Self-monitoring and handling of deviations as a part of the supervision of safety management
Implemented
Rail R
Accident
4.5.2022
2022-S13
Suosituksen perustelu
Currently, ensuring the safe operating condition of the railway rolling stock is based on self-monitoring by the railway operators and the party responsible for maintaining the rolling stock. The aim is to identify the risks caused by the rolling stock through safety deviations and address them.
Based on the investigation, it can be stated that self-monitoring and the supervision of its implementation in their current form are not enough to guarantee the safety of rail traffic. The connection between the fires and the deteriorating condition of the Dm12 rolling stock was not recognised in the self-monitoring, and the recurring fires in the rolling stock have not been addressed sufficiently. The risk to passenger safety caused by several similar incidents has not been identified, either.
Recommendation
The Finnish Transport and Communications Agency develops its operating methods and the focus of its supervision to ensure the functioning of the operators' self-monitoring and handling of deviations in practice.
Suosituksen tarkennus
The recommendation can be implemented by including the matters as a part of the supervision focus area programme of the Finnish Transport and Communications Agency.
Toimenpide-ehdotukset
Currently, ensuring the safe operating condition of the railway rolling stock is based on self-monitoring by the railway operators and the party responsible for maintaining the rolling stock. The aim is to identify the risks caused by the rolling stock through safety deviations and address them.
Based on the investigation, it can be stated that self-monitoring and the supervision of its implementation in their current form are not enough to guarantee the safety of rail traffic. The connection between the fires and the deteriorating condition of the Dm12 rolling stock was not recognised in the self-monitoring, and the recurring fires in the rolling stock have not been addressed sufficiently. The risk to passenger safety caused by several similar incidents has not been identified, either.