Railway Accident

Railway Accident Inquiry Reports-Pub.-2010

PROCEDURE

STATUTORY INQUIRIES INTO RAILWAY ACCIDENTS RULES, SCOPE AND PROCEDURE

1. RULES

1.1 Rules for Inquiry into Railway accidents :-

Rules for the guidance of the Officers of the Commission of Railway Safety for holding inquiries into Railway accidents are contained in the "Statutory Investigation into Railway Accidents Rules, 1998" notified by the Ministry of Civil Aviation in the Gazette vide G.S.R.No. 257 dated 26 12.98 and G.S.R. No. 63 dt. 2.1.99.

1.2 When should a Statutory Inquiry be held? :-

A statutory inquiry by the Commissioner is obligatory in every accident to a passenger-carrying train which is attended with loss of human life, or with grievous hurt as defined in the Indian Penal Code, to a passenger or passengers in the train or with serious damage to railway property of the value exceeding Rs. 25 lakhs. The Commissioners may also inquire into any other accident which in the opinion of the Chief Commissioner or the Commissioner of Railway Safety requires the holding of an inquiry. Where the Chief Commissioner of Railway Safety considers the holding of an Inquiry into an accident necessary, he may either hold the inquiry himself or direct the Commissioner of Railway Safety to do so.

The Inquiry shall be obligatory only in those cases where the passengers killed or grievously hurt were travelling in the train. If a person travelling on the foot-board or roof of a passenger train is killed or grievously hurt or if a person is run over at a level crossing or elsewhere on the railway track, an inquiry is not obligatory. Workmen's trains or ballast trains carrying workmen shall also be treated as passenger trains and in the event of a workman getting killed or grievously hurt as a result of an accident to the train, an inquiry shall be obligatory.

1.3 Procedure when Commissioner is unable to hold an inquiry:-

When a Commissioner is unable to hold an inquiry, he is to inform the Chief Commissioner of Railway Safety of the reasons as to why an inquiry can not be held by him. The Chief Commissioner may himself hold the Inquiry or may direct another Commissioner to inquire into the accident or else the inquiry can be entrusted to the Railway itself, who will then appoint a Committee of Railway Officers to inquire into the accident. The Committee's inquiry report is submitted to the Commissioner of Railway Safety who scrutinises it and in case he agrees with the findings, forwards it to the Chief Commissioner of Railway Safety along with his views on the findings and recommendations made. If, on the other hand, the Commissioner of Railway Safety considers that an inquiry should be held by himself, he proceeds to do so.

1.4 When shall the Commissioner stop or discontinue his inquiry?

Whenever the Central Government appoints a Commission of inquiry under the Commission of Inquiries Act, the Commissioner shall discontinue his inquiry.

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PROCEDURE 2. SCOPE

The Commissioner holds inquiries into accidents with a view to ascertaining the causes. Investigations are also carried out into the question whether prompt and adequate steps were taken by the railway administration for relief measures such as provision of first aid, medical treatment and refreshments to passengers, evacuation of injured passengers and other facilities like arrangements for transhipment, completion of their journey to destination, running of duplicate trains etc. As a result of his inquiry, the Commissioner may also make recommendations which are designed to prevent the recurrence of similar accidents, and which may suggest laying down new rules or modifying existing rules of working, and improved standards of signalling, installation and maintenance of track, bridges, etc. He also comments on matters observed by him during the course of his inquiry which may not have any direct bearing on the cause of the accident under investigation but which may in some cases affect the safe working of the railway and lead to accidents.

3. PROCEDURE FOR CONDUCTING A STATUTORY INQUIRY

As soon as the Commissioner of Railway Safety receives intimation about the occurrence of a serious accident, he proceeds to the site, conducts inspection of the accident site and records all particulars relevant to the accident. He then fixes a date for the inquiry, which is given publicity in the media. Officers of the local Magistracy and police are separately advised of the dates of the inquiry. The public is invited to give evidence in the inquiry in person or to write to the Commissioner.

4. POWERS OF COMMISSIONER IN RELATION TO INQUIRIES.

As per the Section 116 of the Railways Act, 1989, Commissioners are deemed to be Civil Court.

Section 116 read as under -

Section 116 (1)- For the purpose of conducting an inquiry under this Chapter into the causes of any accident on a railway, the Commissioner shall, in addition to the powers specified in Sec. 7, have the powers as are. vested in a civil court while trying a suit under the Code of Civil Procedure, 1908 (5 of 1908), in respect of the following matters, namely

(a) summoning and enforcing the attendance of persons and examining them on oath;

(b) requiring the discovery and production of documents;

(c) receiving evidence on affidavits; (d) requisitioning any public record or copies thereof from any court or office;

(e) any other matter which may be prescribed. (2) The Commissioner while conducting an inquiry under this Chapter shall be deemed

to be a Civil Court for the purposes of Sec. 195 and Chapter XXVI of the Code of Criminal Procedure, 1973 (2 of 1974).

*******

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ABSTRACTS OF

RAILWAY

INQUIRY

ACCIDENT

REPORTS


ACCIDENT - (i)

THE ABSTRACT OF THE REPORT OF COMMISSIONER OF RAILWAY SAFETY, ON THE FIRE IN 1520 UP (DMU SHUTTLE) AT KMS. 1238/7 BETWEEN MARKUNDI (MKD) TIKARIYA (TKYR) STATIONS OF MANIKPUR-SATNA SECTION OF JABALPUR DIVISION OF WEST CENTRAL RAILWAY AT 20.20 HOURS ON 10.05.2005 I. BRIEF DESCRIPTION

1.1 THE ACCIDENT :- The 1520 Up arrived at MKD on 10.05.2005 at 20.19 hrs and started at 20.22 hrs. After departure of the train, Station Master/ MKD felt some burning smell from the passing train. He informed the Section Controller, Jabalpur and SM/TKYR that there was brake block jamming in some coach of 1520 Up and requested SM/TKYR to check it. In a short while, when the train had passed the Starter signal, the Guard of the train saw smoke coming out from the engine room of DPC (Diesel Power Car). He immediately informed the Pilot of the train regarding smoke and asked him to stop the train. The train was stopped at km.1238/7 after traveling about 2.3 km from MKD. The guard informed SM/MKD about the fire in his train who in turn informed section controller, Jabalpur about it.

The Assistant Pilot and Guard asked the passengers to get down and stand away from the burning train. The burning had started from the Rectifier panel of DPC No. 12003 at MKP end. Fire brigades were called by SM/MKD and Civil Authorities from Karvi. The fire tenders arrived at site at 22.35 hrs. and ART/Satna arrived at site of accident at 22.45 hrs. The fire continued to burn the coaches in series @ 20 to 30 min. per bogie, and by the time ART/ Satna reached, all the bogies were burnt. The fire had reached DPC car no. 12009 at Satna end. Attempts were made to extinguish the fire with sand and water in the ART. The fuel tanks and supply pipe lines of DPC intact.

The Asst. Pilot and Guard uncoupled the Schaku coupling between the burning DPC and the 1st passenger coach No. 12417 A at about 21.10 hrs. The Loco Pilot of front DPC No. 12009 tried to restart but could not start the engine. Hence, the burning DPC 12003 could not be isolated from unburnt coaches. The Relief Loco, to pull and isolate the unburnt coaches from burning DPC12003 reached the site of accident at 22.45 hrs. By that time all coaches were burnt. There was little damage to undergears but interiors were totally burnt.

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ACCIDENT - (i)

1.2 The train at the time of the accident was stationary.

1.3 The weather at the time of accident was clear and visibility was good in the train head light.

1.4 No passenger causalities as a result of the accident.

1.5 The total cost of damage to Railway assets was assessed at 26.5 lakh. II CAUSE OF THE ACCIDENT

2.1 Having carefully considered the factual, material and circumstantial evidence CRS has concluded as under :-

2.1. 1 Cause :- Accident occurred due to malfunctioning of auxiliary rectifier-cum-regulator panel of DPC 12003.

2.2 The Zonal Railway has agreed with the findings of CRS in respect of Cause.

2.3 On scrutinising the report CCRS considered that the conclusion arrived at by CRS are acceptable.

2.4 The cause as established by CRS was accepted by the Railway Board.

III. REMARKS AND RECOMMENDATIONS

3.0 The Remarks and Recommendations made by CRS and the Comments of the Zonal Railway are reproduced below alongwith remarks of CCRS and Railway Board thereon :-

3.1 (a) Recommendation :- The Railway Administration should issue guidelines for action to be taken by field staff in case of fire in one of the coaches of DMU rakes.

(b) Zonal Railway Comments :- Guidelines issued to field staff on combating fire in such cases.

(c)

(d)

3.2- (a)

Remarks of the CCRS :- Railway Board may like to issue comprehensive guidelines for DMU and other trains having Schaku couplers.

Remarks of the Railway Board : The matter has been exmained by Board and issue of any guidelines from the Board in this matter is not considered desirable.

Recommendation :- For skill development of Mechanical Officers training programmes should be organized at various levels regarding configuration

and operation of various types of locomotives and rolling stock.

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ACCIDENT - (i)

(b) Zonal Railways Comments :- For skill development of Mechanical Officers training programmes are regularly organized at IRIMEE/ Jamalpur, ICF-Chennai, RCF-Kapurthala and DLW-BSB at various levels such as configuration of various types of locomotives and rolling stock. Officers of mechanical department are nominated and directed regularly for these courses.

(c) Remarks of the CCRS :- Noted.

(d) Remarks of the Railway Board : The position has been explained by the Railway Administration to the satisfaction of the Commission.

3.3 (a) Recommendation :- In addition to above recommendations, action or following aspects having oblique relation with safety may be taken:-

Recommendation :- Asst. Driver to look around both the DPCs on stopping stations.

(b)

(c)

(d)

3.4- (a)

(b)

(c)

(d)

3.5- (a)

(b)

Zonal Railways Comments :- It is not possible for the ALP to do ook around duty of front and rear DPC during stoppages (being of 2/

3 minutes). Instructions already issued to book one ALP at rear DPC also for this work.

Remarks of the CCRS :- It should be duty of the Guard who is in the rear DPC and not that of ALP. Railway Board may like to take a view in this regard.

Remarks of the Railway Board : Necessary instructions in this regard have been issued vide Board s letter No.2008/Safety(A&R)/19/8 dated 09.09.2008.

Recommendation :- Guard should be counseled for better response in emergency.

Zonal Railways Comments :- Letter to Area Manager/Satna already written for counseling the guards working on DEMU as desired.

Remarks of the CCRS :-Action taken noted.

Remarks of the Railway Board : The position has been explained by the Railway Administration to the satisfaction of the Commission.

Recommendation :- Concerned officers should be verbally counseled.

Zonal Railways Comments :- Officers have been verbally counseled.

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ACCIDENT - (i)

(c) Remarks of the CCRS :- Action taken noted.


3.6- (a) Recommendation :- Mock trials to be conducted to train HQ officers regarding functioning and duties of HQ Disaster Management Cell.

(b) Zonal Railways Comments :- Mock trials concluded as under :-

(i) In Jabalpur division between ET JBP section on 08.06.2005 at 1/55 hrs at Kms 962/7-8 between Bhitoni and Bheraghta.

(ii) At STA-KTE section on 27.07.2005 at 1/45 hrs at Lagargunwa (LGCE) station of JBP division.

(iii) Mock trial also concluded in BPL division between BIN MKG section Kms 993/05 on 16.08.05 at 13.00 hrs. HQ officers nominated to attend disaster management cell are as per the list enclosed.

(c) Remarks of the CCRS :- Action taken noted. Mock drills have to be regularly conducted as it is not a one time affair.

(d) Remarks of the Railway Board : Necessary instructions in this regard already exist which were issued vide B s letter No.99/M(M&P)/7/ 6 dated 24.09.1999 and 16.05.2000 and 12.09.2002.

3.7 (a) Recommendation :- Raising Minimum Educational qualifications of loco pilots from VIII standard to Diploma in Engineering or Graduation.

(b) Zonal Railways Comments :- Pertains to Railway Board.

(c) Remarks of the CCRS :- Commission has always been advocating for raising the educational standards of the technical staff and enhancement of their skills. Railway Board should seriously consider the recommendation.

(d) Remarks of the Railway Board : In terms of extant instructions, following qualifications are already prescribed for direct recruitment to the post of Asst. Loco Pilot :

Matriculation pass plus

(i) ITI in specified trades/Act Apprentices;

OR

(ii) Diploma in Mechanical/Electrical/Electronics/Auto-

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ACCIDENT - (ii) Mobile Engineering in lieu of ITI.

3.8- (a)

(b)

Recommendation :- Implementation of various items mentioned in Manual for Prevention of Fires in DMUs to be monitored.

Zonal Railways Comments :- Noted. The entire item proposed for modification in existing DPC will be completed during rehabilitation in the workshop. maintenance practices for prevention of fire on DEMU coaches in service covered in Para-II of the report are being follow.

(c) Remarks of the CCRS :- Action taken noted. Railway Board may

like to issue suitable instructions in this regard to all the zonal railways.

(d) Remarks of the Railway Board : Necessary instructions in this regard have been issued vide Board s letter No.2005/M(L)/101/1(Spares) dated 16.05.2005.

3.9 (a) Recommendation :- More Mock trials to be conducted to improve turning out and running of ARTs during accidents.

(b) Zonal Railways Comments :- Mock trial is also being regularly done, remote control arrangements have been made to sound the hooter from the control by divisional control to improve movement of the tool van, ARTs and ARMvs



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ACCIDENT - (ii)

THE ABSTRACT OF THE REPORT OF THE COMMISSIONER OF RAILWAY SAFETY ON THE DERAILMENT OF 3049 UP, HOWRAH-AMRITSAR EXPRESS BETWEEN PURAINI AND NAGINA RAILWAY STATIONS AT KM 1473/16-17 ON MORADABAD-SAHARANPUR BG DOUBLE LINE NON-ELECTRIFIED SECTION OF MORADABAD DIVISION ON NORTHERN RAILWAY AT ABOUT 00.30 HRS. ON 26.02.2006. I. BRIEF DESCRIPTION

1.1 THE ACCIDENT :- The train 3049 Up, worked by diesel locomotive No. WDM2 16262 and with a load of 13 coaches, arrived at Moradabad railway station on 25.02.2006 at 23.05 hrs and departed at 23.20 hrs. It was by this time late by 01.20 hrs. It ran through Puraini railway station at 00.25 hrs and when it was approaching Nagina railway station the Outer Signal and the Warner were both taken off for it to run through this station. It ran past the outer signal at its booked speed of 90 km/hrs and when it was reaching the Up Home signal it suddenly derailed. The diesel locomotive derailed by all its wheels except the front two wheels of the front axle which were on the rails. The following next eight coaches also derailed, the first seven coaches derailed by all wheels where as the eighth coach derailed by its leading bogie. No coach had capsized.

1.2 The speed of the train at the time of accident was about 88 kmph.

1.3 The weather at the time of accident was clear and visibility was clear under the head light of locomotive.

1.4 As a result of the accident one train passenger was grievously injured who later died in the hospital at Moradabad where as 02 train passengers received simple injuries.

1.5 The total cost of damage to Railway assets was assessed at ` 61.25 lakh.II CAUSE OF THE ACCIDENT

2.1 Having carefully considered the factual, material and circumstantial evidence CRS concluded as under :-

2.1. 1 Cause :- The accident occurred due to tampering with the track by removal of fish plates and fish bolts of both the rail joints of the glued

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ACCIDENT - (ii)

rail joint and all its fastenings, ERC clips, by some unknown outside persons in the night of 25.02.06/26.02.06.



2.4 The cause as established by the CRS was accepted by Railway Board.


3.0 The Remarks and Recommendations made by CRS and the Comments of the Zonal Railway are reproduced below alongwith Remarks of CCRS and Railway Board thereon :-

3.1- (a)

(b)

(c)

(d)

Recommendation :- There have been number of cases of tampering with the track in the past in the block section of Nagina-Puraini and FIRs in all those case were lodged. The police must work out these tampering with the track, and the tampering with the track must be stopped.

Zonal Railway Comments :- Accepted. Necessary instructors have been to avoid such incidents in future.

Remarks of the CCRS :- A regular mechanism with divisional committee on security must already be in place on Moradabad Division where such cases need to be reviewed and regular interaction with police authority is needed for follow up action.

Remarks of the Railway Board : The Chief Security Commissioner/ Railway Protection Force, Northern Railway has issued guidelines to all the Post Commanders of Moradabad Division for necessary action in this regard. In addition, regular co-ordination meetings with the State Police authorities are being organized by Divisional Railway Manager and Divisional Security Commissioner/RPF. Supdt. Of Police/Bijnore and other Police/GRP authorities are also being coordinated regularly by DSC/RPF/Moradabad. A case of theft on 22.08.2007 of Pendrol Clips from railway track near Purani Railway Station was reported on 23.08.2007 in which one offender was arrested and 05 pendrol clips were recovered. In this connection a case vide crime No.34/2007 under Section 3(a) RP(UP) Act has been registered at RPF Post/Moradabad. Standing Committee on sabotage cases has been nominated under

10


ACCIDENT - (ii)

the Chairmanship of ADRM/Moradabad. Periodical meetings are being held with local police and followed up.

3.2 (a) Recommendation :- To keep the Manned level crossing gates closed, locked and without gate man during the night, the Railway Board should circulate approved gate working instructions, to the Railways.

(b) Zonal Railways Comments :- Reference has been made to Railway Board. It has been decided to continue with the system of night close gates on Division where traffic is very low.

(c) Remarks of the CCRS :- Noted. However, the Railways should frame the working instructions of such gates accordingly and boards should be displayed guiding the public about the action to be taken and whom to approach in case the vehicles have to cross the level crossing during the night.

(d) Remarks of the Railway Board : Necessary instructions in this regard have been issued vide Boa s letter No.2009/CE-I/LX/39 dated 21-08-2009 drawing attention of the Zonal Railways to B s letter No.2006/CEI/LX/WP dated 10.06.2008; and No.E(MPP)/2008/1/2 dated12-03-2008.

3.3 (a) Recommendation :- Till such time the approved gate working instructions for keeping the manned level crossing gates closed, locked and without gateman during the night are received by the railway, gatemen should be posted during the night to man the level crossing gates.

(b) Zonal Railways Comments :- This is policy matter and commented as under :- Problems, if any, in manning the gates which are closed during night :

Additional posts of gateman are required to man the gates (Engineering), which are closed during night.

(c) Remarks of the CCRS :- The working of such gates may be reviewed and action as identified by the Railway may be expedited.

(d) Remarks of the Railway Board : Necessary instructions in this regard have been issued vide Boa s letter No.2009/CE-I/LX/39 dated 21-08-2009 drawing attention of the Zonal Railways to B s letter No.2006/CEI/LX/WP dated 10.06.2008; and No.E(MPP)/2008/1/2 dated12-03-2008.

11


ACCIDENT - (iii)

THE ABSTRACT OF THE REPORT OF COMMISSIONER OF RAILWAY SAFETY, ON THE COLLISION OF 5273 UP RAXAULA-DELHI SATYAGRAHA EXPRESS WITH A JCB MACHINE AT THE WORK SITE AT JAHANI KHERA HALT RAILWAY STATION OF ROSA-SITAPUR CANTT. BG SINGLE LINE NON ELECTRIFIED SECTION OF MORADABAD DIVISION OF NOTHERN RAILWAY AT 03.13.HRS ON 10.04.2006 I. BRIEF DESCRIPTION

1.1 THE ACCIDENT :- 5273 Up, Raxaul-Delhi 17-coach Satyagraha Express train, after undergoing Primary Maintenance at Raxaul and having only one SLR arrived at Sitapur Cantt. Railway station on 10.04.2006 at 01.20 hrs and departed at 01.35 hrs with the diesel locomotive in long hood leading. At 02.58 hrs it departed from Maingal Ganj railway station and while it was running through Jahani Khera railway halt station, between Maingal Ganj and Jangbahadur Ganj block section, at a speed of about 70 kmph, suddenly at about 03.12 hrs the Assistant Loco Pilot of the train saw that something was going to hit the locomotive and he immediately moved towards the Loco Pilot side, shouted and asked him to apply the emergency brakes. Just then a part of the JCB machine collided with the diesel locomotive and on collision the JCB fell on its sides. The excavator of this machine fell towards the railway track and damaged the lower parts of the body of the coaches there by causing injuries to the train passengers sitting near the windows and in the doorways.

1.2 The speed of the train at the time of accident was about 70 kmph.

1.3 The weather at the time of accident was clear and visibility was clear under the head light of locomotive.

1.4 As a result of the accident 2 persons died of which 01 was a train passenger and other was outsider standing near the JCB machine, 06 were grievously injured of which 05 were train passengers.

1.5 The total cost of damage to Railway assets was assessed at 5.60 lakh. II CAUSE OF THE ACCIDENT


2.1. 1 Cause :- While 5273 Satyagrah Express was running through Jahani

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ACCIDENT - (iii)

Khera railway halt station, loader of the JCB machine hit the sides of the locomotive of the train. The JCB machine was standing close to railway track after finishing the excavation work in the night.






3.1 (a) Recommendation :- All sites adjoining railway tracks, where work is required to be undertaken by the use of road vehicles or machines, should invariably be barricaded irrespective of distance of the worksite from the track. The barricading should be under taken from level crossing gate to level crossing gate in order to prevent any vehicle to come close to the railway track during their operation or when they are parked near the railway track.

(b) Zonal Railway Comments :- This is already incorporated in the tender condition for future works in respect of barricading near running track of trains as under

Barricading with the help of portable fencing shall be provided in the length where the days work is to be done in close vicinity of the track irrespective of the distance of the work site from the track. The fencing shall consist of self-supporting steed column connected with at least 20mm thick red nylon rope. The columns shall be of 1.2 meter height. This will be placed at distance of 3.5 meter from center line of the nearest track. This shall be put under relevant item.

(c) Remarks of the CCRS :- Noted. However despite this provision the accidents continue to happen. Thus there is laxity in the implementation. Periodical checks at higher level, especially during the night are essential.

(d) Remarks of the Railway Board : Necessary instructions have been issued to Northern Railway vide B s letter No.2009/W2/CCRS/ NR/01 dated 27.03.2009.

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ACCIDENT - (iii)

3.2 (a) Recommendation :- All Guards of the trains should be given a list containing the locations of all the emergency sockets provided in various sections of their Division.

(b) Zonal Railways Comments :- Accepted. List of locations of emergency sockets on electrified sections is already given in the Working Time Tables of all Divisions. On Non-electrified sections, wherever underground cables are being provided, such sockets have been made available.

(c) Remarks of the CCRS :- In non-electrified sections, where underground cables have been laid and emergency communication sockets have been provided, hectometer posts should be erected on the cess which should indicate the direction in which the crew/guard should walk to the nearest socket. Commission has been emphasing on this for last many years.

(d) Remarks of the Railway Board : Necessary instructions have been issued to the Zonal Railways vide B s letter No.2004/CE-II/TK/1 Policy dated 24.02.04 & 23.04.07 and No.2006/Tele/AR/12 dated 20.06.2007.

3.3 (a) Recommendation :- TTEs and railway officials traveling in the train must reports to the Guard of the train and also inform the Section Control and adjoining Station Masters of their presence at the site of accident.

(b) Zonal Railways Comments :- Accepted. Safety Circular No.13 reiterating the above instructions has been issued to all the concerned for strict compliance.



3.4 (a) Recommendation :- Digital cameras must be provided to all the branch officers of the safety organizations of the Divisions and safety officers of the Headquarters and they should invariably carry these to the accident sites for undertaking photographs to preserve the clues.

(b) Zonal Railways Comments :- Accepted.

(c) Remarks of the CCRS :- Action taken noted. Railway Board may like to decide a uniform policy for all the Zonal Railways. The clues

14


ACCIDENT - (iii)

have to be preserved to facilitate the inquiry and to determine the cause of the accident.

(d) Remarks of the Railway Board : Necessary instructions have been issued to the Zonal Railways vide Board s letter No.2007/Safety-I/12/ 2 dated 05.05.2009.

3.5 (a) Recommendation :- Mail Express trains should not be allowed to run with single SLR only and in case it is unavoidable then Railway board should lay down the necessary conditions to do so.

(b) Zonal Railways Comments :- Mail/Express trains are run with SLRs as per the provisions of Operating Manual except in case of emergencies. Board would be asked to issue guidelines on the subject for these cases where running of Mail/Exp. trains with single SLR cannot be avoided in extreme emergency situation.

(c) Remarks of the CCRS :- Railway Board may kindly issue detailed guidelines in this regard.

(d) Remarks of the Railway Board : Necessary instructions have been issued to the Zonal Railways vide Bo s letter No.2007/Chg-II/22/ CRS/NC/5273 dated 23.10.07 and No.87/Chg-II/14/7/Marshalling dated 14.05.2009.

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ACCIDENT - (iv) ACCIDENT - (iv)

THE ABSTRACT OF THE REPORT OF COMMISSIONER OF RAILWAY SAFETY ON THE DASHING OF A TRUCK WITH 2321 UP HOWRAH-MUMBAI MAIL AT CONSTRUCTION SITE AT KM. 1324/5-6 BETWEEN MADARAHA AND LOHGARA RAILWAWY STATION ON ALLAHABAD-MANIKPUR, BROAD GAUGE SINGLE LINE NON-ELECTRIFIED SECTION OF JHANSI DIVISION ON NORTH CENTRAL RAILWAY AT 13.20 HRS. ON 28.04.2006. I. BRIEF DESCRIPTION

1.1 THE ACCIDENT :- 2321 Up Howrah-Mumbai Mail train, an air braked train, Ex. Howrah hauled by multiple unit WDM-2 locomotive Nos. 17433 & 18721 short hood leading having 18 coaches passed through link Jn. At 13.05 hrs. (1.00 hrs. late). Air pressure continuity check was carried out at Allahabad. It had an uneventful run up to Madaraha station, the last passing station prior to the accident site and the driver did not issue any message relating to brake power of the locomotive or any other problem in its running. The train passed through Madaraha stn., at 13.19 hrs and while the train was on its run in block section Madaraha-Lohgara, at a speed of about 99 kmph, an empty truck, while moving in the backward direction (front facing Madaraha stn.), dashed with the 15th and 16th coaches nos. ER 99265 CN and ER 93518 GS respectively of 2321 up train. The driver stopped on through signal at Lohgara at 13.23 hrs without any derailment of the locomotive or any of the coaches.

1.2 At the time of accident the speed of the train was 99 Kmph.

1.3 The weather at the time of accident was clear and visibility was good.

1.4 As a result of the accident 06 persons sustained grievous injuries and 01 person sustained simple injuries.

1.5 The total cost of damage to Railway assets was Nil.

II CAUSE OF THE ACCIDENT


2.1. 1 Cause :- Accident occurred due to infringement by the truck caused by negligent driving by the driver of truck no. UP-70 X 9421.

16


ACCIDENT - (iv)






3.1 (a) Recommendation :- Regular devise have been launched by North Central Railway Administration to inculcate safety sense among the Railway officials, contractors and their workmen and for ensuring safety of track, trains/engines, passengers, labour, staff etc. at construction/ work site by observing various precautions while working in the vicinity/ adjacent to track.

(b) Zonal Railway Comments :- Safety drives have been launched by the Division for safety sense among the railway officials, contractors and their workmen and for ensuring safety of track, trains/engines, passengers, labour, staff etc. A Safety Circular 103 has been issued by Engineering department.

(c) Remarks of the CCRS :- Instructions already exist to observe various precautions while working adjacent to track. The regular drives should be launched to ensure the compliance of the instructions.

(d) Remarks of the Railway Board : Necessary instructions in this regard have been issued vide Boa s letter No.2006/CE-II/PRA/8(CRS) dated 26.09.08.

3.2 (a) Recommendation :- At all construction/work sites where road vehicles or machinery can come closed to the Railway track, the Railway track should be protected by providing suitable, properly designed semi-permanent fencing alongside the track for which the approved plans and instructions should be issued by North Central Railway Administration.

(b) Zonal Railways Comments :- IRPWM para 806(I) already exists for some, instructions are being reiterated.

(c) Remarks of the CCRS :- IRPWM para 806(I) deals with the protection

17


ACCIDENT - (iv)

of work site by flagmen for works of short duration when the train is required to stop at the site of the work. It has got no relation whatsoever, with the fencing at the site of the work. It is not appreciated how the Railway has quoted this para. Semi-permanent rail fencing consisting of vertical & horizontal members should be provided at worksite to isolate the running traffic from the workspot preferably unto the height up to which the construction machineries can operate similar to any Metro site or multistoried building site at a city. Suitable para about this should be added in IRPWM. The dramatic change in adoption of mechanized construction in recent years have not been adequately reflected in the additional precautions at work site.

(d) Remarks of the Railway Board : Suitable instructions in this regard already exist which were issued by Board s letter No.2000CE-II/PRA/ 12 dated 18.11.2003.

3.3 (a) Recommendation :- North Central Railway Administration should ensure that the sanction of the Commissioner of Railway Safety is taken before the minor works are commenced. No work should be started unless CRS sanction is obtained for the works.

(b) Zonal Railways Comments :- The administration agrees with the recommendation.



3.4 (a) Recommendation :- While the work of doubling are done by construction organization, the open line supervisors and officers should also have a close watch on the activities done by the construction organization and their contractors to ensure the safety of running train.

(b) Zonal Railways Comments :- Instructions are reiterated.


(d) Remarks of the Railway Board : Railway Administration has explained the position to the satisfaction of the Commission.

18


ACCIDENT - (v)

THE ABSTRACT OF THE REPORT OF COMMISSIONER OF RAILWAY SAFETY ON THE DERAILMENT OF K-93 DN EMU SLOW LOCAL TRAIN AT KM.44/6-7 BETWEEN DIVA AND DOMBIVLI STATIONS OF ELECTRIFIED BROAD GAUGE QUADRUPLE LINE OF CSTM-KYN SECTION OF MUMBAI DIVISION ON CENTRAL RAILWAY AT ABOUT 20.25 HRS ON 03.05.2006.

I. BRIEF DESCRIPTION

1.1 THE ACCIDENT :- The Dn. EMU CSTM-KYN slow local left CSTM at 19.05 hrs on 03.05.2006 and arrived Diva at 20.18 hrs, leaving Diva at 20.19 hrs on through signals. It was running at a speed of about 65 kmph. while the driver passed km.44/9 there was an ACP. He applied emergency brakes and stopped the train. On looking back, he noticed that the train had derailed. The rear bogies on 5th, 8th and 9th coaches from the front had derailed and traveled for about 400 mts till the Moto s cab stopped at Km.44/14-15 and the Gu s cab at Km.44/12. The derailed coaches did not infringe the Up local line.

1.2 The speed of the train at the time of accident was 65-70 kmph.

1.3 The weather at the time of accident was Clear and visibility was Good.

1.4 As a result of the accident 01 passenger was simply injured.

1.5 The total cost of damage to Railway assets was assessed at ` 1,15,000/ II CAUSE OF THE ACCIDENT


2.1. 1 Cause :- The accident occurred due to multiple fractures of rail (60 kg 110 UTS head hardened) on the left side of the alignment, under the train.




19


ACCIDENT - (v) III. REMARKS AND RECOMMENDATIONS


3.1 (a) Recommendation :- The speed restriction imposed on slow local lines on HH rails should not be relaxed till either deep screening and ballasting are done or rails are replaced.

(b) Zonal Railway Comments :- Noted. The speed restriction imposed on slow local line is continuing at the location where HH rails have not been replaced. Division has been supplied 6.5 track km of rails for replacement of HH rails and speed restriction is being relaxed only after replacement of HH rails.

(c) Remarks of the CCRS :- The replacement of HH rails should be expedited.

(d) Remarks of the Railway Board : Accepted. Condition Survey of all scabbed Rails was carried out and replacement of these Rails was planned on programmed basis. However, till the replacement, necessary precautions are being ensured. The following replacement has already been done.

Year Kms.

2006-07 7.034

2007-08 20.757

2008-09 7.060

The necessary modification in all the machines have been carried out for GFCD testing and same is being done along with normal testing as per Need Based Concept.

3.2 (a) Recommendation :- Many remarks and observations have been made in Chapter VII of this report for improving the quality of the track maintenance and the break down train operations with overall objective to enhance the safety and efficient restoration. These are indicated below in reference to relevant paragraphs of this report. These are indicated below in reference to relevant paragraphs of this report. Compliance of the same may be reported early.

20


ACCIDENT - (v)

Para No.

Brief description

Zonal Railways Remarks

CCRS Remarks

Railway Board Remarks

7.6.3

CTE should ensure proper analysis of each RF/WF in items of the IRPWM

On Central Railway all the cases of rail failures and weld failure are investigated at divisional level and HQ level. A monthly review and analysis of rail fracture & weld failure is carried out all the rail pieces are examined at divisional level and in HQ. Typical cases are investigated by calling for the rail pieces. In view of CRS recommendations the system has been further streamlined and instruction for regular analysis of R/F, W/F has been reiterated.

Noted. The working of the system should be monitored as per provision in IRPWM.

Accepted. With the issue of USFD Manual, the provision therein regarding monitoring of RF/WF are more exhaustive and Zonal Railways have been advised to monitor the RF/WF as per USFD Manual. Accordingly, Correction Slip to IRPWM for substituting existing Para of IRPWM to reconcile with the USFD Manual is under process. Further to facilitate critical monitoring of Rail/Weld failure, Zonal Railways have been provided with software developed by Railway Board.

7.7

To monitor scabbing of rails, SSE should open proper register g iv ing details of the rails replaced and the development of new scabs.

Division has since opened a register for giving details of ra il replaced and development of new scabs

R a n d o m c h e c k s / i n sp ect io n should be carried out the check the working at ground level.

Accepted. Necessary instruct ions to monitor scrabbing of rails and its repair procedure have been issued vide RDSO's Code of Procedure No.MC-47, Nov.2001. However, the necessary instructions regarding monitoring at SSE level and random check by higher officials have been issued vide Board's letter No.Track/21/99/0508/7 dated 03.03.09.

7.8

HQ should issue definite guidelines for monitoring of the scabs, replacement of the scabbed HH rails with respect to depth of the scabs and imposition of the speed restriction.

Guidelines have been issued regarding monitoring of scabs, replacement of scabbed HH trails with respect to depth of scab and imposition of the speed restriction.

Noted.

Accepted. Necessary instruct ions to monitor scrabbing of rails and its repair procedure have been issued vide RDSO's Code of Procedure No.MC-47, Nov.2001. However, the necessary instructions regarding monitoring at SSE level and random check by higher officials have been issued vide Board's letter No.Track/21/99/0508/7 dated 03.03.09.

21


ACCIDENT - (v) ACCIDENT - (v)

Para Brief description No.


CCRS Remarks


7.8.1 The Railway Administration As regards ballasting in Noted. The Accepted. The progress of should plan and make addition to the normal progress of insertion of ballast is being preparation of the adequate ballast procurement, mega b a l l a s t i n g monitored closely and ballasting and the ballast depots are being should be insertion of ballast mechanized ballast planned in each division and monitored. increased in the last cleaning in suburban tenders have already been financial year Tender have section. invited. been invited for Mega

As regards mechanized ballast Depot at Jasai on ballast cleaning, though Mumbai Division and are due to the presence of a under final ization. I t is large no. of cables it is expected that supply/ d iff icult to carry out delivery of ballast will further screening by BCM, it is increase on supply of ballast decided to give it a try and through Mega Depot.

is planned beyond Thane as have muchlof experience in

regard to HH Rails. Necessary instructions regarding locations where HH Rails are to be used, have already been issued vide Board's letter No.Track/ 21/95/0800/7 dated 6.2.95 and is also provided in the IRPWM para 248 Note (iii). For Rail renewal, the GMT cr iter ia , is one of the guidelines of the IRPWM. Other parameters also are to be followed for proposing need based Rail renewals and accordingly Rail renewal works are justified and proposed by the Railways and sanctioned by the Board. Therefore, there is no need to issue separate guidelines regarding premature renewal of HH Rails. The instructions are already existing to fill up the vacancies and the process is on and being monitored.

7.8.2 Individual responsibility Vide this para Engineering i) Bad cases may be decided by PCE department of Central of as deemed fit. Railway is held derailments

Blameworthy & CRS has have

Accepted. The progress of insertion of ballast is being monitored closely and insertion of ballast

22

accordingly BCM working

the obstruction of cables etc. is less.

Indian Rai ways does not


ACCIDENT - (v)

Para Brief description No.


CCRS Remarks


advised to fix indiv idual happened increased in the last responsibility. This is not earlier due financial year Tender have acceptable due to following to fracture of been invited for Mega considerations : H.H rails. ballast Depot at Jasai on i) Railway Board vide L. No. Railway Mumbai Division and are Track/21/95/0800 dated Board may under finalization. It is (not clear) had stipulated fix suitable expected that supply/ the use of H.H. rails on guidelines delivery of ballast will further "local line where dedicated for their increase on supply of ballast EMU stock is running". The premature through Mega Depot. continuation of replacement Indian Railways does not HH rails on local line was early. have much of experience in as per the above guidelines ii) The regard to HH Rails. given by Railway Board. excuse of Necessary instructions i i) M&C directorate of not enough regarding locations where RDSO in its report stated manpower HH Rails are to be used, that the fractured rail pieces cannot go have already been issued contains transverse defects on vide Board's letter No.Track/ in the head covering approx perpetually. 21/95/0800/7 dated 6.2.95 35% of rail head area. the The and is also provided in the report a lso specifically vacancies IRPWM para 248 Note (iii). states that the defect is not should be For Rail renewal, the GMT detectable at the time of urgently cr iter ia , is one of the last ultrasonic testing by filled as the guidelines of the IRPWM. following normal procedure power has Other parameters also are as per USFED manual. been to be followed for proposing iii) In para 10 of the above delegated to need based Rail renewals report it is also concluded G.M's and accordingly Rail that rail head has failed in renewal works are justified fatigue mode initiated from and proposed by the deep shelling. The shelling Railways and sanctioned by is result of formation of the Board. Therefore, there hardened zone on rail table is no need to issue separate due to unusual rail wheel guidelines regarding contact. As the unusual rail premature renewal of HH wheel contact has not yet Rails. been analyzed it is not The instructions are already possible to determine the exist ing to f i l l up the responsibility. vacancies and the process iv) It is also brought out that is on and being monitored. the analysis of rail fracture in CSTM-KYN section indicates that 7.5% failures have taken place in HH area rail sect ion, whereas the length of HH rails in th is section is 10.24%

23


ACCIDENT - (v)

Para No.

Brief description


CCRS Remarks


This indicates that ra il fractures in HH rail section has been marginally less than the rail fractures in other rail section. Thus the fractures in HH rail did not show any abnormal trend in fractures so as to initiate special action. v) As regards contamination of ballast and poor condition of cushion, it is brought out that division was well aware of the problem and division had invited seven tenders for deep screening. However, the same could not be finalized. Division has made required efforts for carrying out deep screening but has failed. Considering the above facts nobody is held responsible for the derailment. It would not be fair to fix the responsibility on Engg. Officials as they did what ever was required to be done as the proposals for deep screenings were made and also departmental deep screening was not possible due to large scale vacancies of gangmen. The scabs were measured subsequently at other places also and were found to be less than 2mm. As such no one is held responsible.

7.9.1

ADEN&Ss DEN should concentrate on the proper utilization of the manpower, avoiding use of gangman for other than the track maintenance works to the minimum. Monthly advance planning of track work may be done by ADEN in terms of IRPWM 206

Division has been advised to monitor the utilization of gangman and ensure proper utilization of gang man for track works. The instruct ions regarding proper utilization have again been reiterated.

P r o p e r u t i l i z a t i o n needs to be ensured.

Accepted. The necessary instructions have already been issued vide letter No.2006/CE-I/GNS/3 and 2006 /CE- I I /PRA/PRA/ 3(CRS) dated2.4.07 & 26.09.08 respectively.

24


ACCIDENT - (v)

Para No.

Brief description


CCRS Remarks


7.9.2 (i)

SR. DSO may examine why ART/CLA was ordered late.

Accident took place at 20.25 hrs. Only KYN BDT was ordered at 20.37 hrs as it was initially felt that since only 3 coaches had derailed that too by one bogie each, KYN BDT would be sufficient for restoration purpose. However, when senior officers reached site around 21.30 hrs. it was reassessed that a fu ll complement of BD staff was not available with KYN BD HRE. therefore as backup CLA BDT was ordered at 21.35 hrs.

Noted.

Accepted. Railway Administrat ion has explained the position to the sat isfact ion of the Commission.

7.9.2 (ii)

To examine whether KYN/ ART can be placed under Mechanical Dept.

The matter has been examined and it has been decided that Kalyan ART shall continue with KYN Loco shed. In this case, restoration work is stated to be quite efficient. There have been no. of instances when the efficiency of ART KYN has been proved during various installation work in BB divn. An exceptional instance of absenteeism on particular day has been taken up with defaulters appropriately. Good infrastructure support and staff exist at ELS/KYN and therefore there is no need to shift ART any where. No extra sanction of staff is necessary.

Noted.

Accepted. Railway Administrat ion has explained the position to the sat isfact ion of the Commission.

(vii)

To check up whether provision of additional staff has been considered while providing additional tools and machinery as per recommendations of High Power Committee.

There is only one set of equipment as per standard list of equipments for 'B' class ART. After considering HLC's recommendation, restorat ion gang of 2 supervisors and 21 shed staff is earmarked for 'B'

Noted.

There is only one set of equipment as per standard list of equipments for 'B' class ART.After considering HLC's recommendation, restorat ion gang of 2 supervisors and 21 shed staff is earmarked for 'B'

25


ACCIDENT - (v)

Para No.

Brief description


CCRS Remarks


class ART. In addition a gang of 8 C&W staff is also earmarked for 'B' class ART.

class ART. In addition a gang of 8 C&W staff is also earmarked for 'B' class ART.

(viii)

Action taken in regard to Road Based ARTs may be advised to the Commission.

Road based ART with one set of HRE has commissioned at Diesel Shed Kurla on 15/06/06.

Noted.

Accepted. Railway Administration has explained the position to the satisfaction of the Commission.

7.9.2 (ix)

Mechanization of the engineering work of the restoration may be considered for future and necessary action taken.

Division have been advised to ensure follower small track machine manual. i) Abrasive rail cutter. ii) Rail drilling machine. iii) Rail drilling machine. iv) Concrete sleeper breaker with angle grinder. v) Heavy duty Hydraulic extractor for jammed ERC's. As regards nomination of Engineering staff, divisions have been advised to nominate 20 staff each by name for ARTs. As in the present system there is no provision of breakdown allowance for engineering staff, a proposal has been processed for according breakdown allowance to Engineering staff.

Noted.


7.9.2 (x)

Additional HR equipment may be loaded in ARMVs also as done in KRCL.

The standard l ist of hydraulic rerai l ing equipment which should be available in medical van has not yet been issued. This is a policy matter and policy decision taken in this regard will be implemented for ARMV KYN also.

Railway Board may deliberate & issue suitable guideline.

Accepted. A Committee consisting of Field (Divisional) Officers of Mechanical, Civil, Electrical, Medical and Finance Department is being constituted to draw up a list of equipment of ART/ARME for looking into the issue raised by the Commission.

7.9.2 (xi)

A brain storming session of the Branch officers and BD incharges (SSE)may be organized to improve that capabili ty and efficiency of BD trains in Mumbai division. Copy of minutes of meeting may

A meeting regarding accidents and restoration was held on 29.05.05 as part of Safety Meeting by DRM along with al l Branch Off icers where brain storming was done regarding restoration

Noted.

Accepted. Railway Administration has explained the position to the satisfaction of the Commission

26


ACCIDENT - (v)

Para No.

Brief description


CCRS Remarks


be sent to Commission also.

operat ion on Mumbai division Meeting with Sr. Supervisors will also be arranged shortly.

7.9.4

Administration may plan additional technical inputs to the THODs for better utilization of the institution of THODs

Noted for compliance.

Noted.


7.9.5

Managerial inputs may be given to ADENs of Group 'B'

Group 'B' ADEN's are regularly being nominated for Group 'B' foundation Course being organized by Railway Staff College, Baroda for improving Management skills.

Noted.


27


ACCIDENT - (vi)

THE ABSTRACT OF THE REPORT OF COMMISSIONER OF RAILWAY SAFETY ON THE EXPLOSION IN COACH NO. NF 8321 GS 6TH FROM ENGINE OF 618 DN HALDIBARI-NEW JALPAIGURI PASSENGER AT ABOUT 1819 HOURS OF 20.11.2006 AT BELAKOBA STATION ON NEW JALPAIGURI-NEW COOCH BEHAR BROAD GAUGE SINGLE LINE NON ELECTRIFIED SECTION OF KATIHAR DIVISION OF NORTHEAST FRONTIER RAILWAY. I. BRIEF DESCRIPTION

1.1 THE ACCIDENT :- On 20.11.2006, 618 Dn was on its run from Haldibari to New Jalpaiguri. The train was received on line No. 1 at Belakoba station at 1818 hours. At about 1819 hours, an explosion took place in Coach NF 8321 GS, 6th from engine while the train was stationary.

Explosion was so strong that it ripped through the coach shell and created a opening on the roof and torn the right side panel near the door at New Jalpaiguri end on track side whereas the same bulged on the opposite (platform) side. Also, blast shattered roof, floor, seats, window shutters louvers and glass panes including electrical fittings and fans inside the entire coach. One door on right side (track side) of the coach at its New Jalpaiguri end with broken window frame and broken parts of window frame were thrown between line No. 3 & 4. One hinge of the middle door on left side (platform side) of the coach broke and the door fell down on the platform. Pellets of the explosive device caused holes in the floor and inside panel sheets of the coach.

However, neither any coach nor locomotive of the train derailed as a result of explosion.

1.2 At the time of accident the train was stationary.

1.3 The weather at the time of accident was fair and visibility was clear.

1.4 As a result of the accident 07 passengers were killed and 45 were injured, 20 of them grievously.

1.5 The total cost of damage to Railway assets was assessed at 12,11,680/. II CAUSE OF THE ACCIDENT


28


ACCIDENT - (vi)

2.1. 1 Cause :- The accident occurred due to certain explosive device/bomb planted or left in the coach and triggered with remote control or otherwise by some unknown person(s).






3.1 (a) Recommendation :- Appreciation and appraisal reports of Head of the Departments should bring out shortfalls jeopardizing safety/security and suggest improvements whatsoever so as to enhance safety and security of passengers.

(b) Zonal Railway Comments :- Accepted. Instructors are being issued to all concerned.



3.2 (a) Recommendation :- Security department of railway need to be proactive in its approach so as to be more effective in their task of ensuring security of passengers.

(b) Zonal Railways Comments :- Accepted. The RPF personnel are being sensitized to play proactive role for passengers security. The RPF Assistance Booths have been made functional at major/important Railway stations, Access Control at Major stations are being enforced, re-orientation in nature of duties and attitudinal change in staff are being brought about. CCTVs are installed at Guwahati, New Jalpaiguri and Dimapur Railway stations for monitoring the activities of the antisocial elements. CCTVs are likely to be installed at New Bongaigon & New Tinsukia stations. CCTVs are also proposed to be installed at Dibrugarh Town, Mariani, Lumding, Rangiya, Alipurduar Jn., New

29


ACCIDENT - (vi)

Coochbehar, Katihar and New Alipurduar stations. Various physical and mechanical measures have been put in place for ensuring safety & security of the passengers.



3.3 (a) Recommendation :- Security Department of railway should be strengthened to shoulder additional responsibilities entrusted vide Railway Protection Force (Amendment) Act, 2003 within a fixed time frame.

(b) Zonal Railways Comments :- The RPF has been shouldering additional responsibilities such as passenger train escort, access control for safety and security of passengers and passenger area after the amendment of RPF Act, 2003.

(c) Remarks of the CCRS :- Noted.


3.4 (a) Recommendation :- Security department of Railway should be equipped with proper state of the art equipments for detection of explosives and trained adequately so as to ensure security of passengers.

(b) Zonal Railways Comments :- At present RPF Dog Squad are available at Maligaon HQ, Guwahati, Alipurduar Junction & Katihar for detection of explosives in platform, trains, passengers area etc. Additional Dog Squads at New Tinsukia, Mariani, Dibrugarh, Badarpur, Rangiya and New Jalpaiguri are being set up consisting of two sniffer dogs each location. The pups are being purchased shortly. 2 units of BD & DS are proposed to be located at Guwahati & New Bongaigaon which has been included in the M&P programme in 2007-08.

(c) Remarks of the CCRS :-Noted.


30


ACCIDENT - (vi)

3.5 (a)

(b)

(c)

(d)

3.6 (a)

(b)

(c)

(d)

3.7- (a)

Recommendation :- Railway should adhere to the norms of manning coaches strictly so that Train Ticket Examiners can discharge their roles to enhance security of passengers.

Zonal Railways Comments :- Accepted. Board s instruction in this regard are strictly adhered to.

Remarks of the CCRS :- Action taken noted.

Remarks of the Railway Board : Railway Administration has explained the position to the satisfaction of the Commission.

Recommendation :- Railway should not withdraw existing amenities for deficiencies and constraints related to infrastructure or whatsoever and instead address them and make them good. Savings in expenditure and bringing down the staff requirement for maintenance shall not be at the cost of passenger amenities.

Zonal Railways Comments :- Accepted. Blocked toilets of coaches of short distance passenger trains had been restored.

Remarks of the CCRS :- Action taken noted.


Recommendation :- Depletion of organizational strength of security department to the tune of 50% as well as that of other service departments should be a serious matter of concern of the Railway from

consideration of safety and security of passengers. Corrective measures should be taken within a fixed time frame.

(b)

(c)

(d)

3.8- (a)

Zonal Railways Comments :- Accepted. Almost all the vacancies have been filled up after recruiting over one thousand men and women in the recent past.

Remarks of the CCRS :- Noted.


Recommendation :- Provision in the Accident Manual of the Railway related to inquiries for preparations of necessary documents/record including preservation of clues should be strictly followed by the Railways.

31


ACCIDENT - (vi)

(b) Zonal Railways Comments :- Accepted.

(c) REMARKS :- Noted.


32


ACCIDENT - (vii)

THE ABSTRACT OF THE REPORT OF COMMISSIONER OF RAILWAY SAFETY ON UNUSUAL OCCURRENCE OF THE FIRE WHICH TOOK PLACE AT ABOUT 23.53 HRS ON 18.02.2007 IN THE COACHES OF 4001 UP ATTARI SPECIAL WHILE IT WAS ON THE RUN THROUGH DIWANA RAILWAY STATION ON DELHI-AMBALA CANTT DOUBLE LINE ELECTRIFIED SECTION OF DELHI DIVISION OF NORTHERN RAILWAY. I. BRIEF DESCRIPTION

1.1 THE ACCIDENT :- The rake of 4001 Up Attari special underwent primary maintenance at Coaching Depot at Delhi Jn. on 18.02.2007 and after undergoing this maintenance the shutters of all the windows of the coaches were dropped and closed and doors padlocked and this rake was placed on platform no.18 at Delhi Jn. Railway station. The doors and windows of the coaches were opened after when the rake was placed at this platform for the passengers to board the train. The train had 16 coaches including two SLRs. It was fully air-braked and was worked by diesel locomotive no. WDM2 17382 which departed from Delhi Jn. station at 22.50 hrs on 18.02.2007. Till Samalkha railway station it ran through without stopping en route and had an uneventful run. It observed one speed restriction of 20 kmph form km 14/03 to 14/19 between Badli and Holambi Kalan railway stations on the Up line due to deep screening of the railway track.

The train ran through Samalkha railway station and when it entered Diwana station section the gateman of the traffic level crossing gate no. 47 class heard two sounds of explosion one after the other in quick succession when the complete train had cleared his level crossing gate and had gone ahead by 3 to 4 OHE mast length and when the train ran past by the Diwana railway station building, ASM/Diwana, who had come out of his office to exchange alright signals with the crew of this train, saw fire in one of the coaches of this train. He immediately ran to his office and tried to put the Advanced Starter signal to ON (red) position and thereafter on the VHF set asked the loco pilot of the train to stop the train as there was fire in the train. The loco pilot of 4001 Up Attari Special heard the voice of the guard of the train on his walkie talkie set and another voice asking him to stop the train because there was fire in the train and he immediately applied A-9 brake and stopped his train and the train came to a stop at 23.51 hrs, its two coaches were on

33


ACCIDENT - (vii)

fire and these coaches stopped at level crossing gate no. 49 class.

After warning the loco pilot of the fire in the train ASM/Diwana asked the gateman of level crossing gate no. 50 C class to put the gate signal to ON position in order to stop the train in case it did not stop immediately. However the train stopped much short of this gate signal.

On the off side pointsman was deputed to exchange alright signals and he too saw fire in one of the coaches of 4001 Up and he raised alarm to warn the guard of the train of danger in the train and also showed red signal.

On stopping, train crew tried to put out the fire by fire extinguishers but these were inadequate and could not control the fire. The coaches on fire were separated from the rest of the train by the crew of the train. Fire engines were requisitioned from fire station Panipat which on arriving put out the fire by about 02.00 hrs on 19.02.2007

After when the coaches on fire were separated a Constable of GRP, who was on leave and was at his residence near level crossing gate no 49 C class, attended the accident and he found two suitcase suspected to be containing bombs, one lying in the down line track and other lying in one of the coaches in the rear of the train, and handed these over to RPF and GRP. In this unusual occurrence of fire there was no derailment of the train.

1.2 The speed of the train at the time of accident was 100 kmph.

1.3 The weather and visibility at the time of accident were clear.

1.4 As a result of the accident, 68 train passengers died, 12 passengers were injured 07 of them grievously.

1.5 The total cost of damage to Railway assets was assessed as 15,65,000. II CAUSE OF THE ACCIDENT

2.1 Having carefully considered the factual, material and circumstantial evidence CRS has concluded as under:-

2.1. 1 Cause :- Unusual occurrence of fire in the coach of 4001 up Attari special, while it was running through the stations section of Diwana railway station situated on Delhi-Ambala double line electrified section of Delhi Division of Northern Railway, took place at about 23.53 hrs on 18.02.2007 and it occurred due to explosion of bomb kept on the upper rakes near doorways of coaches GS 03431 and GS 14857. These

34


ACCIDENT - (vii)

bomb on exploding caused severe fire which burnt the coaches vigorously. The high winds due to high speed of the train aggravated the spread of fire.


2.3 On Scrutinising the report CCRS considered that the conclusion arising by the CRS are acceptable.




3.1 (a) Recommendation -: Design of coaches needs a review and should provide for quick emergency exists in case of fire. Existing emergency windows are inadequate and give no additional outlet for the train passengers to escape from the fire in coaches.

(b) Zonal Railways Comments -: At present all the coaches other than GS&SLR have vestibules at the end and body side doors for easy exit of passengers. Emergency window are provided in all the coaches. The work for review of emergency window design is under consideration in RDSO.

(c) Remarks of the CCRS -: Railway Board is requested to expedite the review of emergency window design by RDSO.

(d) Remarks of the Railway Board : Unreserved passenger coaches have been provided with 6 body side doors. The reserved coaches are also provided with 4 body side doors besides vestibules at either end of the coaches. The arrangement can facilitate quick/emergency exit in case of untoward incidents like fire and accidents etc. Besides the body side doors there has also been a provision of 2 emergency exit windows in each coach. The size of the window is comparatively much larger (1210mm x 550mm) in AC coaches as compared to a non AC coach (610mm x 560mm). In view of relatively higher occupancy in non AC coaches and the window sizes, the emergency windows in non AC coaches have been increased from 2 per coach to 4 per coach. This exercise has been completed on all existing non AC coaches. In

35


ACCIDENT - (vii)

the enhanced capacity layout for AC three tier coaches the emergency windows have been increased from 2 to 3.

The arrangements for emergency exit through vestibules, body side doors and emergency windows in the coaches as above provide reasonable time and options for emergency exit in case of fire and other accidents.

3.2 (a) Recommendation :- There should be strict baggage check of the train passengers traveling by 4001 Up at Delhi Jn. railway station as is done at Attari railway station since the train after starting from Delhi Jn. station stops only at Attari railway station and is received on platform which is a protected area and from where the train passengers are required to undergo immigration and customs checks and are then required to board Samjhauta Express

(b) Zonal Railways Comments -: After the incident of bomb blast, arrangements have been further strengthened for providing security to train no. 4001/4002 Delhi-Attari Express at Delhi & Attari Railway stations, enroute and in train in coordination with GRP, Civil Police, IB, RAW, Immigration & Railway authorities.

(c) Remarks of the CCRS -: Such intensive checks should be the part of regular checking to ensure the safety of train operation & passengers.

(d) Remarks of the Railway Board : Accepted. Necessary instructions have been issued vide Board letter No.2008/Sec.(Cr.)/45/88 dated 16.07.08

3.3 (a) Recommendation :- Vestibuling of all coaches in trains should be there as this would be of great help to train passengers to move safely away from the coaches on fire.

(b) Zonal Railways Comments -: All the coaches other than GS & SLR have vestibules design of 2nd class General Service coaches as per Board s letter no. 83/M/C/142/3 dt. 06/07/1984. This matter has been referred by RDSO to Railway Board for further guidelines.

(c) Remarks of the CCRS -: Railway Board is requested to consider the recommendation of RDSO and issue guidelines early.

(d) Remarks of the Railway Board : Vestibules have been presently provided only in the reserved coaches. This provides a sense of security

36


ACCIDENT - (vii)

by physically segregating the unreserved/unidentified passengers of the train from the reserved ones.

Not withstanding the above, given the situations of overcrowding in unreserved coaches like GS/SLR etc., in the event of not finding space in the compartments, there would be a tendency for some passengers to also travel in vestibule portion which will have serious safety concerns. Such a situation will worsen the safety arrangements more than providing relief/emergency exit to the passengers.

3.4 (a) Recommendation :- Specifications of the materials used in the coaches should be such that they do not emit toxic smoke on burning.

(b) Zonal Railways Comments -: RDSO has incorporated the clause of toxicity test as per NCD-1409 (Naval) specification in the specification of materials used in the interiors of the coaches.

(c) Remarks of the CCRS -: Action taken noted.

(d) Remarks of the Railway Board : The Railway administration has explained the position to the satisfaction of the Commission.

3.5 (a) Recommendation :- Communications with the site of accident should invariably be established immediately through setting up of emergency phones at site and maintained till the traffic is restored.

(b) Zonal Railways Comments -: Instructions have been issued to Drivers and Guards to establish communication from the site of accident by setting up of phone and maintain communication till the traffic is restored.



3.6 (a) Recommendation :- Guards of the train on Northern Railway must perform their duties as per para 122 of the Accident Manual of Northern Railway.

(b) Zonal Railways Comments -: Instructions contained in Para 122 have been reiterated to all concerned.


(d) Remarks of the Railway Board : The Railway administration has

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ACCIDENT - (vii)

explained the position to the satisfaction of the Commission.

3.7 (a) Recommendation :- Railway should immediately review the working of the level crossing gates and where the TVU have gone high and quality to be upgraded to A class on such level crossing gates three gatemen should be posted immediately. Railway should also under take up gradation of the level crossing gates without further loss of time.

(b) Zonal Railways Comments -: The necessary action for upgradation of level crossing is being taken regularly. Total 102 no. of plans have been approved during 2007-2008 for upgradation on account of provision of lifting barriers and interlocking etc. A proposal for providing 3 gatemen on 3 nos. of level crossings on MB division is also under process. As far as manning of level crossing is concerned, 82 no. of plans have been approved during 2007-08. Total 116 no. of proposals for changing normal position of gates from closed to road traffic to open to road traffic are under consideration, out of which 13 nos. have already been approved recently.



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ACCIDENT - (viii)

THE ABSTRACT OF THE REPORT OF COMMISSIONER OF RAILWAY SAFETY ON THE UNUSUAL OCCURRENCE OF DASHING OF A TIPPER LORY WITH 3351 DHN/TATA-ALLEPEY EXPRESS BETWEEN ATTIPATTU-PUDUNAGAR-ENNORE STATIONS OF CHENNAI DIVISION OF SOUTHERN RAILWAY ON 27.04.2007. I. BRIEF DESCRIPTION

1.1 THE ACCIDENT :- Train no. 3351 DHN/TATA-Allapuzha (Allepey) express commenced its journey on 25.04.2007. Initially at DHN, it had 12 coaches and train no. 8189 starting from TATA had 10 coaches attached to it. The respective BPCs were issue by TXR/DHN and TATA. At Rourkela, the coaches of both the trains were attached together and one SLR each from both trains was detached. The fresh BPC for train no.3351 consisting of 20 coaches, was issued by TXR/rourkela dated 25.04.2007. The crew members were last changed at BTTR/South Central Railway. Based on the statement of crew members of the train, there was no problem upto the time of above incident. While passing Km 19 at 75 Kmph near ENR, they saw a road vehicle very close to the track on the LH side. Though they started whistling and applied emergency brakes, the train could not be stopped prior to the tipper and as a result the locomotive collided with the tipper and the above incident occurred.

1.2 The speed of the train at the time of accident was 90 Kmph.

1.3 The weather at the time of accident was normal and visibility was clear under headlight.

1.4 As a result of the accident one train passenger was killed, 10 passengers were injured 02 of them grievously.

1.5 The total cost of damage to Railway assets was assessed at 13,750.00. II CAUSE OF THE ACCIDENT

2.1 Having carefully considered the factual, material and circumstantial evidence CRS has concluded as under :-

2.1. 1 Cause :- Accident occurred due to negligence of driver and cleaner of Tipper lorry. The construction organization failed to take necessary precautions while plying of contractor s vehicles near to existing railway track.

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Railway Accident Inquiry Reports-Pub.-2010 ACCIDENT - (viii)

2.2 The Zonal Railway has agreed with the findings of CRS in respect of cause.

2.3 On scrutinising the Report, CCRS considered that the conclusions arrived at by CRS are acceptable.

2.4 The cause as established by the CRS was accepted by the Railway Board.


3.0 The remarks and recommendations made by CRS and the comments of the Zonal Railway are reproduced below alongwith remarks of CCRS and Railway Board thereon :-

3.1 (a )Recommendation -: The instruction issued vide Joint Circular No.1/ 2007/Safety duly signed by PCE, CSO, CAO/CN/MAS relating to measures to be ensured during execution of work at site should be reiterated and strictly adhered to.

(b) Zonal Railways Comments -: Accepted. Instruction issued vide Joint Circular No. 1/2007/Safety has been reiterated to all concerned for strict adherence.

(c) Remarks of the CCRS -: Noted. The measures taken at work sites may be checked during scheduled inspections to enhance their ef fectiveness.

(d) Remarks of the Railway Board -: Accepted. Instructions have been issued vide B s letter No.2007/CE-II/PRA/9(CRS)dated 04.05.09.

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ACCIDENT - (ix)

THE ABSTRACT OF THE REPORT OF COMMISSIONER OF RAILWAY SAFETY ON UNUSUAL OCCURRENCE OF EMISSION OF SMOKE FROM THE BRAKE BLOCKS OF COACH NO.GS 028444 SE OF 8104 DOWN TATA NAGAR-AMRITSAR JALLIANWALA BAGH EXPRESS AND TRAIN PASSENGERS FALLING OFF THE BRIDGE NO.1136 FROM THIS COACH WHILE IT WAS ON THE RUN BETWEEN KATGHAR (E) AND DALPATPUR RAILWAY STATIONS ON MORADABAD-SHAHJAHANPUR DOUBLE LINE NON-ELECTRIFIED SECTION OF MORADABAD DIVISION OF NORTHERN RAILWAY WHICH TOOK PLACE AT 22.00 HOURS ON 16.05.2007. I. BRIEF DESCRIPTION

1.1 THE ACCIDENT :- The rake of 8103 consisting of 17 coaches underwent primary maintenance in the washing line no.1 at Tata Nagar Jn. On 14.05.07 and on reaching Amritsar it underwent secondary maintenance in the washing line no.4 on 16.05.07. Out of 17 coaches one coach no GS 868447 was marked sick and was detached. After undergoing secondary maintenance a 16 coach train, including two SLRs fully air-braked with 100% brake power by diesel locomotive no. WDM2 16868 departed from Amritsar railway station on 16.05.2007. When the train arrived at Moradabad railway station its rolling in and rolling out examinations were undertaken. After departing from, Moradabad it arrived at Katghar (E) railway station at about 21.56 hrs and while the train was entering this station the approach signal of this station was not taken OFF. Seeing the signal as red the loco pilot of the train applied the brakes to stop the train short of it but before the train could stop the approach signal was taken OFF and the train moved on and picked up the speed. When the train was just approaching bridge no.1136 Bhainsia 5x12.2m plate girder bridge, alarm chain was pulled in this train as panic was raised by some passengers of fire in coach no.GS 028444 SE as some of the passenger saw smoke in this coach. The train stopped with coach no. GS 028444 SE on this bridge and the train passengers started jumping out of this coach. It was a dark night and since there was no room for any train passenger to stand on the bridge they fell down on to the bed, which was dry.

1.2 The speed of the train at the time of accident was 49 kmph.

1.3 The weather and visibility at the time of accident were clear.

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ACCIDENT - (ix)

1.4 As a result of the accident, 15 train passengers were injured of which 08 train passengers were grievously hurt and 07 received simple injuries. No train passenger died.

1.5 The total cost of damage to Railway assets was assessed as Nil.

II CAUSE OF THE ACCIDENT

2.1 Having carefully considered the factual, material and circumstantial evidence CRS has concluded as under:-

2.1. 1. Cause :- Accident occurred due to the unusual occurrence of emission of smoke from the brake blocks of coach no GS 028444 SE of 8104 Down Tata Nagar-Amritsar Jallianwala Bagh express train, while the train was on the run between Katghar(E) and Dalpatpur railway stations on Moaradabad-Shahjahanpur double line non-electrified section of Moradabad Division of Northern Railway, at 20.54 hrs. on 16.05.2007 as heavy smoke, sparks, flames got generated in the brake block areas due to the combustion of the materials of composite brake blocks. On seeing the smoke, sparks and flames the train passengers panicked and raised alarm of fire in the train and when this coach stopped near the bridge No.1136 the train passengers jumped off not knowing that there was bridge beneath and fell off the bridge onto the dry bed of the river/stream. There was no fire inside the coach.


2.3 The cause established by CRS was accepted to Railway Board.



3.1 (a) Recommendation -: The composition of the materials used in the composite brakes blocks conforming to RDSO specifications no.C-9809(Rev 2) must be specified by the supplier and approved by RDSO while approving the Quality Assurance Plan of the supplier.

(b) Zonal Railways Comments -: This para pertains to Railway Board.

(c) Remarks of the CCRS -: Railway Board to look into this issue.

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ACCIDENT - (ix)

(d) Remarks of the Railway Board -:RDSO has furnished their comments on this recommendation as under :-

The composition of the material used for manufacture of composition brake blocks is proprietary in nature. The composition of the material and physical properties of the composition brake block are decided by the manufactures. RDSO specification No.C-9809 (rev.2) has been made in line with international specification UIC 541-4 for composition brake blocks. The composition of the material used in composition brake blocks and the physical properties are also not specified in UIC 541-4 and left to manufactures of composition brakes blocks.

In view of the above comments furnished by RDSO, the recommendation is not found feasible for acceptance.

3.2- (a)

(b)

Recommendation :- There was no stretcher available in the SLR of the train. In this unusual incident stretcher was most required to enable handling of the injured train passengers when they lay helplessly injured with fractured limbs under the bridge.

Zonal Railways Comments -: As per SR 4.19/2(b) following complement of brake van equipment shall be provided in a cupboard

to be provided in the brake van of all coaching trains.

(i) Portable control telephone.

(ii) Portable train lighting equipment.

(iii) Portable fire extinguisher.

(iv) Wooden wedges/skids.

(v) Stretcher.

The responsibility to ensure full complement of brake van equipment in working condition is of the primary maintenance depot.

Primary maintenance of Train no. 8103 Down Tata Nagar Amritsar Jallianwala Bagh express is at Tata Nagar on SER.

It was the responsibility of concerned incharge at SER, Tata Nager as well as the Guard taking over charge to ensure full complement of brake van equipment (including stretcher) in train no. 8103 Down, before starting train from Tata Nagar.

All GM s (Operating) of Zonal Railways including SER are being requested

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ACCIDENT - (ix)

to ensure compliance of SR 4.19/2(b) i.e full complement of brake van equipment should be ensured in the cup board of brake van of all coaching trains before starting of train.

However, it is relevant to mention here that even if a Stretcher was available in the SLR of the ill fated train, only a limited no, of injured passengers could have been shifted to the nearest ambulance/hospital. The Guard of train could not have shifted all the 15 train passengers who were injured. A stretcher in SLR is basically meant for shifting injured/sick passengers from a train to the nearest station to be handed over to SM/ASM for rendering medical assistance. During train accidents/untoward incidents involving passengers, ARME is ordered to provide relief to the injured passengers.

(c) Remarks of the CCRS -: The full complement of equipments was not available in the guard van. Railway Board to look into the lapse and take action accordingly.

(d) Remarks of the Railway Board -:Necessary instructions have been issued to the Zonal Railways vide Board s letter No.2008/Safety-I/12/ 1 dated 19.04.2010.

3.3 (a) Recommendation :- Protection of train should invariably be done by the crew of the train and the emergency phones must be set up in the block section during the occurrences of unusual incidents.

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