and Procedures. Concerning the DART electrification, the relevantdocuments are the 4000 series (overhead line – OCS) and 5000 series (electrical –ELE). Within each category, three sets of documents are being produced:

0. High Level Standards

1. Procedures

2. Work Instructions

In the OCS series, we have not yet seen any High Level Standards, howeverconsultants have produced as drafts the majority of the Procedures and WorkInstructions identified. The status of OCS documents as at 26/2/01 is thus:

PROCEDURES.

Standard/Procedure No.

Title Status

I/OCS/4101 Maintenance Parameters for 1500V DC OCS. Awaiting Final Review.

I/OCS/4102 Routine Track Patrols on Electrified Lines. Awaiting Final Review

I/OCS/4103 Tension Length Inspection & Maintenance. As above

I/OCS/4104 Setting of Balance Weight Assembly. As above

/OCS/4105 Replacement of a Section Insulator As above

I/OCS/4106 Replacement of Contact Wire As above

I/OCS/4107 Replacement of Catenary Wire As above

I/OCS/4108 Replacement of an In Line Tension Insulator As above

I/OCS/4109 Replacement of a Registration Arm As above

I/OCS/4110 Re-alignment of Registration Arms. As above

I/OCS/4111 Replacement of a Cantilever. As above

I/OCS/4112 Replacement of a Span Wire Draft 90% complete

I/OCS/4113 Recording Heights & Staggers Awaiting Final Review

I/OCS/4114 Installation of Jumper Cables. As above

I/OCS/4115x Installation of Droppers. Awaiting Final Review



I/OCS/4116 Installation of a Mid Point Anchor Awaiting Final Review

I/OCS/4117 Local Earths. As above

I/OCS/4118 Testing Equipment - Use of. For Drafting

I/OCS/4119 Completion of Job Cards / ComputerisationSystem

For Drafting

WORK INSTRUCTIONS.

Standard/Procedure No.

Title Status

I/OCS/4201 Height & Stagger Record Form Awaiting Final Review

I/OCS/4202 Overhead Line Patrol Report Form. As above

I/OCS/4203 Inspection / Overhaul Record Form. As above

I/OCS/4204 Balance Weight Setting Adjustment Form. As above

I/OCS/4205 Basic Training-Use of Hand Tools. Awaiting Final Review

I/OCS/4206 Use of Ladders. As above

I/OCS/4207 Working on Isolated and Earthed Equipment As above

I/OCS/4208 Use of Rail Mounted Scaffolding andTrolleys.

As above

I/OCS/4209 Lighting (Worksites) As above

I/OCS/4210 Use of Safety Equipment. For Drafting

I/OCS/4211 Use of Small Mechanical / Electrical Plant. For Drafting

I/OCS/4212 Operation of Lineside Switches. For Drafting

Add to 1/OCS/4208

I/OCS/4213 Operation of Road / Rail Equipment. For Drafting

I/OCS/4214 Job Cards Issue of. For Drafting

Add to 1/OCS/4119

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

We have also reviewed one of the P. Way Standards – Technical Standard PW7 -,which deals with Electrification Clearances. Whilst it is a most useful document, it isnot clear how this PW series fits into the published Infrastructure Standards andProcedures document structure.



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

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

Volume Title

1 Operating Instructions for Overhead Line Equipment

2 Control Room Operating Instructions – Faults and Failures

3 Isolation / Working Instructions – Fairview Depot

4 Control Room Operating Instructions for Signalpersons

5 Operating Instructions for EMU Drivers

6 Isolation Instructions – Substations and Switch-houses

Again, whilst the content of these documents is valuable, it is not clear to us howthese Volumes are integrated into the overall IE document structure and hierarchy.

2.1.2 Safety culture and occupational safety*;

There are encouraging signs, particularly in Fairview Depot, where a Health andSafety Committee regularly meets and carries out audits.

Many staff now carry the ‘likelihood and consequence’ Risk Card.

Major cultural problem results from staff refusing to sign forms.

2.1.3 Accident and equipment performance information systems;

No changes yet noted

2.1.4 Human resources and training*;

There was at the time of the second audit an acceptance of the need to enhance boththe quantity and calibre of IE staffing in certain areas of work. Since then, positiverecruitment moves have been taken in relation to both OLE and substation staffing.There are continuing concerns about the level of success IE may expect in attractingnew staff, owing to the booming Dublin economy and correspondingly high wagesbeing offered in the private sector. Considerable progress by the HR Department isapparent in the areas of recruitment and re-training strategy. However, there is someway yet to go in the negotiations of more flexible rostering and working practices.

Substation staff

The establishment remains at one Foreman, four electricians and four mates forsubstation and general electrical services work, and one electrician dedicated to themaintenance and repair of Ticket Issuing Machines. Staff duties, rostering andtransport arrangements remain as recorded in the two previous reports. IE hashowever re-considered the staffing level necessary both to undertake the extramaintenance work-load imposed by the three new substations and two new switch-



houses on the Greystones and Malahide extensions, and to provide cover for holidaysand sickness. As a result, an extra two electricians and two mates are to be recruited;this will enable 24-hour cover to be provided instead of the present 18, and opens upthe possibility of allocating two teams, to cover substations north and south of theriver.

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

Overhead line staff

At the time of the original and second audit inspections, we had to report a seriousshortfall in overhead line staffing levels. The situation reported was that, althoughoverhead line was the maintenance responsibility of the Technical Assistant, 90% ofhis time was spent on other duties. Responsible to him was the Overhead LineSupervisor, who in turn was responsible for 5 linesmen. The linesmen normally workday shift (0800-1700); there is no rostered evening or night cover, nor are linesmen oncall. To cover night inspection work, staff were re-rostered on to night shift for twoweeks every three months.

At the second audit we were able to report encouraging progress towards increasingoverhead line staffing resources in line with our earlier recommendations:

The Technical Assistant was to be relieved of his other duties, so as to be able toconcentrate on overhead line responsibilities;

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

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

Much progress has been made on the industrial relations front, in recognition both ofthe need to increase maintenance and wire renewal cover, and of the expansion ofelectrified services. Our original recommendation called for 12 linesmen (6 teams of2). We can now report that the establishment is to be increased well beyond thesefigures, in return for relaxation of restrictions on working practices. Theestablishment is now planned for 25 linesmen, comprising 21 on a ‘5 out of 7’ rosterand 4 on a re-rosterable ‘as required’ basis. The normal shift pattern would allowround-the-clock cover with shift change-over periods, and would comprise 4 linesmenon Early Shift, 4 on Late Shift, and 8 on Night Shift (nominally 4 north of the river,



and 4 south, for maintenance purposes. It is also recognised that a second OLESupervisor will be required. Key points for negotiation are:

• Linesmen to work on any IE electrified line;• Linesmen to operate new systems of work;• Linesmen to undertake all Isolations and take their own Possessions;• Linesmen to work with all grades of staff both in CIE and with outside

contractors;• Linesmen to operate all types of plant and machinery on completion of training

and having achieved Certification of Competency;• Linesmen to undertake necessary training and re-training;• Linesmen to co-operate with implementation of formal Competency Certification.

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

IE are actively considering our recommendation for relocation of the overhead linestores, which suffer at present from inaccessibility by road and rail vehicles, and froma lack of workshop facilities. Storage for the road / rail OLE access vehicles now onorder is a further factor, together with revised OLE staff accommodation. City Centrere-development is having a considerable influence on these plans, but a site at Conollyis the preferred option. A budget estimate of £1.5m has been set aside for this facility.

During the second audit (November 1999) we encouraged IE to share views on itsoverhead line maintenance staffing levels and practices with similar undertakings inthe UK, Tyne and Wear Metro being the most similar in characteristics (DART andT&W Metro both use 1500 Vdc overhead line systems). PB Power made thenecessary introductions and a visit to Tyne and Wear took place in January 2000.Useful contacts were made between the organisations, and resulted in IE adoptingsome of Tyne and Wears Metro’s procedures.

We reported our concerns at the last audit about the level of responsibility shoulderedby the Technical Assistant. Although, as reported here, he has been relieved of mostof his non-OLE responsibilities, and he will be better supported through increasedstaffing levels, we continue to press for the technical and operational responsibility forthe equipment (particularly when Competency Certification is introduced) beingvested at a more senior management level, under a recognised Electrical Engineeringqualification.

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

Electrical control staff



The two previous reports found the staffing level, management and general running ofthe Electrical Control Room very satisfactory, and we found that this continues to bethe case.

The ECOs find that the new SCADA system is more user-friendly and morecomprehensive than its predecessor. It seems to be popular with the control staff, whohave quickly become adept in its use.

Physical changes are at present being undertaken. This has increased the area of theroom, which was previously rather cramped. A new long curved control desk is nowin place, at right angles to the former desk, and the lighting and decoration is atpresent being modified to suit the new layout. Telephone instruments, VDU screensand duckets for forms and files are still to be rationalised, but already theimprovement in working environment is plain to see. Consideration has been given tothe installation of a repeat SCADA printer at Pearse offices, so that electrificationsystem faults can be monitored by Engineering staff. However, an alternative solutionhas been adopted whereby the Substation Technical Assistant can log on to theSCADA system remotely, with permission from the duty ECO. This arrangementseems to be very satisfactory.

2.1.5 Management of contractors and third parties;


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


2.1.7 Organisation (including: job descriptions, safety responsibility statements,competency, etc.)*;

Head of Profession - Electrification

There was a realisation at the time of the second audit that the IE establishment didnot include a ‘Head of Profession’ for Electrification. This caused concern in relationboth to the impending formalisation of electrical training, competency andcertification, and to the planned expansion of the electrified network and staffing.There was evidence at that time of a lack of consultation within IE between thoseprocuring new substations and OLE for the DART Extensions, and those who were tooperate and maintain the new equipment. Unfortunately, at the present audit, thisappears to have been the main contributory factor in the failure to provide safetyaccess interlocking in the new substations (see new Risk E14). There is howeverpositive progress to report. An Electrification Engineer post is to be established,reporting through the Divisional Engineer to the Chief Engineer Infrastructure (CEI).This may initially be a Contract post, and the effectiveness of the arrangement is to bemonitored by an independent ‘Advisor’ to the CEI. Reporting to the ElectrificationEngineer will be a Power Engineer, an Overhead Line Engineer, and anAdministrative Section (dealing with such subjects as Standards, Procedures,Training, Certification, Incident Investigation, Administration, etc.). This is awelcome move, which should be encouraged and monitored.



2.2 Site Visits

The discussion interviews and site inspections were conducted over a three-day periodbetween 12 - 14 February 2001.

Interviews were conducted, by prior arrangement, with:

• John Haughey (Divisional Engineer)• Barry O’Riordan (Technical Assistant - OLE)• Diarmuid McDonnell (Technical Assistant – Substations)• Robin Byrne (Substation Foreman)• Oliver Doyle + ECO (Manager - Control)• Jerry Whelan (Manager - DART Depot)

During this visit, audit inspections were carried out at the following locations:

• Connolly CTC (ECR) – 14/2/01• Fairview Depot (OLE) – 12/2/01• Malahide Substation (new) – 13/2/01• Bayside Substation (original) – 13/2/01

2.3 Systems

2.3.1 Substations and switch-houses

The operational 1500 V dc overhead line system now includes the new ADtranzequipment for the Greystones and Malahide DART extensions, now taken over by IE.The Graystones extension is fed from new substations at Bray (replacing a switch-house) and Graystones, with a switch-house at Bray Head. The Malahide extension isfed from a new substation at Malahide, with an intermediate switch-house also namedMalahide. At each substation, 38 kV ac supplies are taken from ESB, transformedand rectified to 1500 V dc via 3 MW rectifiers, and fed to the OLE via feeder circuitbreakers and trackside mast-mounted isolators. The negative pole of the dc supply istaken through a negative isolator to the negative busbar, from where it is connected tothe traction return rails via impedance bonds. A Soule voltage limiting device is fittedbetween the negative busbar and earth, in order to limit touch and accessible voltages.The track-paralleling switch-houses contain dc circuit breakers only.

At the second audit, we inspected the new equipment at Bray Substation; however thisinspection was superficial only, as the equipment was not fully commissioned and wasnot yet taken over by IE. At the recent audit however, we inspected the newequipment at Malahide Substation in detail, and discussed its operational safetyfeatures with IE staff. As a result, we have had to declare what we consider to be anew Unreasonable Risk (See Risk E14). The equipment is specified, constructed andinstalled to a high standard, and gives no general cause for concern from the safetyviewpoint when in normal operation. The risk identified relates to the method ofmaking the equipment electrically safe for access to persons for maintenance. Best



practice in electrical safety for complex substations such as these allows a choice ofapproach. For either, the principles of making the equipment electrically safe arecommon, however, comprising:

• Open circuit breakers both sides of the equipment to be worked upon;• Isolate both sides, lock off and secure, and apply earths;• Release the equipment, so made safe, for work.

The choice of approach concerns the last point, the method of release. The equipmentin the original DART substations (manufactured by Siemens) is fully mechanicallyinterlocked, in order to impose a fixed sequence of switching operations, throughopening circuit breakers, opening isolators, applying earth switches, to releasing keysfor access to equipment enclosures. This method was demonstrated to us during ourrecent audit at Bayside Substation. The alternative approach to full interlocking is tocover the step by step sequence by written procedures, ending with the release ofequipment for work through the issue of a written Permit-to-Work form. In theabsence of interlocking at the new ADtranz substations, the latter approach wouldhave to be taken. However, not only would it be unwise to expect the Electricians tofollow two different electrical safety schemes at the two types of substation, but IE donot have a Permit-to-Work system for their substations (as previously they did notneed it for the fully-interlocked equipment installed). As the ADtranz substationsstand at present, it is possible, for example, to gain access to live rectifier transformerssimply by using a padlock key kept in an unlocked box by the substation desk.Similarly, it is possible to open a live rectifier cubicle in the substation with a simple‘budget lock’ key; although this action would trip a micro-switch on the door, in turntripping the 38 kV and 1500 Vdc supplies, this certainly neither isolates nor earths thesupplies. The Electrical Foreman himself declared that he is always wary of the newdanger posed by the new equipment, and is uneasy that two standards now exist.Whilst accepting that the emerging Substation Procedures should no doubt include theintroduction of Substation Permits-to-Work for some of the more complexmaintenance tasks - on old and new substation equipment - we have to make a strongrecommendation to design and retrofit mechanical interlocking at the new substations.There is also a corresponding soft issue to address, concerning the apparent lack ofconsultation between those specifying the new equipment and those destined tooperate and maintain it.

At the November 1999 audit we raised an operational query concerning the provisionof load-measuring auto reclose equipment on the feeder dc circuit breakers. In theevent of a short circuit tripping, the equipment makes an assessment of the loopimpedance of the circuit (i.e. whether the fault still exists); and, if favourable, allowsthe operator to reclose the breaker. It will try to do this three times, and ifunsuccessful will then lock out. As configured at present, this state requires asubstation visit to reset the lock-out before further attempts can be made to reclose thebreaker. DART have now initiated a modification with the Contractor to remove thislock-out feature. As the modification still requires the intervention of the ECO to re-close a circuit breaker after a fault trip, the load-measuring circuit simply prevents theECO from re-closing on to a short circuit, this entry on the risk register is nowconsidered to be closed (See risk entry E11 in updated Schedule).



2.3.2 Overhead line equipment

There have been some changes on the overhead line equipment on DART since theNovember 1999 audit report was issued. The most significant is the taking over by IEof the equipment on the Graystones and Malahide extensions. Some minormodifications have been carried out, partly by ADtranz under contract, and partly byIE, to accommodate the longer platforms currently being prepared for longer EMUformations. Currently Wicklow Sidings are being wired to provide stabling for DARTEMUs.

At the November 1999 audit we were able to report that a budget allocation of ~£800khad been allocated to the choice and procurement of road and rail mounted OLEaccess and maintenance specialist plant. The aim at that time was to have plantdelivered by May 2000, but this time-scale proved to be very ambitious. Workingwith PB Ltd, once the combination of vehicles and equipment had been settled, aSpecification was prepared and tender enquiries went out to 14 firms in June 2000.Four offers were received in July 2000, followed by Tender Queries and evaluation upto August 2000. IE Board approval was granted in September 2000 for a contractwith SRS valued at £725 000. Since then there have been a number of technicalmeetings held, resulting in negotiated changes and additions. The plant now to bedelivered comprises:

• Volvo road/rail vehicle, 7-man crew cab, 3-man access basket (3m x1.4m);

• Multi-purpose road/rail vehicle, with crane and 2-man basket (1.5m x1m);

• Trailer for P Way material, cable drums and other equipment.

Staff training is included in the package. The procurement programme has thereforeunfortunately become very protracted, and the target delivery date of August 2001 isnow unlikely to be met; the new date is now November 2001.

Contact wire thickness measurements continue to be undertaken, in order to estimatewhen sections of wire will need to be renewed due to wear. Most of the originalsystem has now been surveyed, showing that much of the wire is still 10.0 – 10.6 mmthick. The thickness limit is 9.4 mm, and this will be reached in places by the year2003, requiring the renewal of about 80 tension lengths.

OLE on the two extensions to the DART electrification from Bray to Graystones, andfrom Howth Junction to Malahide, are now taken over from the contractor, ADtranz,and familiarisation training has been carried out. However, further training in the useof specialist tools and equipment has yet to be undertaken. At the November 1999audit, we reported a number of concerns; the updated situation is thus:

Corrosion had become apparent, on some overhead line fittings in the tunnels on theGreystones extension. ADtranz have now changed these for corrosion-resistantfittings and Minoroc droppers under the terms of their contract;

Exposed mains voltage terminals had been noted in the motorised isolator cubicleswhen open for manual operation). It is now noted that it is not necessary to gain



access to this cubicle during manual operation of the isolator, but this is yet to beconfirmed by the Contractor;

An Unreasonable Risk had been noted in that the section of contact wire used on theextensions is different from that elsewhere on the electrification system (See RiskE12). This could have been avoided at the start of the ADtranz contract, had therebeen involvement by maintenance staff in the procurement process. For ease ofreference, under the new Cenelec standard EN 50149 there are two ‘standard’ wirecross sections, both of 107 sq. mm area, referred to as AC-107 and BC-107. The twosections are of separate national origin (AC-107 from France and BC-107 fromGermany), both have equal standing, and one is not likely to supplant the other. TheAC-107 wire has a narrower top lobe than the BC-107, requiring different mid-spansplices and section insulator end-fittings. There is a potential risk of a wire parting ifthe wrong splice or end fitting is used. This risk (E12) did not exist before. The OLEstaff now clearly recognise this new risk. It has been accepted that the risk can bemanaged, by clearly segregating and marking (perhaps by different colours) drums ofspare wire and associated fittings, and allocating these as section ’A’ for the originalDART and ‘B’ for the extensions. It is also appreciated that, when the time comes torenew contact wire, the section must be used appropriate to the location, withoutmixing sections anywhere on the system. These mitigation measures have yet to beimplemented, and therefore are still to be audited. At present, all ADtranz spares areheld at Inchicore, separate from existing Siemens spares, so care is taken not to mixstock.

2.4 Procedures

2.4.1 Substation work

During the November 1999 audit visit, a number of points were noted. These were allchecked during the current audit, and progress is reported here:

The comprehensive range of safety equipment available in each of the original DARTsubstation buildings needed to be considered for the new substations, whereappropriate to the use of metal-clad construction. This has now been inspected at atypical new substation (Malahide) and found to be satisfactory.

We recommended that a Substation Log Book be kept in each substation and switch-room, and that times and details of personnel entry and exit be entered, with acorresponding entry in the ECR Log. During the current audit we found that thisprocedure had now been adopted in both the old and new substations, and appeared tobe followed rigorously.

The operation and maintenance manuals for the equipment supplied by ADtranz havebeen made formally available to IE at the taking over of the equipment. We believethat IE’s contracted consultants are including these documents as part of their work onmaintenance management standards; these are not yet ready for auditing;



We have noted our concerns elsewhere in this report about the lack of safetyinterlocking on the new substation equipment (see under ‘Systems’), resulting in thelogging of a new Unreasonable Risk. (See Risk E14)

2.4.2 Overhead line work

Since carrying out the November 1999 audit, which identified procedural shortfalls ofonly a minor nature, a number of further remedial changes have been put in hand:

The live line detectors now in use are provided with proving units; linesmen are nowinstructed to prove that the detector is operating correctly before and after each linetest (see comment on E3); and

A Caution Notices has now been introduced to signify an isolator locked off for safetypurposes, (see comment on E6).

2.4.3 Electrical control procedures

As stated in the earlier reports, the DART electrical control procedures arecomprehensive and well managed. Since the last audit, the ECR and its staff havetaken over responsibility for the DART extensions, and the new SCADA system,which covers the whole electrified network, is now taken into full use. As noted inthis report, the revised layout for the Control Room affords a greatly improvedworking environment for the staff.

Since the last audit, a system of reporting tripping incidents on the overhead line hasbeen introduced; the ECO fills in a form for each such event for investigative andstatistical purposes

A revision of the Electrified Lines Working Instructions ‘Yellow Book’ has beenissued, as well as revised Isolation Documents which include the two DARTextension. Within the document hierarchy of the Yellow Book, six DepartmentalProcedures have now issued, some of which relate to the Control Room.

The addition of ‘limits of isolation’ graphics to the signalling mimics is stillconsidered to be a sound idea, and will be incorporated when the signalling panel isrenewed (see comment on E10).

2.4.4 Fairview Depot isolation procedures

Since the last audit, there has been a change of Manager at the Depot. Tony Keoghhas retired, and Jerry Whelan is now Depot Manager. Safety Audits continue to forman important part of the running of the Depot, and, since our last audit inspection andreport, the Depot management team have considered all the minor safety suggestionsput to them, discussed them with the electrical switching staff, and amended theDepot Procedures accordingly:

The team had already decided that delineation of the safe working limit at high level isunnecessary (risk reference E7), and may indeed cause confusion. As there is onlyone section insulator at the half-way point of each road, different limits would apply



depending on which half road was isolated. In any case, Depot staff never work oncar roofs other than off the access gantries. If outside contractors come in to work onthe building roof structure, a whole-road isolation is taken, which removes the hazardtotally. This principle is now incorporated into the Isolation / Working Instructions –Fairview Depot (Volume 3) and the risk item is therefore hereby closed.

The team had already agreed to the use of individual personal padlocks on Depotisolation key safes (risk reference E8), and had implemented this procedure. This isnow incorporated into the Isolation / Working Instructions – Fairview Depot (Volume3) and the risk item is therefore hereby closed.

It was realised that the red emergency trip buttons are ineffective during alternativefeeding of the Depot from the main line rather than from the substation Depot circuitbreaker. It had already been agreed to isolate the Depot OLE in these circumstances.This principle is now incorporated into the Isolation / Working Instructions – FairviewDepot (Volume 3) and the risk item is therefore hereby closed.

Since the last audit, additional red emergency trip buttons have been fitted in theinspection pits, as a result of an internal safety audit.

It is also now agreed that the OLE will be isolated during car body lifting operationsas an additional precaution. Again, this principle is now incorporated into theIsolation / Working Instructions – Fairview Depot (Volume 3) and the risk item istherefore hereby closed.

It is worth noting that the Depot is becoming busier with the expansion of the DARTfleet. In addition to the original fleet of 80 cars, 10 cars (5 x 2-car sets) have nowbeen delivered from Alstom / CAF Spain; these are now entering passenger service.Delivery is also now being taken of 16 cars (4 x 4-car sets) from Mitsui. Additionalcars are required for future 8-car operation, imposing further burdens on Depot spaceand facilities.



2.5 Progress on Previous OLE Issues

(New risks shown in italics, and progress in bold)

Ref Safety Issue L C H Sa%

Cost & Cat Remarks

E1 New OLE maintenance/repairaccess equipment & plant

4 6 24 40 £800 000 C6 In progress. Budgetallocated, contract placed,delivery now expectedNovember 2001

E2 Familiarise staff with newelectrification equipment onGraystones and MalahideDART extensions

3 5 15 62 £5 000 C2 In progress. Additionaltraining and familiarisation tobe undertaken in conjunctionwith the contractor, ADtranz.

E3 Prove voltage testing devicesbefore and after eachverification

3 4 12 70 £5 000 C2 Implemented and added intoprocedures. Closed.

E4 Log in and out of substationswith Control

2 4 8 80 £500 C1 Implemented. Closed.

E5 Prove OLE sections deadbefore earthing

2 4 8 80 £5 000 C2 In progress. New testingdevices procured, andprocedure introduced. To beadded into procedures.

E6Use ‘Caution Notices’ atlocked-off points of isolation

2 4 8 80 £800 C1NOTICES PROCURED ANDIN USE. PROCEDUREIMPLEMENTED. CLOSED.

E7 Provide delineation of safeworking limits at Depot centrewalkway for half-roadisolations

2 4 8 80 £2 000 C2 Depot Procedures (Vol 3)have been revised to cater forContractors. Closed.

E8 Use multiple padlocking facilityon Depot OLE lock-off boxes

2 3 6 85 £1 000 C1 Implemented, and DepotProcedures revised. Closed.

E9Provide and use ‘open doorkey release’ interlock key onDepot high-level access gantry

2 3 6 85 £500 C1 Agreed unnecessary as E8implemented. Closed.

E10 Add ‘limits of isolation’graphics to DART signallingmimics

3 1 3 92 £800 C1 In progress. Awaiting newsignalling mimic.

E11 Use of load-measuring auto-reclose on Extensions feedercircuit breakers

2 6 12 70 £5 000 C2 Scheme modified – reclosingnot automatic. Closed

E12 Incompatibility of two contactwire sections now in use. Riskof mechanical failure atsplices.

3 4 12 70 £2 000 C2 In progress. Risk beingmanaged out by markingdrums etc., and introducingprocedures.

E13 Exposed terminals inExtension motorised isolators.

2 4 8 80 Nil to IE C1 In progress. Contractor toconfirm whether operationalaccess necessary.



Ref Safety Issue L C H Sa%

Cost & Cat Remarks

E14 Lack of safety interlocking foraccess to substationequipment on DARTExtensions.

4 6 24 40 £30 000 C3 In progress. IE investigatingmethods of retro-fittinginterlocks, to gaincompatibility with earliersubstation procedures.



3. CONCLUSIONS

3.1 Way Forward

There were three general management recommendations resulting from the first andsecond safety audits:

• A review of the adequacy of maintenance staffing numbers;

• The introduction of Standards and documented maintenance and fault-reportingsystems; and

• The introduction of formal training, and certification of electrical staff.

These issues were discussed during the latest audit visit and summarised thus:

Overall, the staffing and Industrial Relations outlook is more encouraging than thatpreviously reported. There are of course still the problems arising from the buoyanteconomy of Ireland, resulting in high house prices and the provision of highly paidjobs. This, coupled with IE’s industrial relations problems and outdated practices,conspired to attract labour away from the railway. From the recent visit, however,IE’s HR Department seems to be making significant progress towards alleviatingthese problems. Specific to DART, the situation is encouraging, although slow, asauthority has now been obtained to increase the overhead line and substation staffingto levels well beyond our recommendations. This is being progressed through thedelicate stages of negotiation of staff conditions, flexibility of working, and shiftpatterns.

There is some progress to report on the establishment of standards, maintenance andquality systems. Output in the form of emerging Overhead Line procedures and WorkInstructions has been reviewed, but no documentation is yet available for Substations(Electrical). The ‘Yellow Book’ has been expanded through the addition of six‘Procedures’, whose content is sound. It is not however clear how such documentsrelate to the overall IE document hierarchy.

The need for formal training, competency assessment and certification of AuthorisedPersons on the DART electrification system is now strongly recognised by IE, and isbeing addressed as part of the overall management process review. There is nowpositive action towards the establishment of a post of ‘Head of Profession’ forElectrification, together with a monitoring role for an external ‘Advisor’. Thispromise of progress must be encouraged and closely monitored.



4. RECOMMENDATIONS

IE should implement a range of remedial actions to address the safety of maintenancestaff working on high voltage and traction supply equipment, both equipment andmanagement systems related:

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

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

• Longer term introduce a substation Permit to Work scheme;

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

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



5. 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

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