Risk Analysis Report

Client: Yarra Trams

Contractor: Risk Removals Ltd
Location: Melbourne, Australia

Location: Melbourne Australia

2014

INTRODUCTION AND PURPOSE

Description of the Assignment:

Risk Removals Ltd. is an experienced firm in the Risk Management Industry.
Based in Australia, Risk Removals operates in the Melbourne Metropolitan precinct and operates as a service
provider on a contractual basis. Risks Removals main focus is on identifying and working on projects within the
Metro sector that contain extensive technical and/ or commercial risks.
KDR Victoria Pty Ltd has approached us on behalf of their Yarra Trams division to qualitatively perform a risk
assessment evaluation on the Operations and Maintenance of their new E class trams.
This assignment aims to collate qualitative data in the form of a report that will outline the Scope of the
Operations and Maintenance (hereinafter referred to as O&M), the risk analysis tasks undertaken and the final
evaluation and treatment of the identified risks.
The main emphasis is on the following:
-

Identifying at least 8 risks in the context of O&M

Performing a Qualitative risk analysis through a workshop format

Using a Qualitative risk analysis matrix to categorize risks based on a 2 dimensional risk factor rating
system (likelihood & consequence)

Evaluating risks Determining treatment & priorities Recommending monitoring & review
procedures per risk.

The AS/NZS ISO 31000:2009 Risk Management Principles and Guidelines standard will be utilized throughout
this assignment as a reference.
Objectives of the Assignment
Through undertaking this Risk assessment assignment, the following objectives are to be met:
-

Raising awareness of the need to identify and treat risks

Increase levels of Stakeholder confidence and trust through risk reduction procedures

Initiating or enhancing controls

Effectively recognize and utilize resources for risk treatment

Highlight the significance of Health and safety as well as Environmental protection

Recognize loss prevention and improving incident management

EXECUTIVE SUMMARY
To Identify, assess, treat and monitor prevalent and hidden risks in the operation and
maintenance of the Yarra trams within the context of the E class sector. Primary research was
undertaken by Team A. This involved consultation of engineering representatives of Yarra
trams and ground support staff; whereas Team B followed through with secondary research
methods, such as usage of the internet. 8 risks with associated controls were identified; they
range from passenger belonging damage to onboard fires. As for the assessment process,
ISO 31000:2009 was used as a benchmark during the identification, analysis and evaluation
process. The treatments were also formulated with the standard in mind; as such they have
been designed with a treatment plan as well.
The findings and recommendations section outline the residual risk and related mitigations.
Our final recommendation is that Yarra Trams should implement all the possible mitigations
that we have proposed within this Risk Management report. Furthermore we would strongly
recommend an annual risk re-evaluation as part of the monitoring and review process
outlined in ISO 310000:2009.

CONTEXT OF ANALYSIS
The advent of Yarra Trams E class is representative of Melbournes rich history, Architecture and Design (Design
Institute of Australia, 2014) and its continuous evolving presence on the global stage as a modern metropolis.
These state of the art trams are the longest in Melbourne at 33m with a capacity of 210 passengers. The arrival
th

of the new E class trams was announced to the public on the (Public Transport Victoria, 2013a) 17 April 2012 by
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The Hon. Terry Mulder, Minister for Public Transport in Victoria, and on the 4 November the first official public
run was held. These next generation trams have been dubbed as E for everyone trams and are part of The
Victorian governments Tram procurement program (Public Transport Victoria, 2013b).The program endeavors
to:
-

Purchase and Operate 50 low-floor trams (E class)

Revamp the existing route 96 line by improving accessibility for individuals with disabilities.

Renovate the Southbank and Preston Tram depots which will house the new E class trams.

The trams are assembled at the Bombardier Rail Vehicle production site in Dandenong; this has resulted in the
creation of 50 new jobs (Public Transport Victoria, 2013b). Although only 5 out of the planned 50 Bombardier

trams are operational along route 96, once all 50 trams are in service, the capacity will increase by 10,500
passengers per day (Public Transport Victoria, 2013a).
Each E class tram costs six million dollars. The total cost of the E class projects implementation is estimated at
exceeding $800 million and is expected to be completed by late 2017.
The E class O&M project is intrinsically fragile; the cost of the implementation is immense, the nature of the
service (transport) means that passenger safety is of utmost importance and the high probability of external
influences affecting the availability of the services are only a few reasons why this project is ideal for an in-depth
qualitative risk management exercise.
Finally, this report is intended for use by the Operations manager of Yarra trams and the scope in terms of the
period under consideration for this risk management report is continuous. Key stakeholders range from
commuters (consumers) to staff and management. As a result, risks could range from physical accidental
damage to intangible financial losses, which could alter the balance of resources, thereby increasing the chances
of similar events occurring repeatedly.

METHODOLOGY USED & KEY STAKEHOLDERS

INVOLVED
Risk Removal (PVT) LTD is a well reputed company in Melbourne which follows the all standard Risk
Management - Principles and Guidelines stated in the AS/NZS ISO 31000:2009. Hence this section was also
conducted as pre-specified.
As advised by our client: Mr. Ramesh Liyanagedera (Director of Infrastructure & Director of Operational
Performance - Yarra Trams (Keolis DownerEDI Rail)), the basic boundaries of this quantitative risk analysis was
defined and a quite a minor research on the company external and internal environments.
The next stage was to identify the hazards, their respective risks and the current mitigations implemented. So we
divided our project team into two groups A and B. Team A was responsible to gather risks the analysis of past
records and incidents regarding trams while team B was responsible to gather information from the field by:
1.
2.
3.
4.

Questioning the passengers for the risks that they had faced
Interviewing tram drivers
Interview with an Engineer at Yarra Trams
Information from public relation officer

Now with almost all of the hazards and their risks identifies the next step was to analyze the risk by evaluating
the consequences and likelihood of the risk based on the statistics found by team A. Each of the risks was rates
according to the predefined risk criteria and the risk matrix found on page (The page which contains the
consequence n likelihood table). And then the risk were prioritized according to their ratings

With this stage completed, we started brainstorming on more effective mitigations to treat the risk identified.
And once the new treatment methods were all sorted out, a treatment plan was made per each risk.
It must be noted that, due to the lack of statistical information regarding E class trams, data from other incidents
relating to trams was obtained and utilized in some sections of this assignment. This is following the underlying
assumption that a tram will always have certain unavoidable hazards in all cases.
Finally as the last stage, the new mitigations were monitored and reviewed. Any remaining residual risk were
identified and treated.

IDENTIFIED RISKS: DESCRIPTION AND EXISTING

CONTROLS
Hazard: Mixed traffic
Risk: Accidents which include:
-

Tram and tram collision,

Tram and other vehicles or public collision

Tram and infrastructure collision.

According to Yarra trams, the average speed of trams is 16 km/h and the maximum speed of the new E class
tram is 80 km/h. So there is a chance of accidents in the shared roads. Transport safety of Victoria website
published the statistics of the various types of accidents. The table below shows their findings.
Occurrence
type
Collision

Derailment
Miscellaneous

Category
type
Person
Road Vehicle
Infrastructure
Running line
derailment
Vehicles
passing
stationary
trams

2008

2009

2010

2011

2012

7
9
7
2
1
2
6
4
Not enough statistics
1
1
0
1

2
3

Figure 1: Rear tram collision at St. Kilda st

Table 1: Adapted from Transport safety website

Existing Controls::
-

Awareness is created among the people to obey the traffic

rules

More road signs are placed

Figure 2: Tram collision at Graham St overpass
(2007)

More service staffs are put on duty in the busy roads to avoid collision with pedestrians like in front of
Myer in Bourke st for route 96.

Hazard:
Wheel worn off beyond limit/ axle failure/over

Running derailment

speeding/coupling failure
Risk:

50

Running line Derailment

40

Wearing away of wheels beyond limit, axle

failures , coupling failures as well as over
speeding could lead to a huge possibility of
trams derailing., which then could lead to a
wide range of other accidents dues to the
derailment which includes tram to tram
collisions, tram to vehicle collisions, tram to

30

Running
derailment

20
10
0
2008

2009

2010

2011

Figure 3: Statistics of derailment in Melbourne

pedestrian collisions etc.

Existing Controls:
Comprehensive check up every two months.

Hazard:
Electricity leakages from the power line onto
the trams
Risk:
Fires on trams
There is always a chance of electricity leaking
on the trams from the power cable above,
which then opens up the possibility of fires
within tram when this residual electricity reach
the electric equipment within the trams.
Existing Controls: Fire extinguished installed in
trams.

Figure 4: Statistics on fire incidents within tram.

Adapted from Transport Safety Australia

2012

HAZARD: Sudden stops

Unwarned stops are a common occurrence with trams. The hazard could be caused by many factors; examples could be:
Drunken pedestrians crossing tram tracks illegally, Vehicles overtaking trams improperly or even drivers temporarily getting
distracted by passenger behavior. Sudden stops give rise to many risks, few of which will be detailed here:
Risk 1: Passenger falling due to inertia resulting in injured passengers
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On the 27 March 2014, a Yarra Trams consumer lodged a complaint via

Facebook regarding many issues facing the E class trams. One major concern
that she touched upon was the poor ergonomic design of commuter support
handles in the context of sudden stops. She says ..and there are multiple spots
where you can't hold on to anything to prevent yourself from falling? Do you
think everyone is tall enough to teach the overhead bars?... And when you
can't reach anything to hold on to, it's really ironic when you hear an
announcement on the speakers going "please hold on as sudden stops are
sometimes necessary". There's nothing to hold on to!!!(Chong, 2014).

Figure 5: E Class complaint [Screenshot]. (2014).

Existing Controls: Passenger support installed

Risk 2: Damage of passenger items

Another risk involving sudden stops is the possibility of damaging commuters personal belongings. Trams in the
metropolitan area travel at an average speed of 11 km per hour (Yarra Trams, 2014). However, tram drivers do have a
tendency to unexpectedly accelerate and maintain a moderately high speed of around 20 30 km per hour. In such cases, a
sudden stop could result in personal belongings falling from the passengers hand or lap and potentially breaking.
In the following account, a passenger details her misfortunate happening when her laptop broke due to a sudden stop:
Hi Yarra Trams, I want to know how I can contact you about damage to my personal property, caused by a sudden stop
and a subsequent fall. I was traveling on a tram on Bourke Street; on Wednesday 13th
November (it was an extremely rainy day and as a result more people than usual were
using the tram). The driver braked suddenly at the Swanston/ Bourke Streets
intersection, causing me to fall (my boyfriend and a stranger came to me assistance),
as a result my laptop screen has been cracked inside and over half of the screen does
not work.(Jayne, 2013)

Existing Controls: Safety brochures already

provided.

Figure 6:Damaged belongings complaint (Swanston st- Bourke St

intersection) [Screenshot]. (2014).

Figure 7: Accident location(Swanston st

Bourke St intersection) [Photograph].
(2014).

Hazard: Brake pads wearing out

Risk: Accident
Due to extensive use for a longer period of time, wear and tear of the brakes is expected in the trams.
So there is a risk of accident if the brakes are not fixed routinely. Accidents may include hitting other
trams from back, failing breaks at signal and failing emergency brakes as well. An example of such
accident is adopted from Herald Sun (Melbourne, Australia), June 2, 2000 News 2 - SECOND, p. 023
1pp which said

"Thirty old W-class trams have been withdrawn from public use because of safety risks

after a serious tram accident yesterday. A tram driver was trapped in his crushed driving cabin for half
an hour after the tram he was driving slammed into the back of another tram in the city. The accident,
which occurred about 4pm near the corner of St Kilda Rd and Albert Rd, is believed to have happened
after the brakes on the W-class tram brakes failed..."
Existing controls: Regular maintenance and repair.

Risk: Health issues, unpleasant travelling experience, less customer satisfaction.

According to Yarra tram website, trams operate for more than 20 hours a day and the annual patronage for
2012-13 was 182.7 million boarding. These figures show how extensively trams are used in Melbourne as a
means of transport. Hence a hygienic and clean tram travelling environment is of great concern for the
operational and maintenance authority of Yarra trams. Especially during the weekend nights the trams become
really dirty and due to the boarding of lots of drunk people the environment becomes unpleasant for many
specially for the children. Therefore there are issues with health and safety and customer satisfaction which
affect the reputation and the income of the Yarra trams. Besides graffiti is also a concern for tram maintenance.
This destroys the look and beauty of trams for which Melbourne is famous.

Figure 8: Graffiti at the body of the brand new tram.

Figure 9: Scratches beside the tram seat

Figure 8 and 9 showing the extent of damage caused

during the first week of operation

Hazard
Tram Drivers

Trams drivers can often be under a lot of stress. Mostly at

the last hour of their work period or the last trip, they
rush to finish the day.
Any fit driver can suddenly grow a physical/mental
condition. It might be some work related injury or an
abrupt health condition such as stomach/intestinal
disorder, muscular (back, neck, shoulder, knee) or some
problems unwinding at home/sleeping disorder thats
affecting his mental state causing disorders like
Figure 10: Drivers cabint in the E class tram.

tension/anxiety/depression/aggression/fatigue.

In heavy traffic congestion a driver can become frustrated pressing the

accelerator and brake pedals an awful lot of times leading to a sore knee
and foot. These could result in wrong judgement and mixing up the
pedals in crucial times. For sometimes the drivers age could also be an
issue. They might not be fit and mentally capable enough to carry on
with the job. Work environment that is the drivers cabin should be be
comfortable enough, not causing further distractions.
Existing Risks
Consequences may be fatal causing accidents such as collisions, not

Figure 11: Graffiti at the body of the brand new tram.

noticing boarding/disembarking passengers while closing doors, inaccurate judgement of traffic lights and
pedestrians and sudden stops. There was even an incident where the driver was flicking through a catalogue
while the tram was in motion.
Existing Mitigations: Regular health checkups

RISK ASSESSMENT: LIKELIHOOD AND CONSEQUENCE

HSE Risk Matrix[Screenshot]. (2014).

Risk: Tram Collisions

Consequence: catastrophic (5)
The severity of the accidents range from injuries to death as well. The pictures above also depict the
consequence of to the accidents. So this is rated as catastrophic due to its significant damage.
Likelihood: Possible (3)
According to the statistics, we have an idea of the frequency of the accidents and we say the likelihood to be
possible.
Overall rating: Extreme
Risk: Running line derailment:
Consequences: Major (4)
According to the past history on tram derailments, it was recorded that such tram derailment caused huge
financial losses due to major accidents involving trams and other vehicles. Furthermore it was also found that
such accident did also lead to severe injuries on passengers. Hence this risk is considered to have a major
consequence.
Likelihood: likely (4)
The statistic on tram derailment over the past few year indicate that tram derailments are likely. Specially
because there have been almost over 30 incidents recorded over each of the past 7years. (Refer to figure 3)
Overall rating: EXTREME

Risk: Fires on trams

Consequences: Major (4)
According to the statistics from the past few years, the fire accidents reported are gradually increasing. Well in
2011 there was a single case reported while in 2012 there were two fires reported in trams. Such an incident
could lead to serious injury to the passengers hence it is considered to have a major consequence. (refer to
graph 1)
Likelihood: Possible (3)
As predicted from the previous statistics it is possible that there can be a fire within any tram.
Overall Risk Rating: HIGH
Risk : Passenger falling off resulting severe injures
Likelihood: 4
Consequence: 3
Although statistical data relevant to this risk was unavailable, upon browsing the internet we came across three
direct complaints on Yarra Trams Facebook page relating to the said risk. Members of the Risk Removal team
are also users of public transport, including the tram services; during their journeys they would experience falls
and witness other passengers getting injured by falling. As a result, the likelihood rating was set at 4. The
consequences of a fall would not result in death or multiple injuries, however it may result in a serious injury
requiring hospitalization. As a result, the consequence rating was set at 3.
Overall Risk Rating: HIGH
Risk : Damage of passenger items
Likelihood: 2
Consequence: 3
Although statistical data relevant to this risk was unavailable, upon browsing the internet we came across one
direct complaint on Yarra Trams Facebook page relating to the said risk. The likelihood of this occurring is
unlikely; however there remains a possibility that occurrences such as this may materialize, hence the likelihood
rating of 2. As for consequences, the damage of consumers property is taken seriously, however it does not fall
under category 4 or 5 due to its unharmful nature. The potential for a lawsuit is valid and as such the
consequence rating is rated at level 3.
Overall Risk Rating: MEDIUM

Risk: Accidents due to wearing out of brake pads

Consequence: catastrophic (5)
The consequences of the accidents due to brake failure range from extensive injuries to death. So the
consequence of brake failing is catastrophic.
Likelihood: Unlikely (2)
Overall rating: MEDIUM

Risk: Health issues and customer dissatisfaction due to unhygienic tram environment
Consequence- Moderate (3)
Herald Sun News reported Graffiti vandals trash Melbourne's new E-Class trams" in November 2013.
The news also said that two seats of the tram were damaged at the same time and this incidence took
place in less than a week the trams were introduced. (Picture 1 and 2 shows the evidence of the
incident.) And couple of maintenance staffs of Yarra tram said "Graffiti is really annoying for us. This
happens sometimes." They also said that during the weekend nights cleaning is a hard job for them. So
the consequence is moderate bearing in mind that it is hard to stop the drunk people but it is
comparatively a bit easier to treat the damage done. But it requires some media attention.
Likelihood: Almost Certain (5)
As people get drunk at every weekend, it is not possible to eliminate the risk entirely and it is expected
to happen. So there is a health and safety issue and also a risk of graffiti.
Overall rating: HIGH
Risk: Irresponsible tram drivers
Consequence- Major (4)
The incident recorded due to irresponsibility of tram drivers are mostly severe incidents leading to huge
financial losses as well as major passenger injuries. Hence this risk is considered to have Major
consequences.
Likelihood: Unlikely (2)
Even though the consequences from this particular risk is quite high, only a very few incidents were
recorded over the past decades, which confirms that it is unlikely to face this risk.
Overall rating: HIGH

RISK TREATMENTS AND PROPOSED

IMPLEMENTATION
Risk
Tram Collisions

Treatment
1.

2.
3.

Running line
derailment

1.
2.
3.

Treatment Plan

Railings should be placed to separate the

tram tracks from the road especially in the
dangerous zone.
Alternative routes should be built to avoid
traffic congestion.
More cameras should be installed to
discourage signal violation.

1.

More frequent overall check-ups on trams

Penalties on tram drivers who exceed the
speed limits
More advanced training on to the
mechanics

1.

As the initial stage we could

implement more frequent
regular tram check-ups. While
at the same time we too could
launch laws to apply penalties
to tram driver who drive over
the speed limit. Finally
introducing modern
technology onto the mechanics
would do it.

2.

More budgets should be

allocated.
Records should be kept
precisely and the accidents
should be investigated to find
the reasons of the accidents
and then necessary steps
should be taken to minimize it
in the future.

Fires on trams

1.

Training Tram drivers to handle minor

incident which involves fires within trams

1.

Tram driver training programs

could be conducted in order to
minimize the chances and the
effects of fires within trams.

Passenger falling off

resulting severe
injures

1.

Lower support handles for better

accessibility for the general population
(high priority)
Padded cork flooring on new low floor trams
to absorb impact upon potential falling
(low priority)

1.

Implementation of this system

could work on a weekly basis
with a select amount of trams
being retrofitted weekly.
However, it must be noted that
potential barriers such as cost
could undermine the
enactment of these treatments.

2.

Damage of passenger
items

1.

2.
3.

Accidents due to
wearing out of brake
pads

1.
2.
3.

Advise customers to use their valuable

belongings such as mobile phones only
when the Tram is stationary. (High priority)
Advise customers to keep their belongings
on the floor next to them (High priority)
Install overhead compartments for fragile
items in tram (Low priority)

1.

Regular and more frequent maintenance

should be done.
Old trams should be replaced and should
not be used under any circumstances.
Staffs should be trained

1.

2.

Implementation of this system

could be immediate through
announcements made on
automated announcements
made on every third tram stop
or through high visibility
posters. However, it must be
noted that potential barriers
such as cost could undermine
the implementation of the final
treatment option
More budgets should be
allocated in repair and
maintenance.
More training session should
be arranged and the staffs
should be encouraged to
attend them.

Health issues and

customer
dissatisfaction due to
unhygienic tram
environment

1.
2.

3.

Irresponsible tram
drivers

1.

More staffs should be appointed for the

weekends.
CCTV camera should be placed inside the
trams like in new E class tram so that anyone
doing any damage inside the tram can be
recorded.
During weekends the trams should be
checked for any alcohol bottles all the time
and should be removed as soon as possible.

1.

Daily rest between two consecutive working

ie. a quality break periods between trips and
a day off/ weekend off.

1.

2.

More workforces should be

recruited
Staff working at weekend night
can be paid higher to
encourage them.

There should be enough

reserve drivers. There should
be regular fitness check-up
before job. Ergonomic layout
of the drivers cabin. To make
them spontaneous you can
involve them in sports or
arrange some quarterly events.

Finding and Recommendations

Residual Risk and Their Mitigations
Risk

Residual Risks

Mitigations

Tram
Collisions

1.

During weekend nights people get drunk

and they drive recklessly which might still
cause accidents.

1.

Running line
derailment:

1.

Tram drivers exceeding the speed limits

1.

Fires on trams

1.

Passengers over reacting during a fire within

a tram.

1.

Passenger
falling due to
inertia of high
speed
resulting in
injured
passengers

1.

Unaware passengers; And there are always

children and aged passengers in the tram
not holding the tram properly

Damage of
passenger
items

1.

Compartment load failure if too many heavy

objects are stowed, resulting in potential
major injuries

1.

By strengthening supporting
structure to withstand 1.5 times
expected load as a safety factor.

Accidents due
to wearing
out of brake
pads

1.

Operation and maintenance staffs might be

irresponsible with their duties.
Maintenance might be infrequent due to
the shortage of funds.

1.

Inspiring the staffs morally and

allocating more funds.

Health issues
and customer
dissatisfaction
due to
unhygienic
tram
environment

1.

Though the new E class trams dont have

CCTV camera, most of the trams do not
have.
There are some graffiti gangs who aim to
target the newly introduced public assets.
It is really hard to control the drunken
people.

1.

More budgets should be allocated

Irresponsibility
of tram
drivers

1.

Still there are few tram drivers who are not

morally perfect with their work

1.

2.

2.
3.

1.

Police patrol in the weekend nights

should be increased to avoid drunk
people coming in front of the trams
or doing any misdeed in the tram
track.
Have speed restriction panels
installed within trams, so that trams
cannot reach speeds above the limit
Launching programs for passengers
to make them aware about how
they should react in the case of a
fire within the trams.

Easily visible warning signs

and more police patrol.

Giving tram drivers training and

encouraging them to do their work
properly(increasing salary helps in

Risk register:

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