Recommendation Date
Recipient Name
Date Closed
KiwiRail's Risk Management Policy for "continuity of core services" did not give proper consideration to the safety of passengers and crew when a core service such as train control failed, causing the widespread stoppage of an entire metropolitan passenger rail system.

On 29 October 2014 the Commission recommended that the Chief Executive of KiwiRail revise the risk rating assessment matrix in its Risk Management Policy to reflect the fact that train control is a safety-critical service, and to consider the safety of people in crowds when assessing and mitigating the risks.
Reply Text
KiwiRail have considered the recommendation and respond as follows:

-The KiwiRail risk matrix, which forms part of KiwiRail's risk management policy, applies across all business units and is designed to provide guidance when assessing many different types of risk for the business.
- The risk matrix provides a consistent methodology that can be applied across different business units and types of risks.
- When assessing a risk, the person or project team responsible must consider the context of the risk; the various consequences that may arise should a risk materialise, and the impacts of those consequences. As there may be multiple potential consequences, the consequence with the highest degree of impact should be used as the factor when determining the overall risk rating. Failure to do this may underestimate the level of risk exposure.
- The Commission have identified that although the initial project team used the risk matrix in order to determine the risk rating, the risk was evaluated based on the impact of continuity of core services being compromised as opposed to potential safety impacts.
- Rating the risk based only on the impact of continuity of core services resulted in the risk not receiving the required level of management attention. Had the risk been evaluated on the basis of potential adverse safety impacts, the risk would have been rated higher and therefore received the required degree of management attention.
- It is KiwiRail's view that the risk matrix did not contribute to the failure to identify train control as a business critical risk. Rather, the consequences of the risk were not adequately identified resulting in the risk not being assessed against potential safety consequences on the matrix. This resulted in a risk rating lower than it should have been.
- A Risk Management Manual was developed in July 2013 to provide guidance to KiwiRail business units in their assessment of risks and the application of the risk matrix. The Risk Management Manual highlights the need to assess all potential consequences and that the highest degree of impact should be used as the factor when determining the overall risk rating. The manual had not been released at the time this incident occurred. It is available to all staff on the KiwiRail intranet and risk assessment practices have improved significantly since this incident occurred.
Related Investigation(s)