Kanchanjunga Express accident was 'waiting to happen': Railway safety report
Times of India | 16 July 2024
Kanchanjunga Express accident (File Photo) NEW DELHI: The Commissioner of Railway Safety (CRS) has said that the Kanchanjunga Express accident, which claimed ten lives including the loco pilot of the goods train was "waiting to happen" because of multiple lapses in train operations management in automatic signal zones and "inadequate counselling" of loco pilots and station masters.
The CRS, in its report, recommended the immediate implementation of the Automatic Train-protection system (KAVACH) to avoid future occurrences.
Following an investigation, the CRS identified that a "wrong paper authority" or T/A 912 to cross defective signals had been issued to the loco pilot of the goods train involved in the crash. The paper authority failed to specify the speed the goods train should adhere to while crossing the defective signal.
"Due to improper authority and that too without adequate information, such an incident was an 'accident-in-waiting,'" the CRS report stated, highlighting the lapses in rail administration.
Besides the Kanchanjunga Express and the goods train, five other trains had entered the section after the signals became defective until the accident occurred. The CRS noted that despite issuing the same authority, different speed patterns were followed by the loco pilots, with only the Kanchanjunga Express adhering to the norm of moving at a maximum speed of 15 kmph and stopping for one minute at each defective signal.
"This shows that 'action to be taken when T/A 912 is issued to them is not clear. Some of the loco pilots have followed the 15 kmph rule while most of the loco pilots did not follow this rule. The absence of proper authority and that too without adequate information created misinterpretation and misunderstanding about the speed to be followed,'" the report said.
The CRS emphasized the inadequate counselling of loco pilots and station masters regarding train operation in automatic signalling territory, creating misinterpretations and misunderstandings of rules. The incident was classified under the "Error in Train Working" category.
“The large number of signalling failures in automatic signalling territory is a cause of concern and should be taken up with those concerned to improve the reliability of the system,” the CRS report noted. The report cited 208 cases of Signal Passing at Danger (red signal overshooting) from April 1, 2019, to March 31, 2024, including 12 cases resulting in collisions, underscoring the limitations of preventive measures taken by zonal railways such as loco pilot counselling, safety drives, etc.
“This underscores the need for implementation of the Automatic Train-protection system (KAVACH) on top priority. Use of non-signalling-based systems such as Artificial intelligence-based detection of the RED aspect of the signal and providing an early warning to the loco pilot/GPS-based anti-collision systems shall be explored for provision in locomotive cabs across Indian Railways in non-ATP (automatic train protection) territory,” the report recommended.
The investigation also revealed a shortage of walkie-talkies in the Northeast Frontier Railway (NFR) Zone, where the accident occurred, preventing the goods train crew from being issued this critical safety equipment.
In the event of multiple signal failures, the CRS highlighted three potential courses of action for the rail administration, none of which were fully followed in this incident. The first option was for drivers to follow the general rule of stopping the train for one minute at the defective signal and proceeding with great caution until the next stop signal. The second option was issuing a T/A 912 form with a caution order specifying the speed to be maintained, which was not done in this case. The third option was treating the scenario as a "major signal failure" and using the Automatic Block System, whereby only one train is allowed between two stations until the preceding train clears the next station.
The CRS pointed out that the control office at the divisional level should be staffed round-the-clock by one Senior Section Engineer, one Junior Engineer, and one helper in an 8-hour shift. However, on the night of June 16 and June 17, the signalling control office was manned only by a technician.
“It is not possible to manage such a major signalling failure by a staff of technician level. The response of higher officials of the signalling department at the divisional level posted at Katihar has been found lackluster as despite being informed about this serious failure, none of them went to the control office to manage and coordinate with other departments for timely attention of signalling failures," the report said.
Since the introduction of automatic signalling in January 2023, the CRS stressed the necessity of implementing all applicable rules at the field level. The prevalent misinterpretation of rules indicated the lack of a system of checks and balances at the headquarters level.