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The Review Panel on the Reporting of East Rail Incidents presented its report to the Secretary for the Environment, Transport and Works, Dr Sarah Liao, today (July 12). The full report was released simultaneously to the public. Copies of the report can be downloaded at http://www.etwb.gov.hk.
The Review Panel, having examined the Kowloon-Canton Railway Corporations (KCRC's) procedures and processes leading to the reporting of the fleet-wide underframe equipment mounting problem of East Rail to the Government on January 10, 2006, came to the conclusion that there was a matrix of relevant inter-related factors set against a special set of circumstances surrounding the East Rail incidents, which led to the inadequacy of communication from the KCRC to the Government until January 10, 2006.
For this inadequacy of communication from the Corporation to the Government, the Review Panel considered that those who had responsibility, including the Acting Chief Executive Officer, Senior Director ¡ª Transport, Safety and Quality Manager (SQM) and Safety and Quality Manager (Acting), during the time under review should learn a lesson, although they did not hold any one staff member of the Corporation responsible.
The Review Panel pointed out that it had high expectations of the Corporation as a public organisation. The compressor incident on December 21, 2005 was a rare incident, which the Corporation was investigating, and the Corporation had initiated a number of checks and precautionary measures along the way.
As the Environment, Transport and Works Bureau (ETWB) has since August 2005 encouraged the Corporation to be more forthcoming with sharing information, and the Corporation had agreed to make its best endeavours in this regard, the Corporation should have been more sensitive and alert to the need for more communication throughout the process. The Corporation should have communicated more even if they considered this to be an issue of perceived public safety and not of real public safety.
The Review Panel further pointed out that if the Hong Kong Railway Inspectorate (HKRI) had been alerted promptly, it could have carried out its duty at the earliest opportunity and have promptly assessed the issue of public safety regarding the continued operation of the affected trains.
In the Review Panel's view, the best safety assurances by the Corporation with respect to their own operation of the railway are not acceptable to the public unless and until they are separately assessed by an independent monitor, in this case the HKRI. If the Corporation does not share the relevant information, the Government cannot be in a position to discharge its role.
The Review Panel said it also had high expectations of the HKRI as the railway regulator to ensure public safety in railway operations. If the HKRI could also be more proactive, the two-way communication between the parties would be different.
During the review, the Review Panel had focused on examining two issues: was there a delay by the KCRC in notification/reporting; and was there enough communication between the KCRC and the Government during the period under review.
Regarding the first issue, the Government considered that the Corporation's report of the finding of further cracks on January 10, 2006 was late, but the Corporation disagreed with this view.
The Review Panel ascribed the differences in opinion between the two parties to three main reasons, namely the difference in interpretation of the notification requirements in KCRC Regulations 3 and 4(3)(b); the difference in recollection of what was concluded at the end of the telephone discussion among representatives of the Corporation and the HKRI on December 22, 2005; and the difference in interpretation of the requirement to report matters that are of "public concerns and media interests" in paragraph 6 of the Environment, Transport and Works Bureau's (ETWB) letter.
For the second issue about whether or not there was sufficient communication between the two parties during the period under review, the Review Panel probed beyond the notification/reporting obligations to consider how specific institutional arrangements have limited communication between the Corporation and the Government. The Review Panel pointed out that there were four institutional arrangements that have limited the communication flow: the existing code of practice agreed between the Government and the Corporation for the conduct of investigation of incidents; the line of reporting of the SQM within the Corporation; the interface between the Corporation and the HKRI; and the culture of the Corporation.
In particular, regarding the first institutional issue, the Review Panel considered that there is a need to improve on the existing code of practice agreed between the Government and the Corporation for the conduct of investigation of incidents. It had concerns about the Corporation conducting an extensive investigation into a rare incident, for which the investigative process could have taken a long time, without Government input.
As regards the second institutional issue, the Review Panel considered that the Corporation's Safety and Quality Division's role and responsibilities could be improved and in particular be given more independence from the operation division so that SQM could provide an independent source of opinion to advise the Chief Executive Officer (CEO) in judging matters of safety and quality. The SQM for example, could report directly to the CEO.
Based on their observations and findings, the Review Panel made a number of recommendations to the Government. These are listed out at Annex.
The Secretary for the Environment, Transport and Works, Dr Sarah Liao, appointed the four-member Review Panel on May 3, 2006 to examine the reporting of East Rail Incidents.
Mr Herbert Hui Ho-ming, who has extensive experience in public service, was appointed Chairman of the Review Panel. The three members are Mr Stanley Hui Hon-chung, a senior corporate executive with rich experience in public service; Mr Vincent Lo Wing-sang, a solicitor and KCRC Managing Board Member; and Mr Otto Poon Lok-to, an engineer and managing director. The Review Panel conducted a number of interviews with 20 representatives from the KCRC, HKRI, KCRC Independent Review Panel and the ETWB during their review.
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Annex
Summary of Recommendations
Notification
1. There are divergent views from the Legal Counsels of the two parties on the interpretation of the notification requirements in the KCRC Regulations. We suggest another approach for the Government to consider, which is to keep the KCRC Regulations intact in so far as notifications are concerned, and separately invite the Corporation to report as much as could be agreed based on a new list to be drawn up.
Reporting
2. The Corporation should follow up with the Government and continue to work to agree on a list of specific examples of matters of "public concerns and media interests" to be reported under paragraph 6 of the ETWB's letter.
3. The Corporation and the Government should review the various reporting requirements side by side with the notification requirements, as well as the issues of how compliance is to be checked and monitored, in order to clarify, update, consolidate and streamline in one exercise.
4. The Corporation and the Government should review the standard notification/reporting forms to see if they could succinctly bring to the attention of the Government the crux of the issue concerned.
Interface between the HKRI and KCRC
5. In future, verbal instructions from the HKRI should be promptly followed by a written record of the instructions given so as to avoid misunderstanding of any telephone discussions.
6. The HKRI should be more proactive in its relationship with the Corporation.
7. There should be more meetings and more two-way communication between the Corporation and the HKRI.
8. As the regulator role of the Government towards the Corporation requires a continuous search for the right balance between controls and autonomy, from time to time the Government should take a look at the working arrangements between the HKRI and the operator and make adjustments.
Conduct of Investigation of Incidents
9. In future, for investigation of more complex or serious incidents, there could be more awareness and flexibility to employ independent party/parties either to work with the Corporation or to lead an independent Incident Investigation Team. The independent parties could include the HKRI and other experts and professionals.
10. Comparatively minor investigations should continue to be handled by the Corporation and be independently assessed by the HKRI. The investigative process should be institutionalised. For example, the Corporation should share logs of work in progress with the HKRI periodically throughout the investigative process until the final report is compiled.
Internal Communication within the KCRC
11. The Corporation's Safety and Quality Division's role and responsibilities could be improved and in particular be given more independence from the operation division so that SQM could provide an independent source of opinion to advise the Chief Executive Officer (CEO) when judging matters of safety and quality. The SQM for example, could report directly to the CEO.
Culture of the KCRC
12. The Corporation should learn to become more sensitive to changing demands and changing circumstances and in the case under review, learn to be more proactive in bringing transparency in a more urgent manner to the HKRI and the public. The whole Corporation should look in detail at managing this change and build a solid foundation for it.
13. The Chairman of the KCRC Managing Board and the CEO are two leaders crucial to sustain any initiatives for change in the Corporation.
14. High level concerted effort of the Corporation to look into the twin issues of public safety and communication should be considered to boost attempts to enhance public confidence in the Corporation and devise a better communication strategy.
15. The Corporation should create and explain to staff members a clear vision of the processes involved in changing the Corporation to become more proactive in the issue of transparency.
16. The Corporation should examine how best to take forward this change with the support of the next tier of Senior Directors. The joint effort should be a guiding coalition to drive the change relentlessly.
17. The Corporation should provide training and development to staff members in the face of change.
18. The Corporation should create and train the change agents to contribute to implementing the necessary change.
19. The Corporation should not let communication over railway accidents, service delays, or railway incidents dominate their communication with outside parties. Positive messages from the Corporation must also be made effectively and regularly.
Ends/Wednesday, July 12, 2006
Issued at HKT 15:37
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