System management
Implemented
Rail R
Accident
31.8.2009
S1/2008R/S270
Suosituksen perustelu
Several parties from the Finnish Rail Administration and VR Group participate in the traffic control system procurement and management. The organising of work packages and the assignment of project ownership and responsibilities over the life cycles of the systems are unclear. The centralisation of traffic control requires continuous introduction of new automation and information technologies. The deviations investigated have involved shortcomings in system user instructions as well as difficulties for the users to identify problematic situations on the display screens. The responsibility for ensuring that the systems function properly and that the corrective actions are monitored should be placed near the end users.
Recommendation
The experts using traffic control systems on a daily basis should participate in the specifications, inspections, and start-up activities of these systems and also take part in the system administration during the life-cycle of the system.
Toimenpide-ehdotukset
Several parties from the Finnish Rail Administration and VR Group participate in the traffic control system procurement and management. The organising of work packages and the assignment of project ownership and responsibilities over the life cycles of the systems are unclear. The centralisation of traffic control requires continuous introduction of new automation and information technologies. The deviations investigated have involved shortcomings in system user instructions as well as difficulties for the users to identify problematic situations on the display screens. The responsibility for ensuring that the systems function properly and that the corrective actions are monitored should be placed near the end users.
Investigation report
S1/2008R Safety study on traffic control deviations in Kouvola, Finland