The reporter has raised a safety concern in relation to inadequate Technical Maintenance Plans (TMP) and identified design risks not being addressed prior to project commissioning.
The reporter states that [State Transport Authority] [department] are responsible for the delivery of the [Program] which includes design and construction of track, drainage signalling and power assets. The project design risks were identified by the consultants in [year] via Safety Assurance Reports (SAR) for each design.
The reporter states, the power assets include [Location 1] substation and [Location 2] substation and cable tunnel. The first high voltage feeder at [Location 1] substation commenced commissioning on [date] and [Location 2] substation on [date]. [Operator] has allowed commissioning to progress without SAR risks being closed out with subject matter experts and without TMPs being ready for implementation. Both of these activities should have been completed in the design phase; not commissioning phase.
The reporter further states, the lack of adequate TMPs and or Claim of Similarity (CoS) can impact on the safety of maintenance staff. Contractors' submissions have been rejected by [Operator] TMP team and new TMPs and CoS have not been submitted. The cable tunnel ventilation does not have a relevant TMP. This activity should also have taken place in the design phase and not the commissioning phase.
The reporter is concerned for the ongoing safety of rail safety workers conducting maintenance of the [Location 1] and [Location 2] substations as the result of inadequate TMPs and identified hazards not being closed out prior to commissioning of the project.
[Operator] response
Response to rail safety confidential reporting RR2024-00012 - [Location 2] and [Location 1] commissioning.
Overview
A safety concern has been raised via the Australian Transport Safety Bureau (ATSB) confidential reporting scheme in relation to inadequate Technical Maintenance Plans and identified risks not being addressed prior to project commissioning of assets at [Location 1] and [Location 2] substations.
Concerns Raised and Responses
1. A safety concern has been raised in relation to inadequate Technical Maintenance Plans (TMP) and identified design risks not addressed prior to project commissioning.
Project teams working across the rail network are required to develop maintenance plans for all assets being constructed and installed across network early in the project lifecycle. If a similar asset exists on the network, project teams can complete a Claim of Similarity (CoS) report and provide evidence the assets being installed are similar or the same.
If similarity can be demonstrated project teams are not required to undertake a Maintenance Requirements Analysis (MRA) which is a significant undertaking to determine the preventive and corrective maintenance procedures to be applied to each asset over its useful life.
If a project team can demonstrate similarity, then the [Operator] Technical Maintenance Plan (TMP) team can apply an existing TMP to that asset and the TMP can be loaded into the [Operator] maintenance system.
The [Operator] TMP team is responsible for the review of all CoS reports to determine if claims provided have the appropriate level of evidence. A CoS report has the following potential outcomes:
- Approved and CoS assets are then prepared to be loaded into [Maintenance system]
- Rejected - additional information required to determine CoS
- Rejected - not similar/errors in submissions etc.
- Rejected - similar however a modified or bespoke TMP to be created.
[Location 1] and [Location 2] substation project has been running since [year], the [Location 2] substation and cable tunnel commissioning happened progressively over a period of [x] months [date range].
The [Location 2] and [Location 1] project team submitted their CoS reports for the construction of assets being built and installed at these locations in [year].
As a project gets nearer to construction it is not unusual for the TMP team to have a closer look at all CoS reports to ensure assets being installed have the appropriate maintenance assigned and to prepare the asset register for loading maintenance plans and task lists into [Maintenance system].
In [date] the TMP team reviewed the CoS reports submitted for [Location 2] substation including the cable tunnel and several issues were identified by the team. These issues were fed back to the project team and a series of discussions, site visits and workshops began. This working group developed a plan for each asset where concerns were raised.
[Operator] TMP team and the [Location 2] project teams worked through the following issues at [Location 2]:
Cable tunnel - A bespoke TMP would be more suitable given the risks identified entering the tunnel for maintenance. The bespoke TMP would align the assets within the tunnel to reduce the frequency in which maintainers entered the tunnel.
Architectural security fence - After a series of workshops with the project teams the TMP team has rejected the original CoS and a new TMP will be developed for the security fence. The fence installed was quite different to what is being used across the network. It has a blast resistant capability and anti-graffiti mesh which [Operator] maintainers have not seen before.
Eye wash station - Has additional functionality, it will trigger an [alarm] if used. [Operator] TMP team will create a TMP by modifying an existing TMP to incorporate the additional functionality.
Oil water separator - Has a digital alarm, an existing TMP will be modified to include additional maintenance requirements.
All CoS reports and bespoke TMP’s for [Location 2] substation are planned to be resolved by [date].
Official handover for [Location 2] substation will be on [date], where a detailed final assessment of the project risk register will take place and any residual risks will be handed over to the appropriate person in [Operator] as identified in projects risk register and as outlined in the SAR.
2. [Operator] has allowed commissioning to progress without SAR risks being closed out with subject matter experts and without TMP's being ready for implementation.
The Safety Assurance reports (SARs) are progressively updated over the life of a project. The SAR is reviewed at each configuration management gate and reviewed by the independent professional reviewer. The SAR report for [Location 2] substation has had [xx] reviews and updates over the life of this project.
Preparation of the final SAR is underway and will be completed in [date] following the final asset handover [date].
Commissioning of [Location 2] substation cable tunnel did take place with the following mitigations:
- TAO (Technically Assured Organisation) issued letter of assurance for all the assets being commissioned.
- Working group established and facilitated workshops between [State Transport Authority], [Operator] TMP and maintenance to develop an appropriate solution for assets requiring further work.
- A (new) weekly Project Control Group (PCG) created to register and track outstanding issues until closed out.
- TMP group leader assigned full-time to oversee [Location 1] and [Location 2] outstanding CoS issues.
- Local instructions issued - Maintenance Engineering Support - work orders until all TMP/CoS resolved.
- No maintenance has been assigned to the cable tunnel to eliminate the risks of entering the tunnel whilst the bespoke TMP is created.
All CoS reports and bespoke TMP’s for [Location 2] substation are planned to be resolved by [date].
3. The reporter further states, the lack of adequate TMP's and or Claim of Similarity (CoS) can impact on safety of maintenance staff. Contractors' submissions have been rejected by [Operator] TMP team and new TMPs and CoS have not been submitted. The cable tunnel ventilation does not have a relevant TMP. This activity should also have taken place in the design phase not the commissioning phase.
On [date] the TMP team reviewed the CoS reports submitted for [Location 2] substation including the cable tunnel and several issues were identified by the team. These issues were fed back to the project team and a series of discussions, site visits and workshops took place to develop a plan for each asset where concerns were raised.
The TMP team also sought advice from the professional heads within [Operator] on [date] on the best outcome considering the risks associated with entering the tunnel for maintenance.
It was agreed on [date] that a bespoke TMP be created using existing TMPs installed across the network and a new TMP for the ventilation system. All the assets including the cable tunnel would be bundled together to create one tailored TMP that lists all applicable service schedules and the required intervals, as well as any special information pertaining to the required maintenance for the [Location 2] cable tunnel.
All CoS reports and bespoke TMPs for [Location 2] substation are planned to be resolved by [date].
No maintenance has been assigned to the cable tunnel to eliminate the risks of entering the tunnel whilst the tailored TMP is created.
4. Concerns raised for the ongoing safety of rail safety workers conducting maintenance of the [Location 1] and [Location 2] substations as the result of inadequate TMPs and identified hazards not being closed out prior to commissioning of the project.
[Location 1] and [Location 2] substation project has been running since [year], the [Location 2] substation and cable tunnel commissioning happened progressively over a period of [x] months [date range]. Final commissioning and asset handover is scheduled for [date].
[Large amount] of assets have been installed and commissioned at these locations. On review in [date] a small number of assets had additional functionality and required a modified TMP be created to ensure [Operator] maintainers had the appropriate schedule of maintenance tasks to undertake maintenance of these assets.
Examples:
1. The oil water separator at [Location 2] and [Location 1] had additional digital alarms which our maintainers had not seen before, we could still leverage of an existing TMP, however add additional scope to include maintenance for additional features.
2. The security fence had a wire mesh not seen before across the network, a new TMP would be required.
3. The eye wash station at [Location 2] and [Location 1] is the same brand/type used widely across the network with an additional [alarm] which the TMP team plan to leverage off an existing TMP and create a modified TMP for these locations.
All CoS reports and bespoke TMP’s for [Location 2] substation are planned to be resolved by [date].
[State Transport Authority] response
[State Transport Authority] has investigated the concerns raised in the report in collaboration with key stakeholders within [Operator] management and notes that [Operator] has previously responded to similar correspondence.
[State Transport Authority] generally concurs with the response provided by [Operator] noting that some of the actions have not been fully closed out as of [date]. [State Transport Authority] will use our best endeavours and work collaboratively with [Operator] to close these actions out as soon as possible.
In the interim [State Transport Authority] does not believe that the assets that have been commissioned into service compromise the ongoing safety of rail safety workers conducting maintenance of the [Location 1] and [Location 2] substations. The new substations at [Location 2] and [Location 1] are the same as other existing substations in the rail network in form and function.
A procedure has been provided to [Operator] along with relevant training to facilitate maintenance staff to safely access the [Location 2] cable tunnel. Safety Assurance Reports will continue to be updated, in consultation with [Operator], to reflect the corresponding staging of the project as it progresses towards completion.
ONRSR confirms receipt of ATSB REPCON report number RR2024-00012 regarding technical maintenance plans and risk management associated with commissioning infrastructure assets. ONRSR has reviewed the reporter’s concerns and the responses by involved parties. ONRSR is satisfied with the mitigation strategies implemented by the involved parties and will liaise with the accredited rail transport operator involved at the next stakeholder engagement meeting to further explore the operator’s processes for technical maintenance plans and commissioning of infrastructure assets. ONRSR will also seek a status update of the actions intended for completion by [date].