SMRT Train Disruptions

Quality & Operational Analysis

Avik Kr. Dutta (17028) Sabyasachi Sarkar (17019) Shouvik Sarkar Production & Operations
(17020) Shubham Raj (17021) Srijon Moitra (17023) Management
INDEX
SERIAL NO. PARTICULAR PAGE NO.
1 SMRT Trains Limited - Company Dashboard 2
2 Operations 3
3 Disruptions 4
4 Causes & Sequence of Events 5-6
5 Ishikawa Diagram Analysis 7
6 5 Why Analysis of the Two Incident 7
7 Measures 8
8 Recommendations of the COI 9 - 11
9 Fine Imposed 12
10 Conclusion 13

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SMRT Trains Limited - Company Dashboard
 Founded - Singapore (1987) (as Mass Rapid Transit Corporation)
 Key people - Desmond Kuek (President & group CEO)
Seah Moon Ming (Chairman) Lee Ling Wee (CEO, trains)
 Headquarters - City Hall, Singapore
 Area served - Singapore
 Services – Railways
 Type - Public
 Industry - Public Transport Operator
 Parent - SMRT Corporation
 Subsidiaries - SMRT Light Rail
 Website - http://smrt.com.sg/
SMRT Trains Limited is a rail operator in Singapore and a wholly owned subsidiary of SMRT
Corporation. Then known as Mass Rapid Transit Corporation (MRTC) when it was incorporated on 6
August 1987, it was renamed as Singapore MRT Limited before taking on its current name, SMRT
Trains, in the year 2004.

On 7 November 1987, MRTC started services on Singapore's first MRT section, consisting of five
stations from Yio Chu Kang to Toa Payoh. SMRT Trains currently manages most of the MRT services in
Singapore except the North East Line and Downtown Line. On 11 December 2001, SMRT merged with
TIBS Holdings. On 10 May 2004, all of the subsidiaries under the SMRT Corporation adopted the SMRT
logo and brand officially.

6 trains – C151, C651, C751B, C151A and C151B are operating on the North South Line and the East
West Line with the newest C151C will be operating in the future. The C830 and the latest C830C trains
are operating only on the Circle Line, the CT251 will be operating only on the Thomson-East Coast
Line, the C801 and the latest C801A are operating only on the Bukit Panjang LRT Line.

The main colour scheme for all the trains are black with red stripe, excluding C651 with the only
exterior with white and red stripes and C801 with green and red stripes. Future SMRT trains and
refurbished trains will bear the new SMRT livery, which consist of white, red, black and yellow pixel
livery, unless LTA uses its own livery for newer rolling stocks, similar to C951 and CT251 (also known
as T251). Current fleets with the new liveries are the C801A and the C151B trains.

SMRT Trains currently has one subsidiary, SMRT Light Rail, which owns the contract to operate the
Bukit Panjang LRT Line.

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OPERATIONS
 Operated in lease from LTA (Land Transport Authority), license and operating agreement.
 SMRT Trains owned operating assets and rolling stock, associated infrastructure such as
tunnel, tracks & stations were owned by LTA.
 Hub & Spoke Model For customer satisfaction LTA worked with SMRT and other Strategic
Business Units to develop the hub-and-spoke architecture for public transport.
 MRT lines acted as hub of the model serving as interchangeable point.
 Bus services were the spoke of the model connecting MRT with nearby locations.

Rail Network growth

LTA recognised the value of optimised road and rail lines due to the increasing scarcity of land. SMRT
focused on building more capacity, adding more stations and bidding for rail lines.

 2004 – Yishun(North) to Jurang East(West).

 2010 – Central Line introduced, expected rise in riders 550,000.
 2009 – 2011 – It had 53 MRT, 14 LRT, 106 trains carrying 106 million people

SMRT Line
 East-West Line (45.4 km)
 North-South Line (44 km)
 Central Line (33.3 km)
 Downtown Line (3.4 km)
 Easing of overcrowding
 Addition of extra trips each train, thus reducing average commuters per train.

Increase in service by adding

 February 2008 – Addition of 83 TTW.
 2009 – Addition of 1000 TTW.
 2010 – Addition of 300 TTW
 2010 – Opening of Central Line
 2011 – Addition of 420 TTW

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DISRUPTIONS
Two Major Train Service Disruptions Occurred on The North-South Line (NSL)
Operated by SMRT Trains Ltd (SMRT) On 15 And 17 December 2011.
Incident on 15 December 2011
 During the evening rush hour on 15 December 2011, four trains lost traction power and stalled
on the north-bound track between City Hall and Braddell stations. The backup power system on one
train (T139) failed prematurely, leaving passengers to put up with darkness and limited ventilation
before the train was hauled to a nearby station. Those on another train (T134) had to detrain onto the
track and walk through the tunnel. Fortunately, apart from two passengers who fainted in the two
stalled trains, there were no casualties arising from this incident.
 The Land Transport Authority (LTA) and SMRT activated their emergency plans in response to
the disruption of service in both directions between Marina Bay and Bishan. However, the bus bridging
services mobilized to transport passengers between the affected stations were unable to
accommodate the volume of displaced commuters. Passengers were also frustrated by inadequate
information and the large crowd. Station staff tried their best to alleviate passengers’ transport
problems, but they were themselves hampered by limited manpower and information. Altogether,
some 127,000 commuters were affected by the disruption which lasted five hours.

Incident on 17 December 2011

 On the morning of 17 December 2011, a number of trains again encountered power supply
problems. Four trains were immobilized along the north-bound and south-bound tracks and another
train was pre-emptively detrained. Fortunately, only one train (T113) needed to detrain its passengers
onto the track and there were no casualties during this incident. About 94,000 commuters were
affected by the ensuing seven-hour disruption which was relatively better-managed, thanks to lessons
that SMRT and LTA had learnt from the incident two days before.

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CAUSES AND SEQUENCE OF EVENTS
The immediate cause of trains stalling was damage to their Current Collector Device (CCD) “shoes”,
resulting from contact with a sagging “third rail”. The third rail supplies electrical current to trains and
is held up above the track-bed by “claws”. During both incidents, sections of the third rail were found
to have sagged after multiple claws were dislodged. With damaged CCD shoes, affected trains were
unable to draw electricity from the third rail to power their propulsion and other systems such as cabin
lighting and air conditioning.

15th Dec 2011

• The incident on 15 Dec 2011 was initiated by a defective fastener on one of the Third Rail
Support Assemblies (TRSAs) on the north-bound stretch between City Hall and Dhoby Ghaut stations.
This caused the claw of that TRSA to dislodge, and the third rail to sag by up to 40mm. By itself, this
would not have caused disruption to train services as the spring-mounted CCD shoes have a tolerance
for sagging of up to 65mm. However, it rendered the adjacent TRSAs more vulnerable to vibration.

• By unfortunate coincidence, the insulators of the two adjacent TRSAs were also defective.
coupled with the effect of greater vibration over time, these two TRSAs also failed gradually. The third
rail then progressively sagged further. As the third rail gradually sagged to around 65mm, passing
trains’ CCD shoes were subjected to abnormal force. (It is believed that as one or more trains passed
this incident site just before the onset of the 15 Dec incident, CCD shoes on some trains experienced
damage that was not easily detectable, such as misalignment, which later led to the 17 Dec incident.)

• The COI is of the view that in the evening of 15 Dec, the third rail sagged beyond 65mm,
damaging two CCD shoes on Train 151 as it passed the incident site. The CCD shoes of subsequent
trains passing the incident site were also damaged by impact with the sagged third rail. Some trains
thus stalled after passing the incident site as they were no longer able to draw sufficient power from
the third rail. At the incident site, multiple trains impacting the sagging third rail eventually caused
three more claws to dislodge, such that a 40m stretch of third rail came to rest on the track-bed.
Thereafter, this segment of the third rail was rendered impassable to all trains.

• Overall, the 15 Dec incident is assessed to be caused by a combination of factors, none of

which individually would have resulted in the incident. The incident could nonetheless have been
prevented. Amongst others, the COI agrees with the expert witnesses that the material defects in the
fastener and insulators likely took time to develop before the 15 Dec incident, but were not identified
and remedied by SMRT’s maintenance regime.

17 Dec 2011
The incident on 17 Dec 2011 to one or more possible “rogue train(s)” that suffered not easily
detectable CCD shoe damage when passing the 15 Dec incident site during the period of time when
the third rail was progressively sagging. Although SMRT conducted CCD shoe checks on its trains on
the night of 15 Dec, these were not sufficiently thorough, such that CCD shoe damage on the “rogue
train(s)” was not detected.

• As the “rogue train(s)” operated along the North-South Line on 16 Dec during revenue service,
it is believed that their CCD shoe(s) became increasingly misaligned as it/they brushed against third
rail covers, thereby destabilising the third rail system. At some point that day, the “rogue train(s)”
caused one claw on the south-bound track between Newton and Orchard stations to dislodge,
resulting in sagging of the third rail by about 40mm.

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• Although SMRT deployed its Multi-Function Vehicle (MFV) to conduct checks on various
sections of the track in the early morning of 17 Dec, the sag in the third rail was not detected due to a
failure of the MFV’s software compounded by shortcomings in SMRT’s maintenance work culture.

• After revenue service commenced on 17 Dec 2011, due to the additional contributory factor
of the offset between the running and third rails being smaller than it should have been (resulting
from possibly improper manual third rail re-gauging, rail head and wheel flange wear, and excessive
vibration if the train had wheel defects), Train 119’s CCD shoes forcefully engaged the sagging third
rail, dislodging an adjacent claw. This then caused a further sag of

the third rail, which caused damage to the CCDs of Train 119 and the trains that passed after it. Four
of these trains subsequently stalled as they were no longer able to draw sufficient power and another
was pre-emptively detrained.

• As with the incident of 15 Dec 2011, whilst the incident of 17 Dec 2011 was caused by a
combination of factors, it could nonetheless have been prevented.

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ISHIKAWA DIAGRAM ANALYSIS

5 WHY ANALYSIS ON THE TWO INCIDENTS

CCD SHOE DAMAGE
•Damage Fasteners
•Defective insulator
•Poor Inherent Claw Design
•Weakness in Design of Third Rail

RAIL SAG
•Damage to Third Rail
•Crack In Third Rail
•Gauge Fouling
•Dislodgement Of More Claws

MAINTENANCE FAULTS
• Poor Maintenance Regime
• Ageing Assets
• Multifuction Vehicle and Software Failure
• Poor Monitoring
• Improper Visual Inspection After 15th December Incident

FAULTY INCIDENT MANAGEMENT

• Inadequate Communication
• Inefficient Crowd Control
• Sabotage or Unlawful Interference
• Improper Bus Bridging Operations
• Inadequate Taxi Service Mobilization

FAULTY MANAGEMENT (Implicated from all above)

•Poor Risk Identification
•Poor Asset Monitoring & Quality Maintainance
•Bus, Taxi & Train Services not in sync
•Inadequate focus on overall quality management

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MEASURES
SMRT was able to fully resume service around noon on Sunday, 18 December.

Speed limit was imposed and directed SMRT to impose a speed restriction of 40kph, instead of the
usual 80kph, on trains running along the floating slab track (FST) sections.

Most of the dislodged claws were found along the FST sections. SMRT also further secured the claws
with cable ties after consulting the manufacturer.

SMRT has also stepped up inspections, along the FST sections, to ensure that any signs of recurrence
are picked up early and rectified.

The condition of the train current collector devices (CCD) is checked daily during operational hours
and also at end when they are sent to depot.

Professional engineers were appointed to inspect the infrastructure integrity of the tunnel fittings
and mountings so that though vibration occurs it won’t lead to any problem.

COI (Committee of Inquiry)

A COI (Committee of Inquiry) was set up that provided detailed reports, causes, recommendations to
SMRT Trains and case report to the concerned Ministry.

The incidents of 15 and 17 December affected more than 200,000 commuters. They have suffered
great frustration, inconvenience and distress.

The execution of Emergency preparedness plans, especially for the first incident, ought to be
significantly improved. SMRT could have better handled the evacuation of the passengers in the
stalled trains to reduce the sense of distress, and provided clearer and timelier information and
instructions to the public, instead of leaving commuters confused and apprehensive in already
disordered circumstances.

That the two incidents have the same proximate cause and happened two days apart raises concerns
about possible systemic shortcomings.

The Committee comprises three capable and experienced members, chosen for their legal,
operational and technical expertise. Under its Terms of Reference, the COI will conduct an
independent investigation into both technical and non-technical aspects of the incidents of 15 and 17
December.

The Committee will investigate the sequence of events leading to the disruptions, as well as establish
the technical, systematic and other causes that may have contributed to the disruptions. Based on
these findings, it will make recommendations to minimise the recurrence of similar incidents, as well
as improve the management of such incidents.

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RECOMMENDATIONS OF THE COI
Engineering & Maintenance
 More effective and timely detection and rectification of third rail sags and TRSA defects
SMRT to develop improved methods for the timely detection of third rail sags, so that the sags can
be treated with utmost urgency as they render adjacent Third Rail Support Assemblies (TRSAs) more
vulnerable to failure. SMRT to formalise procedures to manage dislodged claws and TRSA defects to
ensure that prompt remedial action is taken.

 Strengthen maintenance regime for third rail system

SMRT to fully implement maintenance requirements for the third rail, including annual TRSA
inspections as specified in the original MRTC Maintenance Manual. In addition, SMRT to conduct
non-destructive testing (NDT) on the third rail, in particular the vulnerable areas.

 Review design of TRSA

SMRT and LTA to review current design of the TRSA with view to developing a more robust fastening
assembly for implementation on a prioritised basis. In the meantime, the cable ties used as an
interim solution should be properly inspected and maintained. Furthermore, SMRT to consider
installing steel caps in addition to cable ties to further reduce the likelihood of claw dislodgements.
SMRT should also study if the design of the TRSA covers and claws can be improved to facilitate
inspection.

 Enhance maintenance regime to eliminate third rail gauge fouling

SMRT to enhance the maintenance regime to ensure the third rail alignment is within maintenance
tolerance. Upgrade Multi-Function Vehicle (MFV) capabilities Besides an additional MFV that SMRT
will be purchasing, the existing MFV should be overhauled, or if not cost-effective, be replaced. SMRT
to enhance its SOPs for MFV operation.

 Improve monitoring and rectification of wheel defects

To reduce vibration, excessive levels of which may destabilise the third rail system, SM RT should
introduce a system for real-time detection of wheel defects, and implement robust measures to
ensure that wheels with defects are re-profiled in a timely manner on a prioritised basis. SMRT should
also investigate the root causes of wheel defects and take the necessary corrective/preventive actions
to reduce their occurrence.

 Improve CCD maintenance regime

SMRT should strengthen the CCD maintenance regime by implementing an annual check on the
gauging and upward force of the CCD, and explore the feasibility of equipping trains with sensing
devices to alert if there are CCD shoe problems. SMRT should also conduct a study to determine the
optimum torque for the bolts that secure the copper conductor strips of the CCD shoes to the trains
to minimise the occurrence of CCD shoes not detaching cleanly, and to implement a bolt torque check
regime. To prevent damaged CCD shoes from further damaging the third rail system, SMRT to
consider adopting the practice of immediate removal of damaged CCD shoes from stalled
trains before they are hauled away.

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 Improvements to back up power supply
SMRT should conduct more frequent battery checks, and review the adequacy of the current 45-
minute backup power provision.

 Examine the feasibility of equipping older trains with Train Integrated Management
System ITIMSI
LTA and SMRT to study the feasibility of equipping the older (first and second generation) trains with
TIMS to provide real-time information to detect train faults. Improve Overall Maintenance Regime
and Regulatory Framework.

 Review of asset maintenance and regulatory framework

Given the age and increased usage of NSEWL, SMRT and LTA to jointly review the current asset
maintenance framework to ensure safe and reliable train operations. One specific suggestion is for
LTA to impose a requirement on SM RT to conduct a Maintenance Management System audit, which
can be done on a 3 or 4-yearly basis to identify areas of possible improvements. In reviewing and
enhancing the asset maintenance framework, it is critical that both LTA and SMRT ensure that their
respective roles for asset maintenance are clearly understood by both parties at all levels.

 Move to a risk and reliability-based maintenance approach

SMRT to move towards a risk and reliability-based maintenance approach and adopt more condition
monitoring and predictive maintenance.

 Improve internal processes and harness technology to enhance maintenance regime

SMRT to institute processes and harness technology to improve maintenance capabilities, including
harmonising inspection and maintenance procedures, reviewing its maintenance documentation
processes with a view to ensuring a higher level of accuracy and reliability, reviewing the time that
maintenance records are kept, enhancing maintenance IT systems, and other measures to ensure
greater collaboration among SMRT technical departments for more effective and systematic failure
identification and improvement of maintenance practices.

 Formalise forensic investigation procedures

LTA and SMRT to review and formalise the procedures to ensure thorough forensic investigations and
risk assessments following significant incidents.

Incident Management
 Scheduled closures for maintenance work
LTA and SMRT to study further the need for scheduled closures of sections of the system for more
comprehensive maintenance work to be carried out, taking into account the impact on commuters,
once a more comprehensive maintenance plan has been developed.

 Develop an integrated Land Transport Emergency Plan

LTA to take the lead in working out an overall integrated land transport emergency plan articulating
response strategy and the roles of various stakeholders and their communication and co-ordination
protocols, and to ensure that the other stakeholders also develop and document their respective
supporting plans. LTA to also review the timeliness of its activation of the LTA Public Transport-Crisis

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Management Team (PT-CMT), which is currently stipulated to be convened within two hours upon
activation to assist the Land Transport Operations Centre (LTOC) to oversee the critical system-wide
issues that are beyond the PTO’s role.
 Review SMRT command structure
SMRT currently has a command and control structure centred on the OCC of the incident line. For
major incidents that have SMRT-wide impact, SMRT should review if this current arrangement is
adequate. In particular, SM RT should consider having an overarching SMRT incident "command
centre" suitably staffed and equipped to manage large-scale incidents, to better integrate and manage
the train recovery operations, bus bridging operations, public communications, and interaction with
other agencies and stakeholders.
 Simplify SMRT's command and control structure, and ensuring greater clarity of roles at
different levels
SM RT to review its command and control structure to see how it can be simplified to make it more
effective and clear, ranging from management and OCC to ground staff like station managers. The
SMRT Rule Book, which follows the traditional style of the Railway Rule Book, to be reviewed and
simplified. Improving incident management plan with an emphasis on passenger well-being
 Review of the Railway Incident Management Plan
SMRT to review its RIMP with an emphasis on passenger well-being, as well as to cater adequately to
larger-scale disruptions. Review alternative transport modes LTA and operators to study how to
enhance the current bus-bridging plan, as well as to study alternative transport modes during service
disruptions.
 Review train-to-track detrainment SOPs
LTA and the operators to holistically review train-to-track detrainment SOPs and equipment with view
to enhancing safety and improving the passenger experience.
 Improve information dissemination
SMRT to improve communications and information dissemination to the public, with the police and
SCDF, and between its command elements and its ground elements at the stations during disruptions
and during incident management readiness
 Enhance in-house capabilities
SMRT to look into enhancing in-house incident management capabilities such as in customer service
to assist passengers during disruptions and crowd control. SMRT to also ensure that relevant staff are
briefed in a timely manner about causes and details of significant incidents post-incident, and provide
more comprehensive training to staff on how to respond to disruptions.
 Enhance incident readiness
LTA and the PTOs, together with other relevant government agencies, to conduct train service
disruption exercises, including involving ground deployments.
 Review of risk identification process
SMRT to review its risk identification process to better identify risk scenarios for which it should
develop preventive measures and contingency plans.

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FINE IMPOSED
As sourced in the official Land Transport Authority site news stated on 16th July 2012

Money will be donated to the Public Transport Fund to help needy families with transport fares
The Land Transport Authority (LTA) will impose the maximum financial penalty of S$2 million on SMRT
for the two disruptions to train services along the North-South Line (NSL) on 15 and 17 December
2011.

LTA's investigations have found that SMRT had failed to meet its licensing obligations for the North-
South and East-West Lines (NSEWL). It has failed, among other things, to exercise due diligence and
vigilance expected of a public transport operator, and to maintain its network in good and efficient
working condition. In both incidents, SMRT was also found to be in breach of the Operating
Performance Standards (OPS) for the NSEWL.

LTA's internal investigation on the causes of the incidents is consistent with the findings of that of the
Committee of Inquiry's (COI), in particular that the incidents were preventable. LTA has also assessed
that there were overall shortcomings in SMRT's maintenance and monitoring regime.

Under Section 19 of the Rapid Transit Systems (RTS) Act, a licensed public transport operator can be
fined up to $1 million per incident, if the operator fails to comply with the Operating Performance
Standards and other regulatory requirements. In assessing the penalty amount, LTA considers the
facts of the case, severity of the incident and any relevant mitigating factors that may apply. It will also
consider any representations which the operator may make.

More Holistic and Robust Framework for Maintenance

Following the December 2011 incidents, the LTA-SMRT Joint Team was set up to look into reducing
disruptions and increasing the reliability of the North South East West Line. SMRT has also started a
comprehensive programme to improve its service reliability and incident response capabilities. A
number of improvements have been completed while others are in the midst of implementation.

LTA will continue to work closely with SMRT to follow through with the COI's recommendations. It will
also work with RTS operators to move towards a more holistic and robust framework for maintenance
issues, so that problems can be detected early and there can be timely preventive action.

Donation of Fine to the Public Transport Fund

The $2 million will be donated to the Public Transport Fund to help needy families with transport fares.

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CONCLUSION
Both the 15 and 17 December 2011 incidents were preventable. Effective maintenance on the part of
SMRT will play a critical role to prevent them from happening again. The NSEWL is ageing, and with
the added strain that comes with increasing ridership, there must be increased attention paid towards
the maintenance regime.

Noting that it was only in 2010 that an engineering officer was routinely in attendance at SMRT Board
meetings, there is a need to position SMRT as principally an engineering and operations company, and
to view the two disruptions as an opportunity to undertake a more fundamental review of its
maintenance approach to achieve maintenance excellence.

Nevertheless, LTA as the regulator should also periodically review its regulatory regime to fulfil its duty
in maintaining effective oversight of the PTOs’ maintenance regime. Both sides must play their part.
In terms of incident management, while the scale of the incidents on 15 and 17 December 2011 was
overwhelming, SMRT and LTA have pro-actively identified various improvement measures, some of
which have already been put in place. With the various recommendations implemented, the COI was
confident that future incidents, should they recur, will be much better managed.

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