Maintenance related losses a study at the Swedish National Rail Administration

Abstract: The global competition among companies has lead to higher demands of the production system. Quality has become an important factor for competition. Customer satisfaction depends upon the fulfillment of a number of quality parameters. Two important quality parameters are dependability and safety. Maintenance is performed to ensure dependability and safety of the systems. Normal operation will gradually impair the performance, due to the normal degradation caused by wear, dirt, corrosion and overloading. Maintenance is therefore important for the prevention of hazardous states of the systems, i.e. for incident and accident prevention. However, although maintenance is performed in order to increase the safety, incorrectly performed maintenance can reduce the safety of the systems and create losses. The purpose of this thesis is to explore and describe different deviations from the intended maintenance activities that results in losses, manifested in incidents and accidents. The main aim of this is to better control the contracted maintenance work, and thereby ensure safety for passengers and personnel at the Swedish National Rail Administration. The results are aimed to be a part of the continuous improvement work at the Swedish National Rail Administration. To fulfil the stated purpose an archival study supported by a literature study has been performed. The archival study focused on incidents and accidents related to the Swedish railway. The main objective of this study is to identify, classify and analyze maintenance related incidents and accidents. The result of the study can be described in two parts. The first part is an analysis model for the investigation of maintenance related incidents and accidents. The model is founded on theoretical findings. The model describes the chain of events starting with lack of control and ending in the losses, manifested in incidents and accidents. The second part, which is founded on empirical findings, is a taxonomy of incidents and accidents related to the Swedish railway. The maintenance related incidents and accidents are analysed and classified. The primary causes to these incidents and accidents are determined and discussed. About 30% of the track related incidents and accidents were caused by improper maintenance. Some contributing causes to these were lack of communication and rule violations.