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Rail Accidents due to Human Errors Indian Railways Experience

From:
Amitabh
Director (Saety!"
#inistry o Railways" $o%t& o India
'&( I)*R+D,-*I+)
Safe transportation of passengers is the key business objective of any transportation
system. Railways are recognized as the safest mode of mass transportation and Safety has
been recognized as the key issue for the railways and one of its special attributes. All
business strategies emanate from this theme and strive to achieve Accident Free System.
Safety is, therefore, the key performance inde which the top managements need to monitor
and take preventive steps based on trends of accidents which are the manifestations of some
of the unsafe practices on the system.
!ndian Railways operate on gigantic dimensions covering over "#,$$$ route kilometers
with daily loading of %." million tonnes of freight and daily transporting of %& million
passengers by logging more than ' million train kilometers per day. Safety is of paramount
importance to !ndian railways. (ighest priority is accorded to safety and the rail mode in
!ndia continues to be the safest means of transportation for public. )o compromise is tolerated
in Safety of Rail users and all levels of management keep reviewing the Safety performance
from time to time. *his paper discusses the safety performance of !ndian Railways in brief,
role of human element in railway accidents and various initiatives taken by the !ndian
Railways to help bring down accidents due to human error.
.&( SAFE*/ 0 RE1IA2I1I*/ RE1A*I+)SHI3
Safety and Reliability of assets are closely linked with each other. +eterioration in the
safety performance is preceded by the increase in the number of failures. ,verlooking these
warning signals can be disastrous as each of these is an accident waiting to happen.
-age % of '$
Although no technology is fail.proof, an error rate, howsoever small, being inherent in
any man.machine system, reliability of the e/uipment is the most important factor in the
efficiency and safety of a transport system. ,bjective of the various research organizations is
to develop e/uipment and systems which have near zero level of failure rate. Side by side
with the induction of advanced technology, it is imperative that the same is maintained
properly and replacements, renewals made as and when needed. !f the accidents have to be
minimized, it is imperative that the e/uipment in use is always kept in fine fettle.
!ndian Railways have laid special emphasis in improving health of the infrastructure
and rolling stock resulting in better reliability over the years as can be seen from the table '.$
which has paved the path for safer system.
*able )o& .&(
E4,I3#E)* FAI1,RE +) I)DIA) RAI15A/S
/EAR RAI1 Diesel
1ocom
oti%es
Electric
1ocom
oti%es
5a6ons 3oor
2ra7e
3ower
*rain
3artin6
-oaches
Detachm
ents
+HE Si6nals
0%.0' 1%'0 %#"$0 2%%' 0'102 #&&0 '%&' 31# %$0# '#"'20
0'.0# "30$ %'13# 1031 "$02# &"1% %020 310 112 '$""$2
0#.0& &%2& %%2'' 1$&1 1%3&0 ##%& %1&0 "$' "33 %02&&3
0&.03 '02$ %$''$ "'%0 32&%3 #%22 %32# "$& #2' %"%#03
03.0" '2%$ 2&1& 320% &&'&' #&32 %&'# &#' '3" %#01#$
0".01 '0"3 1"'3 &03" #1%3$ #%&$ %#%# #"% %"0 %'3'30
01.02 '"1' 1$11 &"2" '#&0$ '#"1 %%1' '3$ %"# %%%$%&
02.00 #23' "#&1 &$#3 %1"#% %&'2 %%#3 '$$ %&& %$$33&
00.$$ 2&%" 31$# #2$" %#3'0 2"2 %$#& %"0 %"" %%2#01
$$.$% %$""$ 3#20 #"23 212' &1& %$2% '#$ 3$# %#'1#3
$%.$' %$"12 &2$2 #'%% 1'$0 '30 %$%# %0& #$0 %'%'&'
$'.$# %$#1& &&%" '01" 310" %"& 2'" %&2 "3% %%$"&$
$#.$& 2"%# &#$% '0'0 &32" "$ "22 %3" &13 %%1'&$
8&( Saety on Indian Railways An +%er%iew
8&' -orporate Saety 3lan
-age ' of '$
4ith view to accelerating the pace of the safety drive !ndian Railways formulated a
%$.year 5orporate Safety -lan, which was presented to the )ational -arliament in August,
'$$#. *his plan envisages achieving following broad objectives6.
a7 *o achieve reduction in rate of accidents per million train kilometers from the present
level of $.&& to $.%1 by the year '$%#
b7 !mplement measures to reduce chances of passenger fatalities substantially in
conse/uential train accidents by '$%#.
c7 Focus on development of manpower through major improvements in working
environment and training to reduce the accidents attributable to human failure by &$8
by '$%#.
d7 Achieve safety culture on all fronts including maintenance depots, worksites, stations,
controls etc.
e7 -rogressively achieve an environment of 9Fail.proof9 from the present 9Fail.safe9
system of asset failures by upgrading the systems by '$%#
f7 -rioritization of safety related projects
g7 !mplementation of accepted recommendations of Railway Safety Review 5ommittee
%002 at an accelerated pace.
*o ensure that financial constraints do not inhibit the implementation of the -lan, fund
re/uirement for the Safety enhancement works, as outlined in the -lan, has been identified as
Rs.#%2 billion including Rs.%1$ billion Special Railway Safety Fund already committed.
5orporate Safety -lan envisages reduction of accidents on !ndian Railways by the year '$%'.
%# substantially. 5ollisions are targeted to be completely eliminated. +erailments will come
down by "$8 and Fire accidents by 2$8. !t has not been possible to project assured
improvement in level crossing accidents as there is no control over the circumstances that lead
to such accidents.
8&. As result of regular review and initiatives undertaken Safety on !R has improved
considerably by way of continuous reduction in train accidents as can be seen from graphs
#.'.% : #.'..'6
-age # of '$
3.2.1 Trend of Train Accidents per year
325
351
414
464
757
866
1393
1960s 1970s 1980s 1990s 2001-02 2002-03 2003-04
6
8&8 4hile there has been a gradual decline in number of accidents, what is creditable is
the fact that the !ndian railways have improved on all the productivity indices over the years
as is evident from the graph #.#.
-age & of '$
1.8
2
0.86
0.65
0.55
0.44
0.39
5.5
1960s 1970s 1980s 1990s 2000-01 2001-02 2002-03 2003-04
3.2.2 Trend of Accidents per million Train Kms
8&9 +uring the last decade ;%00#.0& to '$$#.$&7 derailments were a major contributor
;1%87 in the total tally. *hese were followed by level crossing accidents ;'$87. 5ollisions
and <fire in trains< accounted for "8 and '8 respectively
-age 3 of '$
3.4 Type ise Accidents per !ear "1994-95 to 2003-04#
$erailments
71%
&ollisions
6%
'isc
1%
(ire
2%
)nmanned *&
16%
'anned *&
4%
3.3 +, -rot. /is-a-0is 1afety 2erformance
305
312
333
353
373
530
516
494
458
431
0.65
0.65
0.55
0.44
0.39
1999-00 2000-01 2001-02 2002-03 2003-04
3illion 2ass-Km
3illion Tonne- Km of (rei4.t
8&: =ooking at different categories of accidents in graph )o. #.& , derailments which form
bulk of them, have come down from %$"" per year in the sities to '$' in '$$#.$&, collisions
which are the most serious type have come down from 2# per year in the sities to 0 in '$$#.
$&. Fires in trains have also registered substantial decline from %$& to %& per year in this
period. =evel crossing accidents have not shown much improvement. Railways have no
control over the road users whose failures lead to almost all such accidents. Also, there has
been phenomenal growth in the number of road vehicles in this period.
-age " of '$
8&; 5ollisions are the most dreaded accidents for any railwayman. ,n !ndian Railways
collisions accounted for "8 of the accidents of which only &8 involved passenger carrying
trains, but these resulted in #'8 of the total casualties. Accidents at level crossings
accounting for '$8 of the total accidents on !R were responsible for &28 deaths.
+erailments though constituted bulk ;1%87 of the train accidents, these accounted for %18 of
the casualties.
9&( Human Element in *rain Accidents
!n the last %$ years ;%00&.'$$&7 on !ndian Railways, "'8 of the accidents have been
caused due to failure of Railway staff, ''8 have been caused due to failure of other than
Railway staff, failure of e/uipment has contributed 28, sabotage has contributed #8 and
balance 3 8 have been contributed by miscellaneous reasons. From the break.up, it is more
than evident that human error from Railway Staff has been the major factor in causing the
accidents on !ndian Railways.
-age 1 of '$
3.6 &as5alties in Train Accidents "1994-95 to 2003-04#
'isc
0%
(ire
3%
)nmanned *&
38%
'anned *&
10%
$erailments
17%
&ollisions
32%
(igher incidence of human failures surface as technical safeguards and backups do not
always replace the human effort. *hough an accident occurs only when both fail but it
usually gets logged as >human error? with a tendency of glossing over technical failure. @nder
optimum field conditions and with the best of intentions, a human being is likely to commit a
mistake from time to time. *his is the reason why operating rules included many redundancies
in safety procedures and operating practices involve number of checks and balances. Aore
and more automation is resorted to prevent human errors.
Aanpower is the most valuable asset on !ndian Railways which is highly labour
intensive with a work force of nearly %.& million. !t is a challenge to create and maintain high
motivation level and stress free environment for this large workforce encompassing several
categories of staff. Skills of manpower suiting varied job re/uirements are suitably developed
re/uiring ade/uate attention in training institutions.
,n !ndian Railways, while frontline staff is properly trained and their working closely
monitored, staff involved in maintenance activities has also been on sharp focus since they
also have important role to play in preventing accidents. *o enhance the /uality of human
resources multi prompt strategy has been adopted on !ndian Railways success of which can be
gauged from the graph &.$ indicating declining trend in accidents due to failure of Railway
staff from about 1$8 in %00&.03 to about "'8 in '$$$.$% to less than 3$8 in '$$#.$&.
-age 2 of '$
4.0 &a5se ise Analysis of Accidents
d5rin4 1994-95 to 2003-04
49.54
52.99
59.76
61.95
61.99
67.51
66.16
66.14
59.55
70.06
32.92
33.62
24.82
23.04
22.68
15.87 16.92 17.06
17.84
15.17
0.00
10.00
20.00
30.00
40.00
50.00
60.00
70.00
80.00
1994-
1995
1995-
1996
1996-
1997
1997-
1998
1998-
1999
1999-
2000
2000-
2001
2001-
2002
2002-
2003
2003-
2004
< o Railway Sta Failure < +ther than Railway Sta Failure
< o E=uipment Failure < o +ther -auses
9&' ,ver the years !ndian Railways have taken several under enumerated initiatives to
bring down accidents due to human error6
9&'&' Recruitment
Focus on proper aptitude at the time of selection.
Review of minimum /ualifications for different categories of staff taking into
account re/uired knowledge, skills and availability of trained manpower.
Raising of job eligibility standards.
Review of recruitment rules for officers and staff for multi skill jobs.
,ption to seek voluntary retirement to track gangmen and loco drivers beyond the
age of 3$ and upto 31 years with option for appointment to one of their wards.
5omputerized test program for determining the physical attributes such as
alertness, reaction time, stamina and ability to withstand fre/uent changes.
5omputer based psychological test for operating staff.
9&'&. *rainin6
Aodernisation and @pgradation of *raining 5enters.
5ompetency based training to Aaintenance Staff.
!ntroduction of interactive training with personnel computers on the lines of
modern training methods.
5entral *raining 5ell of multidisciplinary team responsible for designing training
courses and preparing /uality.training material.
Selection of trainers based on appropriate aptitude and skill.
Breater emphasis on practical training to the +rivers and Assistant +rivers.
Aore Financial -owers to field units to make liberal and etensive use of outside
training facilities in !* and *echnology areas.
-age 0 of '$
Refresher 5ourse for each category to be based on case study of accidents due to
human failure of that category of staff.
*raining Aodules to stress on >know.why? and >show.how? rather than >know.
how?.
*raining at the work spot via rail net.
9&'&8 Examination System 3romotion and procedure
+ata Cank containing objective type /uestions with multiple choice.
Answers covering the entire syllabus in random order with multiple choice
answers.
@pgrading and revision of pass marks for training during recruitment and
promotion.
9&'&9 Stren6th o Sta and >acancies
Dero based assessment of manpower based on which sanction strength of staff to
be revised and made uniform.
5oncept of multi.skill.
Accountability for filling up vacancies in the Safety 5ategory at an appropriate
level.
9&'&: #odiication o Rules
Revision of Rule books and Aanuals with the changes in operating system,
pattern of working, modernization and technology upgradation for making them
simpler for compliance.
!ndian Railway 5omprehensive Accident Aanual applicable to all Donal Railways.
Separate category wise modules containing do?s and don?ts.
All instructions in consonance with eisting manuals through correction slips.
(andbooks framed in simple language containing relevant rules for different
categories of staff.
9&'&; Inspections
+etailed checklist of various types of inspections to improve the /uality of
inspections.
-age %$ of '$
Special safety audit by multi.disciplinary teams.
5omputer database to assess efficacy of field inspections.
!ntensified safety test checks and more powers to the safety organization.
Element of surprise and opportunity to observe performance of staff under actual
working condition.
*est check of inspections of supporting officers.
)ight inspections of maintenance depots and other activity centers.
9&'&? +thers
-eriodical Safety drives to correct the system failure in which the all e/uipments that
are to be attended would undergo a cycle inspection.
Safety audits to identify system failures and generic shortcomings for making the in.
depth assessment of safety systems.
(uman Resource +evelopment ;(R+7 cell involving dynamic and knowledgeable
supervisors to study working habits of ground level staff, factors leading to short cuts
and to reduce fatigue, minimize monotony and improve safety consciousness.
Review of working hours for identified critical categories of staff.
Aore of Simulator training for drivers.
5rew Aanagement and setting up systems to ensure epeditious correction of enroute
deficiencies noted by crew.
Aobile breathalyzers for testing of running staff with an element of surprise.
*he ergonomic design of loco cab to provide fatigue free driving for long hours.
@pgradation of running rooms with certain basic amenities.
@pgradation of crew lobbies with basic amenities.
Buard friendly Crake Fans.
9&'&@ !t needs to be appreciated that crucialGvulnerable role of human interference comes
into play at the time of abnormal working of Railways mostly due to asset failures. As
reliability of assets improves, opportunities of the human intervention into vulnerable
functioning of railways reduce. Every accident is preceded by failure of asset and
performance of operations from the frontline operating staff becomes key to the safe operation
during such abnormal working conditions. *o manage the abnormal working, the stipulated
rules and regulations are mostly cumbersome and unfriendly to follow especially during long
-age %% of '$
periods of abnormal working. (uman intervention with strictly stipulated rules and
regulations under the abnormal situation of assets failure is likely to falter as such stipulations
are generally not practiced regularly by the staff. Aoreover, there are several etraneous
factors which cause the non adherence of such laid down strict stipulations in actual practice.
Some of these factors are the non acceptance of fre/uent failures due to poor /uality of assets,
stipulation of cumbersome, complicated and vague procedures to be followed during
abnormal working, indifference to the ground realities, etc.
9&&. Following case studies
H
into the recent major accidents have been undertaken to study
the human interference which led to major accidents. *he factors which led to such accidents
have also been discussed in detail in the following case studies6
H Analysis of the 5ases is based on the personal views of the author.

9&.&' -ase '
9&.&'&A Description o Accident
(ead.on collision of 0%%' +n Iammu *awi Ahmedabad Epress with % IA- +iesel Aultiple
@nit -assenger train between Changala and Airthal stations of )orthern Railway on
%&.%'.'$$& at %%.3# hrs.
As result of this accident, #2 persons lost their lives, '% persons were grievously injured and
%0 persons suffered simple injuries.
9&.&'&2 -ause o the Accident
*he two Station Aasters did not follow proper procedure of echange of messages on F(F
sets with other modes of communication between Airthal and Changala stations were out of
order and dispatched both the trains in the same block section towards each other on paper
line clear tickets.
9&.&'&- Aey +bser%ations
;%7 Juad cable supporting the block circuits was damaged due to construction
activity in the section causing failure of Clock instruments and block phones at
both the stations about '& hours before the accident.
-age %' of '$
;'7 Signal and *elecommunication staff was not deployed at the work site of
trouble before starting ecavation of earth, which is stipulated by the Railway
Administration.
;#7 *rains between Airthal and Changala were being worked on paper line clear
;-=57 since about '& hours prior to the accident as the block instruments had
failed. -=5 is one of the prescribed alternative means of train operation when
block instruments fail.
;&7 Clock phones at the subject stations also failed and under such condition, the
line clear should be obtained through section controller in accordance with
)orthern Railway Clock 4orking Aanual. (owever, even though
communication with controller was working in this case, line clear was being
obtained through F(F sets, which the last option and is to be resorted to when
control communication also fails.
;37 )orthern Railway Clock 4orking Aanual pertaining to obtaining the line clear
through the controller indirectly or on inter.wire stipulates for obtaining train
numbers with their description and private numbers of previous # trains passed
over the block section, from the person competent to grant line clear to ensure
that the reply to the line clear in/uiry is emanated from the authorized person
only. (owever, no such stipulation eists for obtaining line clear on F(F sets.
;"7 As a measure of abundant precaution, the Station Aasters while using the F(F
sets for paper line clear working, should have followed the system of taking
the train numbers with their description and -rivate )umbers of three previous
trains passing over the block section, to ensure that reply to line clear en/uiry
was emanated from an authorized persons competent to grant line clear, as in
the case of obtaining line clear though the controller indirectly or on inter.wire.
;17 *here was no problem with F(F communication like clarity of speech.
;27 *his is a saturated section handling both passenger and freight traffic to full
capacity. !t is /uite strenuous to operate even under normal circumstances.
;07 Coth the Station Aasters dispatched trains from their respective stations
towards each other in the same block section by granting line clear on F(F
sets echanging private numbers and issuing -=5.
;%$7 -=5 records were poorly maintained indicating continued neglect despite
detailed instructions from Railway Administration well in advance.
-age %# of '$
;%%7 -oor supervisory and managerial intervention in this most unsafe and accident
prone condition. *he control was well aware that F(F sets were being used
for line clear despite control phones were in working condition, Station
Aasters had been working in %' hours long shift instead of regular 2 hour shift
due to shortage of staff, regular Station Aaster was not available at one of the
stations and no additional reinforcement was provided to manage the situation
re/uiring etra care and concentration.
;%'7 4ork of locating and rectifying the fault was not undertaken on an emergency
basis and was postponed for the net day to avoid night working. *he
rectification work could not take off even before this accident on the net day.
9&.&'&D Human Element
;%7 (uman element came into vulnerable functioning after the technical failure i.e.
the cutting of /uad cable supporting control circuits during ecavation of earth.
;'7 Coth the Station Aasters adopted the least cumbersome process of granting
line clear after the failure of Clock instruments and block phones i.e. F(F
communication over controller communication. +espite F(F communication
being more vulnerable to outside interference, the prescribed safeguard for
ensuring that reply to the line clear in/uiry is emanating from the authorized
person competent to grant line clear was not adopted by Station Aasters.
;#7 *hough the practice of granting line clear using F(F communication had been
going on for about '& hours for several trains in both the directions, some
definite lapse took place at the level of Station Aasters while dealing with
these ' trains resulting in granting of simultaneous line clear for the same
block section in opposite directions causing head on collision.
9&.&'&E Discussion
All the above lapses manifested in the form of dreaded head.on collision with the last string
of frontline action coming from the Station Aasters of Airthal and Changala Stations causing
both the trains entering the same block section simultaneously from the opposite directions.
-age %& of '$
Role of other agencies including the management can not be overlooked in causing the most
vulnerable situation of train operation which ultimately resulted into this accident. 4hile
some of them have been enumerated in the observations as above, certain decisions like
stipulating and enforcing the practicable safeguards for taking line clear using F(F
communication, imposing speed restriction under vulnerable situations like -=5 working for
attracting the attention of Senior Aanagement could have offered favorable opportunities for
this unusual operating situation not to persist as long as for '& hours and to culminate into this
serious accident.
9&.&. -ase II
9&.&.&A Description
5ollision of 0%"2 @p Sabarmati Epress with stabled goods *rain at Samlaya Iunction
Station of 4estern Railway on '%.&.$3 at $#.%$ hrs.
As a result of this accident %" persons lost their lives, #2 persons were grievously injured and
02 persons suffered simple injuries.
9&.&.&2 -ause o the Accident
Signaling and ,perating staff at Samlaya station failed to follow the procedure prescribed for
failure of signal as result of which 0%"2 @p Sabarmati Epress, which was planned to pass
through main line, entered loop line and collided with the stable goods train.
9&.&.&- Aey +bser%ations
%. *he linkage for the operation of the culprit point had been attended on the previous
evening and proper fiing of the linkage was not ensured thereafter.
'. -in for connecting draw bar of the point and adjustable crank of the rodding was not in
position and was found lying nearby after the accident. 5otter split pin to keep pin in
position was lying on the base of the crank.
#. Signal lever for clearing home signal for the mainline was in pulled position.
&. Coth normal and reverse indication lights of the culprit point were in unlit condition.
-age %3 of '$
3. Signal failure register had an entry of failure of indication of the culprit point with
failure time of '.#3 hrs. which is #3 minutes prior to the accident. 5ontrol chart also
had an entry to this effect.
". Station Aaster had prepared a memo addressed to Electric Signal Aaintainer ;ESA7.
Coth original and carbon copies were available in the memo book. ,riginal copy was
in detached condition.
1. -rescribed form for authorizing the driver of 0%"2 Sabarmati Epress to pass the
Signal in Red condition was found prepared by Station Aaster with both the copies
of the authority available in the book.
2. 5abin Relay rooms are double locked with each of the keys remaining in the safe
custody of Station Aaster and Electrical Signal Aaintainer. Key of Station Aaster?s
lock of the cabin relay room ;wherefrom the culprit pointGsignal are operated7 was in
Station Aaster?s key bo and there was no entry for issue of this key on the date of
accident.
0. !t was the time of grouping of important trains in @p direction and failure of signal
could cause detention as the prescribed procedure for dealing with a failed signal
consumes etra time.

9&.&.&D Human Element
;i7 (uman element came into vulnerable functioning after the technical failure i.e.
malfunctioning of @p main line home signal.
;ii7 *he Station Aaster prepared the prescribed documents for advising the signal
failure to the Electrical Signal Aaintainer. (owever, the station master preferred
to advise ESA on F(F set regarding the malfunctioning of @p home signal
instead of sending the written advice. Electric Signal Aaintainer alongwith his
Assistant proceeded to the 5abin Relay Room and opened both the locks without
having taken the key of Station Aaster?s =ock and without making an entry into
the signal failure register to this effect. 4ithout checking the condition of the
point causing failure of signal, Electric Signal Aaintainer bypassed the relay
interlocking the point with the signal so that the signal could be turned on without
setting of the culprit point. *he rectification of signal was communicated on F(F
set to the Station Aaster by the ESA. 0%"2 @p Sabarmati Epress was thus given
-age %" of '$
pass through signal for the main line whereas the culprit point was still set for the
loopline and thus the train entered the loopline and collided with stabled train.
9&.&.&E Discussion
*he lapse from operating and signaling staff occurred due to non observance of prescribed
procedure to deal with the signal failure as per which a written advise is to be sent to the
ESA by the Station Aaster regarding signal failure and signal is considered fit only after
the receipt of written advise back from the ESA to this effect. +uring the intervening
period, written advice is issued to the drivers of the trains for overlooking the aspect of the
failed signal which costumes etra detention to trains. From observation " : 1 it is
evident that the Station Aaster had the intention of following the prescribed procedure for
dealing with a failed signal. (owever, the urgency of running trains without causing etra
detention took the front seat of thought and short cut of verbal communication was
resorted to by the station Aaster which was further compounded by the negligent working
by ESA and his assistant who bypassed the interlocking relay instead of fiing the
defective point which would have taken lesser time. From the report of the railway
administration after the accident, it was observed from the readings of the counters fitted
on the relay rooms at other stations that several other relay rooms had been opened
without the opening the station Aaster?s lock. *his unsafe practice seems to have been
persisting to prevent detentions and may be in the knowledge of higher officials.
5oncerned officials were perhaps shy of reporting such failures and owning the
detentions.
9&.&8 -ase III
9&.&8 A& Description o Accident
Fire in %3'$ @p +iesel Aultiple @nit train between Aarkundi and *akariya stations of double
line section of 4est 5entral Railway at '$.'$ hrs on %$.3.$3.
*here was no casualty as a result of this accident.
9&.&8& 2 -ause o the Accident
Fire occurred due to mal.functioning of auiliary rectifier.cum.regulator panel in the rear
+riving -ower 5ar ;+-57 )o. 45 %'$$#, which spread and burnt all the si coaches of the
-age %1 of '$
train because of failure of train crew to detach the affected coach and delay in arranging relief
loco by the controller.
9&.&8 - Aey +bser%ations
%. *he engine room of +-5 is not provided with fire or smoke alarms.
'. *he fire emanated from below the engine room area of rear +-5 and subse/uently
spread to engine room. !t spread to other five coaches through vestibules at the
average spread rate of '3 minutes per coach.
#. ,n learning that rear +-5 had caught fire and adjoining coupler was uncoupled, the
driving crew could not restart the front +-5 due to lack of trainingGguidance under
such eventuality.
&. *hough the fire had taken place in the mid section and a number of passengers
carrying trains had stopped at the nearby stations whose locos could be detached and
sent for separating the rest of the train from the burning portion, the controller decided
to send a relief locomotive by detaching from a freight train which was very far from
the site of fire and took long time in reaching the site by which time all the coaches
had been burnt.
3. Railway officials present at the site used fire etinguishers to etinguish the fire but
did not succeed. *imely advice to passengers to detrain saved all passengers from
injuries.
". Senior officials present in the control office could not guide the driving crew to start
and work from the front +-5. *hese officials did not play active role in sending the
relief loco at an early time.
1. +issemination of technical instructions on prevention of fire on +iesel Aultiple @nits
issued in )ov. '$$& had not yet reached the field maintenance unit wherein this train
was maintained.
9&8&.& D Human Element
%. Role of human element turned vulnerable after the initial symptoms of fire ;smell and
smoke7 due to failure of rectifier.cum.regulator panel in the rear +-5.
'. -reparedness of the train crew, which includes +river, Assistant +river and Buard,
came for a test under such situation in which they failed primarily due to poor training.
-age %2 of '$
+riving crew was unable to start the front portion by starting the engine of the front
+-5 after detaching the rear +-5 which had caught fire. *he delay was further
compounded by the poor performance of the controller and the officials present in the
control by selecting a freight loco from a distant location despite locos of several
passenger trains being available in the close vicinity.
9&8&.& E Discussion
5ause of the fire in the rear +-5 is undoubtedly the fire in the rectifier.cum.regulator panel
which might be due to poor maintenance in the maintenance depot which was not armed with
necessary technical instructions. *raining of driver : Assistant +river on the working of
+iesel Aultiple @nits under such abnormal situation was the major cause of spread of fire,
which resulted in the burning of all the " coaches. !ndifferent attitude of the controller and
officials present in the control in ensuring epeditious dispatch of a relief locomotive from the
nearest possible location also contributed in delay in separating the burnt coach from the rest
of the unaffected train.
From the above discussions, it is more than evident that there were several factors which
affected the human performance at the time of abnormal working conditions.
:&( -onclusion
Aost of the accidents due to human error are preceded by failure of asset. -erformance of
frontline operating staff becomes key to the safe operation during such abnormal working
conditions. )o human error leading to an accident is caused for the sake of it but is prompted
by several other factors which need to be eamined and investigated in greatest details to
reach the root of the cause. Aajority of accidents on !ndian Railways are reported to have
been caused due to failure of railway staff. 4ith detailed investigation of accidents and
innovative initiatives being taken by !ndian railways, accidents due to human error are
gradually declining over the years. !ndian railways have also made conscious efforts to
improve the reliability of assets to cut down the vulnerability of human element.
LLLLLLLLLLLLLL
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Reerences
%. 4hite -aper. Safety on !ndian Railways, April '$$#, Bovt. of !ndia, Ainistry of
Railways.
'. !ndian Railways 5orporate Safety -lan ;'$$#.%#7, August '$$#, Bovt. of !ndia,
Ainistry of Railways.
#. !ndian Railways Mear Cooks of relevant years, Bovt. of !ndia, Ainistry of Railways.
&. !ndian Railways . Safety -erformance of relevant years, published by Safety
+irectorate of Ainistry of Railways, Bovt. of !ndia.
3. NSafety as Key Cusiness *hemeO .!ndian Railways -erspectiveP, -. 5. Sharma :
Amitabh, !nternational Railway Safety 5onference, '$$&, -erth, Australia.
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