Taking deviations from normal operation such as track buckles into account in safety management systems
Implemented
Rail R
Accident
19.4.2022
2022-S9
Suosituksen perustelu
Currently safety management and systems are mainly focused on managing the risks of situations involving a change. Track buckles and other deviations in the surface structure of the track always pose a serious risk to the safety of railway traffic. They are handled in accordance with the instructions on deviations, but they may not lead to immediate decision-making or a change in the operating methods. Handling deviations and developing operations are a part of safety management, and their processes are defined in the safety management systems required from actors. The problem is that the potentially cumulative risks of deviations that occur in daily activities are not identified.
Recommendation
The Finnish Transport and Communications Agency emphasises safety management methods when auditing the monitoring of deviations in everyday activities and the assessment and management of risks identified through them in addition to situations involving change.
Suosituksen tarkennus
The recommendation can be implemented by including the proposed issue as one of the focus areas of annual monitoring, for example.
Toimenpide-ehdotukset
Currently safety management and systems are mainly focused on managing the risks of situations involving a change. Track buckles and other deviations in the surface structure of the track always pose a serious risk to the safety of railway traffic. They are handled in accordance with the instructions on deviations, but they may not lead to immediate decision-making or a change in the operating methods. Handling deviations and developing operations are a part of safety management, and their processes are defined in the safety management systems required from actors. The problem is that the potentially cumulative risks of deviations that occur in daily activities are not identified.
Investigation report
R2021-02 Derailment of a freight train in Vesanka on 3 July 2021