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Appendix-IV

BRIEF DETAILS OF SERIOUS RAILWAY ACCIDENTS INQUIRED INTO BY THE COMMISSION OF RAILWAY SAFETY

1.01   DASHING OF 4123 UP PRATAPGARH-KANPUR INTERCITY EXPRESS AT MANNED LEVEL CROSSING NO 110'C' WITH TRUCK BETWEEN TALAKHAJURI-GAURIGANJ STATIONS ON LUCKNOW DIVISION OF NORTHERN RAILWAY ON 03/05/2003.                                                                                                

a)  CAUSE Blocking of the opened level crossing by two road trucks no. UP 53L 9195 and HR 37B 7276 entered from opposite directions.

b)  CASUALTIES    KILLEDNIL,         GRIEVOUS 3 (Passengers),

                                                               SIMPLE 02 (Passengers).

c)   COST         -         Rs.55,000/-                             

d)   CATEGORY  -     Failure of Railway Staff and other than Railway Staff combined.

RECOMMENDATIONS :

1.   Level crossing no.110C should be upgraded to appropriate class with utmost urgency as per classification norms laid down in Railway Boards letter No.2001/CE/LC/AC/01(Data) dated 25.09.2004.

2.   The road width, gradients and speed breakers at this LC should be made in accordance with the provisions in IRPWM 1986, treating it as class II road.

3.   Railway Board should review certain provisions of their instructions in respect of working of manned level crossing issued vide letter No.200/Safety(A&R)/19/29, dated 08.05.2002.

4.  Trial of dummy lifting barrier designed by RDSO should be carried out expeditiously and they should be provided on level crossing where the lifting barriers are prone to frequent breakage. 

5.  Review of all the level crossings on Northern Railway should be carried out for classification/upgradation/manning etc. in accordance with Railway Boards letters dated 25.09.2003 and 11.06.2003, within next 03 months. The busy and accident-prone level crossings should be tackled on out of turn basis.

6.  Railway Board should review their recent decision of not agreeing with the Commission with its earlier recommendation and agree for providing stickers/steel plates with suitable inscriptions, inside the II class coaches, cautioning the passengers about the dangers of projecting their body parts outside the doors/windows of the coach and also consider providing additional horizontal/vertical iron bars on the windows.

7.   To establish effective chain of command, the incharge supervisor of safety category disciplines in the field should be at least one grade higher than the Sectional Supervisor. Also no supervisor should continue in the same section for say more than 05 years.

1.02    FIRE IN THREE COACHES OF 2903 UP-GOLDEN TEMPLE MAIL BETWEEN STATIONS LUDHIANA-LADHOWAL ON FEROZPUR DIVISION OF NORTHERN RAILWAY ON 15/05/2003.

a)   CAUSE The most probable cause of the fire that took place in 2903 Up was from a Bag lying on the Upper berth No.22 of S-4 Coach which contained certain combustible, Explosive materials and other compounds capable of spontaneous ignition with some provisions to cause and control the ignition and these materials ignited as soon as 2903 Up departed from Ludhiana Railway Station.

b)  CASUALTIES     KILLED 36(Passengers),      GRIEVOUS-03(Passengers), SIMPLE 13 (Passengers). 

c)  COST              -    Rs.1,52,81,720/-                     

d) CATEGORY  -   TRAIN WRECKING.

RECOMMENDATIONS :

1.  All the coaches in the passenger trains provided with cushioned seats and berths should be equipped with adequate fire fighting equipments. 

2. Railway should not use Rexene and foam in furnishing the passenger coaches, which give out toxic, dense smoke on burning.

3. Smoke and fire in the trains should be detected immediately by the smoke detectors and alarm sounded to warn the traveling passenger, Driver and Guard of the train. Trains must come to stop as soon as the fire breaks out in the train. 

4. The passages and doorway of the coaches should be kept free, All the vestibules should be kept open during the train journey so that in case of any fire in the train there are no obstruction to the movement of passengers rushing out of the coaches or moving into other coaches for safety. Army personnels traveling in trains must co-operative with the railway officials.

5. The design of coaches should be such that during fire in the coach, the smoke should move vertically out of the coach through the ventilators and not horizontally.

6. TTEs should not permit any extra persons to travel in the reserved coaches who are not borne on the reservation charts.

7. TTEs must check the coaches for inflammable and dangerous articles carried by the train passengers and they should work in coordination with GRP/RPF.

8.  Working of TTEs should be closely monitored by the Railway Administration. They may be transferred every 3 years from their station of postings. They also required intensive training regarding duties to be performed by them during Railway accidents.

9.  Any threat to the Railway known to the Police should be intimated to the Railway authorities without loss of time so that Railways become vigilant.

10. Movement of Army personnels required a review and Railway should consider augmentation of coaches reserved for them.

11. For carrying bulky items, provision of enclosure in passenger coaches may be made so that those items which cannot be kept under the seats can be kept in these enclosure in the charge of TTEs/Attendants on duty and to be made over the passenger before approaching the destination station.

Railway may levy extra charge for the loss of seating capacity and for services.

12.  All coaches (including EMUs/DMUs/MEMUs) must be subjected to stringent checks by the EIG at the time of manufacture and at the time of maintenance during periodic overhauls. The maintenance of the Electrical equipments in the coaches must be out only by the staff duly authorized to do by the EIG.

1.03  DERAILMENT of 287-PASSENGER between stations VENKATAMPALLI-GULAPALYAMU on GUNTAKAL division of SOUTH CENTRAL RAILWAY on 25/05/2003                                

a)   CAUSE  Due to improper maintenance of lock bar of slip siding point No.9 which permitted operation of the point from reverse to normal during the passage of train, though he can observe the passage of train visually from siding point.  

b)      CASUALTIES     KILLED 3 (Passengers),       GRIEVOUS-3 (Passengers),

                                                                                    SIMPLE 11 (Passengers) 

c)      COST              -     Rs.1,00,000/-                           

d)      CATEGORY  -      Failure of equipment Signalling/Mechanical.

RECOMMENDATIONS :

1. Maintenance of points and crossings including lock bar, rodding transmission by S&T staff may be toned up 

2.  VHF communication should be provided between the drivers, guards and the ASMs so that the drivers/guards can exchange information regarding safety aspects like complete arrival of train, clearance of fouling mark and in this specific case clearance of slip sliding points etc.

3.   Operating staff particularly in safety category should be discouraged to perform duty beyond their duty hours as a matter of routine. Unimportant stations may be closed. The special features of the station particularly relating to the safety should be explained to the railway staff resuming duty at the station after long time.

4.  Duty roaster of Station staff should be issued indicating the names of the staff in various shifts. Their controlling supervisor in writing should approve any change in their duty roster.

5. Temporary modifications to working instructions in SWRs should be jointly signed by the officers of safety and S&T department. In case of major changes for long duration, these should be got approved from the Commission.

6.  Non-provision of emergency exit window for all the coaches of passenger carrying trains is rejectable defect by NTXR w.e.f. 01.04.2003 in terms of Railway Boards letter No.97/M//137/12, dated 01.04.2002 and its corrigendum dated 11.04.2002. Therefore fitment of emergency exit windows should be ensured for all coaches immediately.

1.04 DASHING OF 959 DN MUMBAI CENTRAL GANDHIDHAM HOLIDAY SPECIAL AT MANNED LEVEL CROSSING BETWEEN STATIONS CHHARODI-JAKHWADA ON AHMEDABAD DIVISION OF WESTERN RAILWAY ON 28/05/2003                                                                                                

a)      CAUSE Due to gate kept in open condition without obtaining permission and private number from SM/Jakhvada, not planting banner flags across the track when gate was in open condition and gateman not being attentive.

b)      CASUALTIES     KILLED 01 (Outsider), GRIEVOUS-NIL, SIMPLE NIL. 

c)      COST                -   Rs.2,000/-                               

d)      CATEGORY    -    Failure of Railway Staff.  

RECOMMENDATIONS :

1.  Railway should identify, through joint inspections by P.Way and traffic officials, those manned non-interlocked level crossings, where normal position of the gate is closed to road traffic but due to high density of road traffic, gates are likely to be opened without obtaining private number from Station Master. 

Railway should arrange to counsel Station Masters of controlling stations of such identified level crossings to arrange opening of these gates frequently for road traffic. Section controllers should also be made aware of the requirement of opening of such level crossings.

2. Railway should consider changing the normal position of level crossings, identified as per above recommendation, from closed to road traffic to open to road traffic. 

3.  Railway should ensure that LC interlocking works are completed within two years of their being sanctioned.

1.05     DERAILMENT OF 2391 UP-MAGADH VIKRAMSHILA EXPRESS BETWEEN STATIONS BARUNA-BUXAR ON DANAPUR DIVISION OF EASTERN CENTRAL RAILWAY ON 01/06/2003.                                                                                              

a)  CAUSE Due to discontinuity in track caused by cutting of cess side running rail and shifting the cut piece from its position towards the other rail on Howrah and approach of bridge No.322 by miscreants.

b)      CASUALTIES     KILLED 01 (Passenger),       GRIEVOUS-12 (Passengers)

                                                                                     SIMPLE 07 (Passengers).

c)      COST                -   Rs.1,85,10,000/-                     

d)      CATEGORY    -    SABOTABE.  

RECOMMENDATIONS :

1 .Stretches of track on East Central Railway attended by miscreants activities may be identified in consultation with State Government and speeds reduced appropriately with immediate effect.

2. Security patrolling of tracks and major bridges be introduced at vulucrable locations.

3.  Any other appropriate measures to eliminate accidents on account of tampering of track by recreant activities and also to minimize consequences of such accidents may be taken by the Railway as deem fit.

4.  Instructions issued vide Boards letter No.2202/CE-II/TK/10, dated 20.02.2002 on patrolling of in sabotage prone areas should be implemented and monitored at all levels 

5. Railway Board should expedite trials and final design of concrete sleepers with anti-sabotage features.

6.  Maintenance facilities for coaching trains at Patna and Bhagalpur should be augmented immediately. Timings of the trains (undergoing primary maintenance there) to be revised to provide minimum 6 hours time for primary maintenance at Rajendra Nagar Coaching Complex and Bhagalpur. 

7.  Intelligence network of Railway in the sabotage prone area needs to be strengthened 

8.  Railway/Railway Board should follow up cases of sabotage/tampering of track with State Government/Union Ministry of Home Affairs. If it does not yield any fruitful result, the running of mail/express trains in sabotage prone areas at night needs to be seriously looked into. 

9.  East Central Railway, Eastern Railway may be directed to provide guard rail on bridges as stipulated in para 275(1) of the Indian Rails Permanent Way Manual and impose suitable speed restrictions which can be relaxed after complying with the stipulations in Indian Railways Permanent Was Manual.

1.06        DASHING OF A TIPPER WITH 559 PASSENGER BETWEEN KOSAI-AMBARI STATIONS RESULTING IN DERAILMENT OF TWO COACHES ON NANDED DIVISION OF SOUTH CENTRAL RAILWAY ON 05/06/2003.                                                                                                

a)      CAUSE Due to trespassing of the tipper at the above unauthorized location. The construction organization failed to take necessary precautions for properly protecting the track and to take sanction of Commission of Railway Safety while carrying out major re-grading work during Gauge Conversion at above location.

b)      CASUALTIES    KILLED 02 (Passengers),      GRIEVOUS-04 (Passengers),

                                                                                    SIMPLE 11 (Passengers).

c)      COST                -  Rs.1,25,000/-                          

d)      CATEGORY    -    Failure of person other than Railway Staff. 

RECOMMENDATIONS :

1. Instructions contained in Engineering Standing Order No.23 issued by Principal Chief Engineer, S.C. Railway, Secunderabad vide his letter No.W/T.3/P/Vol.XII, dated 16.10.2002 basing on Railway Boards guidelines relating to working of contractors machinery near to the track may be incorporated in contract agreements where a contractor has o work in the close proximity of existing running tracks so as to avoid this type of unusual occurrences. Even for the existing contracts, these instructions may be reiterated to the field officials to ensure safe working. 

2.  The sanction of Commission of Railway Safety in terms of 2(f) of Para 1302 of I.R.P.W. Manual for heavy re-grading of running lines involving lowering/raising of track in excess of 500mm should be taken before taking up such works. No unsafe conditions should be permitted during execution of such works.

3.   Since computer chip based speed recorders being now available are provided on Broad Gauge locomotives, these should be provided on Meter Gauge locomotive as well n addition to existing speedometer at a location to be visible to the driver of the train to see its speed while running with long-hood leading instead of looking back to check its speed.

4.   In view of the fact that passenger trains are running on this section without any emergency communication and trains are worked without the section control communication, it is recommended that Quad Cable communication which was sanctioned in Gauge Conversion Project should be provided on top priority by de-linking with track works, as the opening of the section to BG may take some more time.

As an interm measure, it is also recommended that the stations should be quipped with high powered VHF sets and walkie-talkie sets provided for drivers/guards so as to serve as emergency communication.          

5.   For works involving safety of existing train services, Engineering department including construction organization should clearly spell out the methodology of construction including precautions at various stages for ensuring safe running of passenger trains in the section. 

1.07          DERAILMENT OF 5316 DN GOKUL EXPRESS BETWEEN STATIONS RAYA-SONAI ON IZATNAGAR DIVISION OF NORTH EASTERN RAILWAY ON 13/06/2003

a)      CAUSE A hard object was placed on top the outer rail of the curve by some out side person which came under the wheel of the Locomotive and caused the wheels to jump off the rails and derail. 

b)      CASUALTIES    KILLED00, GRIEVOUS-06 (Passengers), 01 (Railway crew),

                                                SIMPLE 02 (Passengers), 01 (Railway crew).

c)      COST                -   Rs.24,07,087/-                        

d)      CATEGORY    -    Failure of person other than Railway Staff. 

RECOMMENDATIONS :

1.  Railway should educated Public not to cause obstruction on the railway tracks particularly the villagers of the village adjoining the site of the Accident. 

2.  Railway Hospitals on Mathura-Kasganj MG Section should be provided with sufficient number of ambulances for the expeditious movement of the Railway Doctors, para medical staff and the injured train passengers when railway accidents take place on this section.

3.   For the First Aid training, models Manequin models should be provided for better training and understanding. 

4.   Guards and TTE must record the complete particulars of all the injured amd the dead immediately after the accident and convey it to the Divisional Control.

1.08          COLLISION OF 542 DN BHATNI-CHHAPRA PASSENGER WITH A TRUCK AT UNMANNED LEVEL CROSSING BETWEEN STATIONS ZIRADEI-SIWAN ON VARANASI DIVISION OF NORTH EASTERN RAILWAY ON 18/06/2003.                                                                                                

a)      CAUSE The Driver of the truck did not stop at the stop boards provided by the Railway at the Unmanned Level Crossing gate when 542 Dn. Was coming Jeradei side. He should have allowed the train to pass by but instead the driver of the truck tried to cross the Unmanned Level Crossing Gate and as a result the rear portion of the truck got hit by the locomotive of the train.

b)      CASUALTIES     KILLED 01 (Rly. crew), GRIEVOUS-NIL,  SIMPLE NIL

c)      COST                -   Rs.1,29,273/-                          

d)      CATEGORY    -    Failure of person other than Railway Staff.

RECOMMENDATIONS :

1.  The District Authorities should ensure that the road warning signs are provided by the concerned road authorities at all the Unmanned Level Crossing and also ensure that these boards are provided at the Unmanned Level Crossing Gate No.94 C Class without delay. Railway should take up the matter with the District and State Authorities. 

2.  Intensive checks should be made by the District authorities to see that the provisions of the Motor Vehicles Act Clause No.131 are observed by the road users while crossing the Railway tracks at the Unmanned Level Crossings.

3. Diesel Assistants should be given intensive training in the application of the emergency brakes during the run of the train and counseled regarding action to be taken when the drivers became incapacitated. They should be trained in the use of walkie-talkie sets. 

4.  The gradient and the width of the Level Crossing Gate No.94 C Class should be provided as per Indian Railways Permanent Way Manual.

1.09  DERAILMENT OF 904 UP-KARWAR MUMBAI CENTRAL HOLIDAY SPECIAL BETWEEN STATIONS VAIBHAVWADI-RAJAPUR ON RATNAGIRI DIVISION OF KONKAN RAILWAY ON 22/06/2003.                                                                                                

a) CAUSE Absence of monsoon patrolling in all the block sections as per 1004 of IRPWM, 1986. 

b)  CASUALTIES    KILLED 52 (Passengers),     GRIEVOUS-15 (Passengers),

                                                                               SIMPLE 10 (Passengers).

c)      COST               -   Rs.3,03,10,000/-         

d)      CATEGORY    -    Failure of equipment (infrastructure) and sudden convulsion of nature. 

RECOMMENDATIONS :

1.  RDSO to inspect KRC alignment and submit a report to MD/KRC. The Railway Board should direct the RDSO without any further delay to comprehend all data so far generated and carry out the inspection of remnant portions of KRC alignment and submit their report to MD/KRC in consonance with the spirit of the Railway Boards letter No.94/CE/II/TK/14 of 10.09.1996 for his consideration and further action by the KRC for more reliable train operations.

2.   Preventive Measures for Monsoon of 2004:  Various preventive measures as given below:  -

i)  Posting a mobile patrolman in cutting of depth more than 12 meters.

ii)   Diesel locomotive patrolling (80 kms. Per locomotive) in identified sections. 

iii)  Imposition of speed restriction of 75 kmph on all cuttings deeper than 12 meters.

iv)  Reiteration of relevant monsoon instructions to all field staff and train crew in the month of April/May, 2004.

These provisions should be ensured on KRC system from 1st June, 2004 onwards without any laxity/hesitation to prevent train accidents. 

3.   The Railway Board may consider increasing the formation width in deep cutting of depth more than 12 meters and issue necessary policy directives.

1.10          EXPLOSION IN TRAIN NO. 194 UP-RENIGUNTA-ARAKKONAM PASSENGER BETWEEN STATIONS RENIGUNTA-PUDI ON CHENNAI DIVISION OF SOUTHERN RAILWAY ON 25/06/2003.                                                                                                

a)   CAUSE Due to the carriage of low explosives, which exploded after being ignited by a careless throw of a beedi/cigarette or a burning mosquito coil. 

b)      CASUALTIES     KILLED 01 (Passenger),       GRIEVOUS-NIL, SIMPLE 01 (Passenger).

c)      COST                -  Rs.20,000/-

d)      CATEGORY    -    Failure of other than Railway Staff. 

RECOMMENDATIONS : 

1.  The Government Railway Police should strengthen its intelligence machinery to get advance intimation of the unauthorized carriage of explosives in passenger trains.

2.   More surprise checks should be conducted by Government Railway Police and Ticket checking Staff like TCs, TTEs to detect the unauthorized carriage of explosives in passenger trains.

3.  Gurards standard equipments as per extent rules should be provided in all the passenger trains.

4. The penalties against unauthorized carriage of explosives should be prominently displayed inside the coaches and effective publicity campaigns should be carried against the same. Exemplary punishments should be attempted in the detected cases of such unauthorized carriage 

5.  Standard brake van equipments should be minimized to fit into the Guards box.

1.11          DERAILMENT OF 7201 UP-GOLCONDA EXPRESS AT WARANGAL STATION ON SECUNDERABAD DIVISION OF SOUTH CENTRAL RAILWAY ON 02/07/2003.

a)   CAUSE Due to delayed application of brakes of the train.

b)   CASUALTIES    KILLED 21 (Passengers),     GRIEVOUS-16(Passengers),SIMPLE 08 (Passengers).

c)   COST                -  Rs.29,73,000/-

d)   CATEGORY    -  Failure of Railway Staff.

RECOMMENDATIONS :

1. RDSO should review the design/drawing of sand hump in view of increase the speed on loop lines and running of longer goods trains. For stations where sand humps have been provided in lieu of adequate distance beyond starter signal as per GR 3.40 of S.C. Railway, Railway Administration should stipulate a minimum distance of 30mts beyond sand hump where there should be no bridges, structures or Level Crossings. At such locations where it is not possible to adhere to this stipulation, in lieu of above 30mts distance, hydraulic/Friction Buffer Stops may be provided where the sanded portion ends. Necessary instructions for maintenance schedule of sand hump/overshoot line as part of relevant Points & Crossings inspection may be issu

  For sand hump on Road No.4 at Warangal towards Kazipet side, the length of formation beyond sanded portion should be increased to Standard length with modifications as suggested in para 7.5.4. Similar modification may also be carried out for other sand humps where standard length of sand hump is not available. 

2 . Para 71(79 and (8) of IRMM Volume-II;  3rd edition-2000 should be modified to provide medical aid/assistance in the Railway Hospital to the injured passengers involved in the train accident covered under section 113 of Indian Railways Act.

3. Instructions relating to preservation of clues and recording joint observations prior to their disturbance at the site of accident as per Para 206(i) of S.C. Railway Accident Manual 1977 should be reiterated. Trains involved in accident should not be moved from the site of accident without its proper examination and certification by the concerned staff and with the approval of competent authority. 

4. Separate set of drivers and Assistant drivers for hauling Diesel and Electric locomotives, Air brake and vacuum brake trains should be nominated for running passenger carrying trains.

5. The RDSO should study the need for provision of PVEF below the drivers desk, (foot pedal switch) in Electric locomotives for isolation of loco brakes from formation brakes, a feature, not available in Diesel locomotives 

6.  The construction of second pit line at Guntur should be sanctioned early for ensuring availability of adequate time for maintenance of coaching stock as per Circular NO.D.O. No.M.271.C&W.P.Vol.XIII dated 05.11.01. As far as possible, the integrity of the rake should not be disturbed while carrying out primary maintenance on pit line. For ensuring attention during day light hours once a week/fortnight, availability of spare rake/coaches may be ensured.

7.  Digital voice recorder with a memory of minimum one week should be installed in driving cabs of all Locomotives for analyzing the conversation between the drivers, the assistant drivers and the stations staff increase of need. Similarly, Voice recorders should also be installed for section control communication circuits 

8.  The timings of data logger, speed recorder chart should be synchronized with periodical checks, with standard control time at the time of their installation.

9.  Railway Administration should procure Trepanning tool and Jig Saws to be kept in ARME for cutting thicker sections like windowsills etc for quickening the rescuing operation.

10. RDSO should undertake the development of multi channel recording system for locomotive, capable of recording additional data like vacuum/Air pressure, notch position, pantograph position, position of brake handles, paralleling of Motors.

11. Railway Board should review twin single line working for the section Kazipet-Warangal and Kazipet-hasanparthi Raod and convert them into orthodox doubling.

12. RDSO should review specification of memotal based speed recording system as issued vide specification No.0.33700.07(Nov.02) and provide for shot term memory of three hours duration in line with the specification of such systems as issued by Motive Power Directorate of RDSO

1.12    DERAILMENT OF 287 UP-PAK-BAT PASSENGER BETWEEN STATIONS MADANAPALLE-TUMMANAMGUTTA ON GUNTAKAL DIVISION OF SOUTH CENTRAL RAILWAY ON 06/07/2003.

a)   CAUSE  Due to tampering with the track by outsiders other than railway Staff.

b)      CASUALTIES    KILLED 01 (Railway crew),             GRIEVOUS-NIL,

SIMPLE 08 (Passengers), 01 (Railway crew).

c)      COST                -  Rs.1,76,70,000/-

d)      CATEGORY    -    Failure of other than Railway Staff. 

RECOMMENDATIONS : 

1.  Boulders including CST-9 plate, rail pieces etc., should not be left unguarded int he mid-section to facilitate miscreants for their unauthorized placing on the track particularly in areas prone for such miscreant activities.

2.   In view of the poor performance of the overhead communication system, Quad Cable communication which is a part of Gauge Conversion Project, should be provided on top priority, as soon as the detailed estimate is sanctioned, as the conversion of the section to BG may take some more time.

3.   The sanction of District authorities and the Commission for closure of level crossing gate No.82 as well as others having low value of TVUs should be obtained expeditiously and their checkrails removed after proper sanction.

1.13          UNUSUAL OCCURRENCE IN THE 347 DOWN CHURCHGATE-BORIVALI EMU LOCALBETWEEN JOGESHWARI AND GOREGAON STATION OF MUMBAI DIVISION OF WESTERN RAILWAY ON 14.07.2003.                                                                                                 

a)      CAUSE Due to steam and heat generated by chemical reaction of lime with water in a plastic bag being carried by a lady passenger, causing panic amongst passengers.

b)      CASUALTIES    KILLED NIL,           GRIEVOUS-02 (Passengers), SIMPLE 03 (Passengers).

c)      COST                -   Nil.

d)      CATEGORY    -    Failure of person other than Railway Staff.          

RECOMMENDATIONS :

1. The Railway should start providing mechanism for closing doors of EMU coaches on command from Driving Cab and also provide the interlocking to ensure that doors of all coaches are in closed condition before the train can move. 

2.  Railway should take steps to ensure that spare P.Way material, like rails sleepers, are not left spread along the track.

1.14          COLLISION OF 5087 UP-JAMMU TAWI AMARNATH EXPRESS AND TRUCK NO.-UP 53 G 2311 BETWEEN STATIONS GORAKHPUR AND DOMINGARH ON LUCKNOW DIVISION OF NORTH EASTERN RAILWAY ON 28/07/2003.                                                                                                

a)   CAUSE Stabling of truck No.UP-53-G-2311 by the driver of this truck alongside the Railway Line very close to the Railway line infringing the Railway Line and when 5087 Up passed by the front SLR got hit which broke part of the rear portion of body of the truck and this rubbed against the coaches of the train and injured the train passengers. 

b)    CASUALTIES     KILLED NIL,           GRIEVOUS-26 (Passengers), SIMPLE 15 (Passengers).

c)    COST                -   Rs.15,000/-

d)    CATEGORY  -      Failure of person other than Railway Staff.        

RECOMMENDATIONS :

1. Entry to the construction site of the earthwork, blanketing and retaining wall between Goarkhpur and Domingarh Railway Stations, from the Level crossing No.163A Class (Engineering) for all the vehicular traffic should be closed by providing a Railway Fencing. 

2.   Whenever construction of the double line is undertaken fencing alongside the Railway line in complete length of the block section where doubling is being done should be erected so as to prevent any infringements to the moving dimensions likely to be caused by moving or stationary vehicles used for execution of the works. The fencing should conform to the design approved by CE/Construction.

3.  IRPWM should specify the minimum and maximum distances at which the fencing to the Level Crossing Gate should be provided so that trespassing by road vehicles is prevented. 

4.  All construction work sites are required to have supervisors for the execution of the work but the severe shortage of such supervisors under CAP/Con exists and should be made good. While placing indents on the RRB for the direct recruitment of the supervisors the work charged requirement of the Supervisors for the execution of various engineering works should be taken into considerations. Railway Board may lay down the necessary provisions for this.

5.  Blood test of the Driver, the Diesel Assistant and the train passing staff of the station should be undertaken whenever any accident takes place.

6.  All the nominated Medical Staff and Railway Doctors for the ARME should proceed to the accident site by ARME irrespective of the number of injured reported. 

7. The reaction time of the drivers of the trains is required to be improved upon as in this accident the driver stopped the train after 1Km. After the front SLR was hit by the truck while moving at a speed of about 50 Kmph.

8. The Contract Agreement should contain all the provisions of safe working as directed by Railway Board and the Railway from time to time when road vehicles are used for execution of works.

1.15          DERAILMENT OF 2779 DN-VASCO-NIZAMUDDIN GOA EXPRESS BETWEEN STATIONS ADARKI-SALPA ON PUNE DIVISION OF CENTRAL RAILWAY ON 10/08/2003.                                                                                               

a)      CAUSE Due to discontinuity in the left rail on account of multiple rail fracture during the passage of train.

b)      CASUALTIES    KILLED NIL, GRIEVOUS-NIL, SIMPLE NIL.

c)      COST               -  Rs.9,19,000/-

d)      CATEGORY    -    Failure Railway Equipment.      

RECOMMENDATIONS :

1.                  The rail having rolling mark CC 90 UTS mm 52 Kg. lsy XII/1987 should be renewed to ensure safe running of the trains in WTR-SPA section. 

2.                  The free rails on sharp curves in the Ghat Sections should be converted to 26 metre long rails thereby reducing the number of joints to half, to improve the quality and productivity of maintenance. 

1.16          SIDE COLLISION OF 1TR TILAK BRIDGE ROHTAK SHUTTLE AND WDS4B SHUNTING ENGINE BETWEEN STATIONS SHAKURBASTI YARD ON DELHI DIVISION OF NORTHERN RAILWAY ON 23/08/2003.                                                                                                 

a)   CAUSE Infringement caused by the Shunting Engine to the route of 1TR Passenger.

b)   CASUALTIES    KILLED 04 (Passengers),

                                    GRIEVOUS-06 (Passengers), 02 (Railway crew), 

                                    SIMPLE 02 (Passengers), 01 (Railway crew).

c)    COST                -   Rs.1,39,50,000/-

d)   CATEGORY    -    Failure of Railway Staff. 

RECOMMENDATIONS :

1.  SR 5.14/1 of Northern Railway should be modified to make it applicable to all types of shunting involving running lines and not only for the passenger or goods train.

2. Railway administration should plan and execute the track circuiting works giving special priority to stations based on the traffic density, frequent shunting on running lines, visibility, size of yard etc. in consultation with COM, as already accepted by Railway Board vide their letter No.98/Sig/A/11 dated 1st Feb., 2000. 

3.  While curtailing the scope of work proposed by the Zonal Railway in the works Programme, the Railway Boards may specifically indicate the portion of work being deleted, so that the railway may change the nomenclature and execute the work accordingly.

4.  The lighting in Shakurbasti yard needs to be improved.

5.   Shakurbasti is a huge yard having large number of non-running line and sidings. There appears a need a study the yard layout and identify the redundant lines for dismantling.

6.  There are frequent shunting in Shakurbasti Yard. Shunt Signals are also provided. But is was revealed that some shunt Signals are not being used. These need to be put to effective use for safe working.

7.   It is considered essential to provide wireless communication between the cabins/ASMs and the shunting staff at Shakurbasti for facilitating safe shunting.

8.  There appears a need for doing job analysis of the workload of various categories of train passing and other operating staff posted at Shakurbasti for rationalization of their duties.

9.  Station working Rules of SSB are quite old. These should be reviewed, corrected and issued afresh. The SWRs of other stations affected by the non-functioning of the CTC system and Delhi Cantt-Rewari section having been transferred from Bikaner Division to Delhi Division, should also be corrected accordingly.

10. The end luggage portion of the front SLR should also be locked along with the Guards brake van, so that the passenger do not travel in this weak part of the SLR.

11.  Many suggestions have been given by CSO, CSTE and DRM/Delhi. Some of them have been specifically covered in the above recommendations. Amongst others, the track circuiting from Home to Advance Starter at either end along with point zone at Shakurbasti, may be executed on priority basis. Being a big yard and complicated working, the work of RRI may also be planned in right earnest.

1.17          FIRE IN 2024 DN PATNA-HOWRAH SHATABDI EXPRESS BETWEEN GURUP YARD ON HOWRAH DIVISION OF EASTERN RAILWAY ON 25/08/2003.                                   a)  CAUSE              Sparking of A.C. Panel.

b) CASUALTIES    KILLED NIL, GRIEVOUS-NIL, SIMPLE NIL.

c)      COST         -         Rs.30,00,000/-

d)      CATEGORY    -    Failure of Railway Staff.           

RECOMMENDATIONS :- 

1.  HRC Fuses should be used in all electrical main circuits of coach wiring and wire fuses should be permitted for branch wiring only. 

2.  It should be ensured that there are no loose/hanging connections, exposed wires, wires shorting defective equipment, fuses of higher capacity etc. in the AC and the Power Panels.

3.  Fire prevention/fire fighting measures provided on trains be got examined by a reputed consultant.

4.  Educational standards of staff maintaining Rajdhani/Shatabdi Express staff should be reviewed

5. Periodical training in fire fighting be imparted to all escorting staff on trains.

1.18    DERAILMENT OF 1057 DN-DADAR AMRITSAR EXPRESS NEAR LASALGAON STATION ON BHUSAVAL DIVISION OF CENTRAL RAILWAY ON 31/08/2003.

a)  CAUSE Due to brake binding and higher carbon percentage in the metallurgy of the wheel disc.

b)      CASUALTIES     KILLED NIL, GRIEVOUS-NIL, SIMPLE NIL.

c)      COST                -   Rs.1,80,000/-

d)      CATEGORY    -    Failure Railway Equipment.      

RECOMMENDATIONS :

1. The Railway Administration should expeditiously decide to provide imported rubber kits in DV to make their performance reliable.

2. The work of providing air driers on the locomotives should be finished on a war footing. The Railway Administration should complete this work in the next one year or earlier.

3.  The train crew should be trained in identifying defective, rejectable wheels so that the effected coach can be timely detached to avoid derailments during the run and further damage. 

1.19   DERAILMENT OF 2056 DN-DEHRADUN NEW DELHI JAN SHATABDI EXPRESS BETWEEN STATIONS DEOBAND-ROHANA KALAN ON DELHI DIVISION OF NORTHERN RAILWAY ON 06/09/2003.                                                                                                 

a)   CAUSE   Fracture of flawed Conventional AT weld in the left side rail                       at km 143/7-8.

b)   CASUALTIES     KILLED 01 (Railway crew),

                                    GRIEVOUS 01 (Passenger), 02 (Railway crew),

                                    SIMPLE 01 (Railway crew). 

c)   COST                - Rs.86,00,000/-  

d)   CATEGORY    -    Failure of Equipment Permanent way.

RECOMMENDATIONS :- 

1.  All AT weld more than 10 years only should be supported on wooden blocks and provided with joggled fishplates without further delay.

2.  It should be ensured that flange testing of all Conventional AT welds still in track, is carried out by hand proving, at the specified frequency

3. To keep the population AT welds to bare minimum, construction organization should make their own arrangement of lash but welding of most of the rail joints in new constructions/doubling etc.

4. Vacancies in P.Way gangs of PWI/MOZ in particular should be filled expeditiously. 

5.  Joint measurements of rolling stock, desired by the CRS in accident inquiries, must by made available to him, without demur.

6.  VHF sets should also be provided at all stations of important single line sections of Northern Railway. 

1.20          UNUSUAL INCIDENT OF SIDE DASHING OF 2SL DN LUCKNOW-SULTANPUR PASSENGER TRAIN WITH A ROAD TRUCK BETWEEN BAKKAS AND ANUPGANJ STATIONS ON LUCKNOW-SULTANPUR SECTION IN LUCKNOW DIVISION OF NORTHERN RAILWAY ON 09.10.2003.

a)      CAUSE Contractors truck came over the new embankment unauthorisedly and too close to the existing track, for unloading the blanketing material.

b)      CASUALTIES     KILLED NIL, GRIEVOUS-01 (Passenger), SIMPLE 01 (Railway crew).

c)      COST                -   Rs.1,500/-

d)      CATEGORY    -    Failure of person other than Railway Staff.        

RECOMMENDATIONS :

1.  To strengthen the safety at work sites, following additional/modified provisions are recommended to be made suitably in the conditions and specifications of the contract:

a)  Duly designed semi-permanent type of fencing should be provided at a distance of 2.5 to 3.0 m from the nearest track, which should be removed only when the track linking of new line is taken in hand. The drawing of the fencing should be a part of the tender documents. 

b)  Suitable gates/barriers should be installed across the new embankment, preferably adjoining the manned/unmanned level crossings. The entry for the vehicles should be regulated by an authorized representative of the Engineer-in-charge during the working hours.

c)  The new embankment for doubling should be made extra wide at every 500m or so interval for permitting turning/crossing of vehicles/construction machinery. The extra earthwork involved in such widening of embankment, may be included in the schedule of quantities as a paid item. 

2.  Caution Order should be issued to all the trains passing by the work sites at least during working hours, for the drivers to be on the look out, with or without any speed restriction as per the site requirement. 

3.  The efficacy of the risk and cost tendering system needs a fresh look. It may be replaced with a more workable system, as adopted by Central Public Works Department, in which the failed contractor is not allowed to participate.

1.21          COLLISION of 728 DN-QUILON-MADURAI PASSE and LORRY NO.TN 47C-4711 between stations SENGULAM-TIRUNELVELI JN. on TRIVANDRUM Division of SOUTHERN RAILWAY on 08/10/2003.

a)   CAUSE Due to the exchange of private number by the gatekeeper of gate No.118 without locking and securing the gate against road traffic.

b)      CASUALTIES     KILLED 01 (Railway crew), GRIEVOUS-03(Railway crew),

SIMPLE 17 (Passengers).

c)      COST                -   Rs.4,88,37,492/-         

d)      CATEGORY    -    Failure of Railway Staff.           

RECOMMENDATIONS : 

1.  The LC No.118 should be interlocked on top priority.

2. The provisions of Safety Circular No.8 issued by CSO/Southern Railway should be immediately incorporated in all GWRs and SERs of the Railway.

3. The gatekeeper of all the non-interlocked LCs closed against road traffic should be suitably counseled to keep the gate closed against road traffic and follow the provisions of GWR and Safety Circular No.8 scrupulously. 

4. The road surfaces at all the LCs should be maintained properly for free flow of traffic. 

5. The Southern Railway should laise with Regional Transport Authority to conduct surprise checks of licenses of heavy haul vehicles, as their movement over LCs will affect the Safety of Railways.

6.  Suitable quicker and cheaper methods of positive interlocking like wireless interlocking or interlocking through the newly laid optical fiber cables for non interlocked the gates with the stations dispatch signals may be explored. 

7.  The possibility of installing and working electric or solar operated time signals at selected LCs on the line of road junction signal may be explored which will eliminate anxiety on the part of road user

8. Specific competency certificate should be issued to the drivers of passenger trains.

1.22   DERAILMENT OF 231 UP-MYSORE BANGALORE PASSENGER BETWEEN STATIONS NAGANAHALLI-PANDAVAPURA ON BANGALORE DIVISION OF SOUTH WESTERN RAILWAY ON 23/10/2003.                                                                                                

a)   CAUSE Due to the fracture of the left hand wheel of the last wheel set of last coach No.SWR/CZ/DT 94681/A/

b)   CASUALTIES    KILLED 04 (Passengers), GRIEVOUS-07 (Passengers),SIMPLE 15 (Passengers).

c)   COST                -   Rs.83,07,000/-

d)   CATEGORY    -    Failure of equipment (Wheel Disc).      

RECOMMENDATIONS : 

1. Ultrasonic testing of the rim of wheels during POH should be immediately implemented all over the Indian Railway. This testing should be preferably done by online machine

2. The unmarked wheels of coaches should be immediately subjected to ultrasonic examination on crash basis to detect the cracks formed in the rim portion due to over braking or any other cause. The wheels detected with serious cracks should be removed from service on top priority.

3. The threshold limits of allowable cracks in the rim of wheels should be fixed by RDSO on the basis of adequate research and field validation for examination of rail wheels in this light. 

4.  The threshold limit of residential stress in the rim of the wheel should be fixed by RDSO as a term measure after adequate research and field validation. The arrangements of its measurement should also be made during POH.

1.23          DERAILMENT OF 2978 UP-JAIPUR ERNAKULAM MARU SAGAR EXPRESS BETWEEN STATIONS PEN-KASU ON MUMBAI DIVISION OF CENTRAL RAILWAY ON 08/11/2003.

a)  CAUSE Due to discontinuity in the rail, on account of rail breakage on continuous welded rails at kms.111/0-1.

b)  CASUALTIES    KILLED NIL, GRIEVOUS-NIL, SIMPLE NIL.

c)  COST                -   Rs.18,59,189/-

d)  CATEGORY    -    Failure of Railway Staff and Failure of Railway Equipment.

RECOMMENDATIONS : 

1.  The P.Way Supervisors including the In charge of the work should be separate for the Track Renewal works and track maintenance, even for smaller work. 

2. The track Quality Control Cell in the HQ should be properly activated to reduce the number of accidents.

1.24  DASHING OF 449 UP-NARKATIAGANJ-GORAKHPUR PASSENGER WITH TRACTOR TROLLEY AT MANNED LEVEL CROSSING BETWEEN STATIONS KHADDA-SISWA BAZAR ON VARANASI DIVISION OF NORTH EASTERN RAILWAY ON 20/11/2003.

a)   CAUSE The Level Crossing Gate was kept in open condition instead of closed while was the normal position of gate is closed to road traffic and was also not protected by the banner flags when in open condition. The Gateman was not alert. Thus seeing the Level Crossing Gate in open condition the driver of the tractor trolley crossed the Level Crossing Gate and in the mean while 449 Up came speeding and collided with the tractor trolley.

b)   CASUALTIES     KILLED 02 (Outsiders), GRIEVOUS-NIL, SIMPLE NIL.

c)   COST               -   Rs.10,000/-

d)   CATEGORY    -    Failure of Railway Staff.

RECOMMENDATIONS :

1. The Magneto Phone which is to be provided at the Level Crossing Gate No.31 A1 C-Class should be commissioned at the earliest after obtaining CRS sanction. Till such time the Magneto Phone is not commissioned the instrument of the telephone should not be kept at the Level Crossing Gate.

2. All engineering manned Level Crossing having normal position of the gate as closed to road traffic should not be worked as open to road traffic. Surprise checks should be made and gatemen found disregarding the extant rules should be dealt with severely under DAR.

3.  CRS sanction should be taken for providing telephone, connected with ASM at Manned Level Crossings at in involves changes in the method of working of trains. Necessary provisions to be made in SEM and IRPWM. (Chapter 13). The instructions issued by CSTE, N.E. Railway Gorakhpur regarding CRS sanction not to be take should be withdrawn immediately.

4. The dead bodies of persons dying in railway accidents should be handed over by Guard of the train to responsible railway officials before he clears the clock section.

5. The system of locking of Level Crossings lifting barriers by pad locking should be replaced by locking through Levers giving priority to Level Crossing having high TVU. Gateman tend to undertake short cut methods, such as avoiding locking of the Level Crossing Gate or locking only one of the lifting barriers due to frequent opening and closing of Level Crossing Gates.

6. Whenever track fitness is given on telephone private numbers should be exchanged between the P.Way Supervisors and the Station Masters on either side of the block section and the track fitness and the private numbers should be made known to the Section Controller who should record these particulars in the control chart and the accident log.

7. The reaction time of the drivers needs improvement.

8.  Goods drivers are being used to work passenger trains. Review of the cadre of drivers should be undertaken and strengthened if required so that passenger drivers work passenger train and goods drivers are not pressed into work the passenger trains

However in case of emergencies it Goods drivers are required to work passenger trains Railway should lay down specific procedure to do so.

9. N.E. Railway should implement Railway Boards orders to provide only W/L Board and not W and W/L boards at the approaches of the unmanned Level Crossings. The overlapping W and W/L boards can cause confusion in the minds of the drivers.

1.25     DERAILMENT OF TDD BCNL-DN GOODS TRAIN BETWEEN STATIONS GUDUR-VIJAYAWADA ON VIJAYWADA DIVISION OF SOUTH CENTRAL RAILWAY ON 19/12/2003                                                                                  

a)  CAUSE        Failure of equipment Railway Bridge.

b)  CASUALTIES     KILLED NIL, GRIEVOUS-NIL, SIMPLE NIL.

c)  COST                      -         Rs.69,00,698/-

d)  CATEGORY    -    Failure of Equipment Railway Bridge.

RECOMMENDATIONS :

1.  Considering the condition of the bridge Rail Traffic should not be restored on existing down line bridge No.518.

2.  Under water inspection for the substructure of bridges that remain under water throughout the year should immediately be carried out before onset of monsoon, assigning priority to those that are under marine condition, the substructure consist of stone/brick masonry with lime mortar, and more than 100 years old, outlived their codal life. In addition, the frequency of underwater inspection should be specified for bridges having substructure under water round the year.

3. Railway Board in consultation with RDSO should lay down limits of allowable settlement/differential settlement of wells during service, similar to what has been laid down by Indian Road Congress for their bridges in terms of Para 706/3/2 of Standard specifications and code of practice for Road Bridges, Section-VII, Foundation and Substructure (second revision) of 2000.

4. Railway Administration should issue CEs circular laying down methodology for shifting of girders for guidance of field staff including taking of approval of Bridge branch of Headquarter office for its shift beyond a specified value to be specified by Engineering Department. The location of lifting of girders, riveted type 18.3 m span being not available in the standard drawing issued by RDSO and for any other type if not available, should be specified.

5.  The line and levels of girders should be checked and corrected before laying of channel sleepers. Detailed procedure in the form of CEs circular for laying of channel sleepers should be issued for guidance of field staff. The maximum thickness of cement mortar below bedplate to adjust levels should be specified, beyond that steel plates of appropriate sizes should be provided.

During the period of laying of channel sleepers the track on the bridge should be maintained by respective SSE/Bridges and there should be proper handing over and taking over by SEE/Bridges to SSE/P.Way for their further maintenance.

6.  The guide and locking strip clearances, their size, type whether welded or provided with countersunk rivets and the condition/thickness of cement mortar below bed plate should be recorded in the bridge inspection register.

Since as per RDSO Standard Drawings for 18.3 m span for riveted girders to BGML Standard and welded girders to MBG loading standards, the cross sectional area of locking/guide strips are 16 X 65 mm and 18 X 25 mm respectively, RDSO may consider to revise their dimensions to a minimum of 25 X 65 mm to avoid lifting of girders and riding over guide strips, under marginal condition of slew 

7.  The conservancy of this river Manneru at bridge location should be improved and waterways should be kept clear of obstruction to have uniformity of flow of water through all the spans. Scoured bed around the well should be filled up with boulders, concrete block in time to provide additional rigidity and for scoured bed where necessary protective flooring should be provided.

8. For bridges on well foundations while strengthening substructure of a bridge, the jacketing should not be confined only to piers and abutments, it should also be carried out for the foundations as well either by concreting exposed portion of well under water or driving piles and connecting them to the piers/abutments at well cap level to have proper transfer of loads from piers/abutments to the foundation. The jacketing of piers and abutments should be carried out based on the drawing and specifications issued by RDSO and the jacketed portion of the pier should be monolithic with the well cap with provision of dowel bars both vertically and horizontally.

9. The details of foundation and completion drawings for all major and important bridges should be made available for ensuring safety of running of various types of rolling stock.

10 . Railway Board in consultation with RDSO should issue guidelines for detailed inspection of major bridges more than 100 years old and the frequency of their subsequent inspections based on studies relating to residual life of masonry structure.

11. Annual inspection of Bridges, after monsoon, by concerned ADEN should be completed every year before 31st March and bridge registers with due observations of concerned Sr.DEN/DEN of the section must reach headquarter office by first week of May for scrutiny of Territorial Head of the Department.

1.26   DASHING OF IMN/WKBN/CR-178 GOODS TRAIN WITH TRUCK AT MANNED LEVEL CROSSING BETWEEN STATIONS NOWROZABAD-KARKELI ON BILASPUR DIVISION OF SOUTH EAST CENTRAL RAILWAY ON 21/12/2003.                                                                                                

a)  CAUSE Due to LC gate being unauthorisedly in open condition.

 b)      CASUALTIES     KILLED 01 (Outsider), GRIEVOUS-01 (Railway crew), SIMPLE 01 (Railway crew).

c)      COST         -         Rs.3,01,400/-  

d)      CATEGORY    -    Failure of Railway staff 

RECOMMENDATIONS : 

1. Railway, through a special check of all stations, should ensure that station staff follows Station Working Rules prescribed for their stations properly, in word and spirit.

2.  Visibility of gate barriers and road from the gate lodge should be improved by pruning down the vegetation from the level crossing side of gate lodge and reducing height of tie bar fencing between gate lodge and track.

3.  Flood light bulbs should be provided on both sides of level crossing. Lights should be so fixed as to illuminate lifting barriers and road in the level crossing.

4.  Lifting barriers should be completely painted with retro reflective paint.

5.  Movement of gatekeeper from gate lodge to level crossing should be eased by removing rail fencing between the gate lodge and Down track, where tie bar fencing is already available.

6.  Gate bells should be repaired and maintained in working order.

7.  Boom locking through winch should be provided at this level crossing at the time of interlocking. On all manned non-interlocked level crossings, wherever feature of boom locking through winch has not been provided, arrangement for pad locking of the winch, both in gate open and gate closed position, should be provided.

8.  Check rails on down line should be refixed so as to project beyond the road by 1.00 m.

9.   Working of Karkeli station should be thoroughly inspected and staff should be counseled to follow correct procedures. Private number books and other standard forms should be supplied in time.

10 . Railway should ensure that gatekeeper should exhibit white light while passing the trains in night as per prescribed procedure.

11. Railway should ensure that correct and updated information about temporary restrictions is available with stations nominated for issue of caution order and control office.

12. Railway should ensure that the time is synchronized by guards as per GR 4.03 and by stations as per GR 4.01.

13. Railway should incorporate in Gate Working Rules, a new rule for time synchronization of gate clock with controlling cabin/station.

14 . Railway should ensure frame and implement a rule for recording the position of the level crossing at the time of duty change of gatekeepers.

1.27    UNUSUAL OCCURRENCE OF COLLAPSING OF FOB UNDER CONSTRUCTION ON EMU KP2 UP SUBURBAN LOCAL TRAIN BETWEEN THAKURLI AND DOMBIVALI STATIONS OF MUMBAI DIVISION ON CENTRAL RAILWAY ON 02.01.2004.                                                                                               

a)      CAUSE Due to structural failure of the structure due to improper design and detailing adopted.

b)      CASUALTIES    KILLED 04 (Outsiders), GRIEVOUS-05 (Outsiders), SIMPLE 07 (Outsiders).

c)      COST                -   Rs.28,00,000/-

d)      CATEGORY    -    Failure of Equipment.

RECOMMENDATIONS :

1.  The RDSO may issue policy guidelines for the design of FOBs to all the Railway Administration.

2.    The skills knowledge of the Railway Design Engineers in Railway HQ and RDSO should be suitably upgraded by organizing training courses to match the present day requirement.

1.28          UNUSUAL OCCURRENCE OF SMOKE IN 5160 DN SARNATH EXPRESS AND RUN OVER BY 8236 UP BILASPUR-BHOPAL PASSENGER BETWEEN ANUPPUR AND KATNI STATIONS OF BILSPUR DIVISION OF SOUTH EAST CENTRAL RAILWAY ON 16.01.2004.                                                                                                 

a)   CAUSE Smoke emission in 5160 Dn Express was due to failure of insulation material of commutator segments TM-6. The subsequent death of three passengers and injuries to eight other passengers of Express Caused due to run over by 8236 Up Passenger.

b)   CASUALTIES    KILLED 03 (Passengers), GRIEVOUS-NIL,

                                    SIMPLE 01 (Passenger).

c)   COST                -   Rs.10,500/-

d)   CATEGORY    -    Failure person other than railway staff.

RECOMMENDATIONS :

1. Whenever the driver of a passenger carrying train makes an unscheduled stoppage of his train in mid section due to fire/smoke emission from the locomotive or any of the coaches or any other reason (except when he is required to stop on account of any signal), on a section having two or more tracks, he should immediately switch on the Flasher Light of his locomotive to warn the driver of a train coming from the opposite direction that his train has come to a standstill, and as a warning of the possibility of a passengers having got down in close proximity of the adjacent track.

2. The traction motors must be subjected to stringent test before fitment in the TM armatures and 100% super checks by all officers of ELS/BIA should be ensured for all the loco maintenance schedules.

3. The guards and drivers of a train must be under strict instruction to convey the message of any injury sustained by any passenger or train crew immediately and in an unambiguous manner specifically stating if there is need for moving out ARME.

4. The electric loco drivers should be properly trained to handle emergent situations.

5. The ARME siding at Shadol should be relocated to ensure unhindered entries/exists from both ends of the siding.

1.29   COLLISION OF BANKING PILOT ENGINE WAG-5 AND 302DN VARANASI ASANSOL PASSENGER TRAIN AT THE DOWN HOME SIGNAL OF YADUGRAM BLOCK HUT OF DHANBAD DIVISION OF EASTERN CENTRAL RAILWAY ON 17/01/2004.                                                                                      

a)  CAUSE Failure of equipment Locomotive and Failure of Railway Staff.

b)   CASUALTIES     KILLED 04 (Passengers), GRIEVOUS-05 (Passengers), SIMPLE 10 (Passengers).

c ) COST                -   Rs.40,10,000/-

d)  CATEGORY    -    Failure of Equipment - Locomotive.

RECOMMENDATIONS :

1. A standby braking system, independent of the loco pneumatic brake system (in line with the Parking Brakes of WAG-9 locos) may be provided on all electric locos so that in case of any damage to the pneumatic brake system, the driver may apply these brakes in case of emergencies.

2.  Modification/strengthening of brake system pipe lines on the underside of the WAG-5 locos on the line of WAG-7 locos may be thought of to prevent damage due to hitting by dragged carcasses etc.

3. The Main Reservoir Isolating Cock should be provided with a lock and key arrangement so that it is not opened inadvertently by the staff.

4. The electric loco drivers must be made thoroughly conversant with the trouble-shooting procedure specifically while working on graded sections.

5. Instructions be issued for drivers to record all relevant parameters (main Reservoir/Brake Power/Brake Cylinder/Feeding Pipe pressure, functioning of equipment etc.) in their loc book at the time of starting the locos. The drivers must start the locos only after Main Reservoir pressure of minimum 8.0 Kg per sq.cm has been created.

6. Catch sidings should be provided on top of Yadugram station.

7.  Railway to separately inquire into the shortage of ladder and one wooden wedge in the loco and fix responsibility for the shortages.

8. Railways should get the blood samples tested by other reputed agencies wherever testing through Government Railway Police is taking time and delaying the finalization of Inquiry Report.

1.30   DERAILMENT OF MSP 17-DOWN EMU SUBURBAN LOCAL BETWEEN STATIONS BASIN BRIDHE JUNCTION KORUKKUPET ON CHENNAI DIVISION OF SOUTHERN RAILWAY ON 09/02/2004.                                                                                               

a) CAUSE Due to freak unintended operation of point contactor unit of point No.42 A resulting in operation of above point from normal to reverse while the EMU train was in motion.

b)  CASUALTIES    KILLED 01 (Passenger), GRIEVOUS-02 (Passengers) SIMPLE 05 (Passengers).

c)   COST                -   Rs.15,33,000/-

d)  CATEGORY    -    Failure of Equipment- Railway Signaling.

RECOMMENDATIONS :

1. The definition of track locking features including the methodology for its implementation should be incorporated in Signal Engineering Manual in the right spirit of SEM para 21.8.2 and 21.12.3 to prevent operation of points even with accidental operation of points contactor unit.

2. Continuous presence of 110 V power supply in the cabling system being hazardous, the point control circuits should be standardized for ensuring availability of power supply for point operation only for a very short duration in conjunction with point operating command.

3. In terms of para 22.5.7 of Signaling Manual, Railway Board should review deployment of magnetic stick relays and issue necessary instructions for their elimination in external circuits viz. outdoor installations in 25 KV AC electrified areas.

4. Point control circuitry shall have over load protection in terms of SEM 21.12.2 & 21.12.3.

5. Crank handle must be interlocked with signal in terms of SEM 21.8.6.

6.  Front and rear motor coaches should be provided with automatic flasher lights instead of existing manually operated one. In addition to speedometer, one of the motor coaches either front or rear should also be provided with speed recorder chart preferably memotal type.

7.  The disaster management booklet as issued by Madras Division should be modified with respect to medical department and the passenger train accidents should not be sub-divided into two classes viz., minor and major, and the responsibilities of various officials should be well defined including sounding of siren.

8.  The reconditioning of built-up points and crossings at side should be carried out under block protection for ensuring proper quality.

1.31          FIRE IN 2562 DOWN NEW DELHI-DARBANGA SWATANTRA SENANI EXPRESS BETWEEN BLOCK HUT D AND KAURARA STATIONS OF ALLAHABAD DIVISION OF NORTH CENTRAL RAILWAY ON 19.02.2004.                                                                                               

a)  CAUSE Some of the passengers have stuffed polythene bags and other such materials in the ceiling of the toilet which caught fire through a lighted Cagrette or bidi or burning match stick which kept smoldering till such time it burst into a big fire a later putting the furnishing materials on fire.

b)  CASUALTIES    KILLED NIL, GRIEVOUS-NIL, SIMPLE NIL.

c)   COST                -   Rs.1,25,00,000/-

d)   CATEGORY    -    Failure of a person other railway staff.

RECOMMENDATIONS :

1.   Through inspections of the coaches must be undertaken at the time of primary, secondary maintenance and terminal examination of the rakes for the polythene bags and other materials which are stuffed inside the broken ceilings and the side walls of the coaches, and no such materials should be allowed to remain in the coaches.

TTEs must also check and remove the stuffing etc. in the coaches and also report to TSR through control.

2. Cushions used in seats and berths to provide comfort to the passengers are inflammable and not fire resistant and should be replaced by alternative materials. Once the foam catches fire these produce to toxic smoke and also produce fire, which becomes uncontrollable by the fire fighting equipments provided in the train.

3. The fire detected in the train must be immediately put off before it becomes uncontrollable for which trained railway official alongwith the fire fighting equipments should be on duty in each of the coach. The passengers on seeing fire panic and rush towards the exit doors and do not try to extinguish fire.

Railway should undertake detailed studies of the coaches designed by RCF, which detect fire/smoke and thereafter apply brakes automatically and induct such coaches into the services.       

4. Emergency lights should be provided in the coaches which should light up whenever the lights go off when fire in the coach take place. Illumination should be such that in the dense smoke the passages and exit points of the coaches are visible.

5.  The size of the emergency windows should be sufficiently large and distinguishable to enable easy exit for the passengers.

6.  Railway must ensure that the coaches which catch fire are separated from other coaches immediately, it was the delay which caused the speed of fire and extensive burning of the coaches of the train.

7.  Railway should issue suitable directives regarding switching on the OHE after it has been switched off in case of accidents, keeping in view of the safety of the train passenger.

8.  Emergency phones must be set up by the guard/driver of the train immediately for establishing communications from the accident site with the Section Control and should not consider Walkie-Talkie sets to be such means.

9.  Drivers and guards of the train must protect the train and the adjoining line or lines, in case of any unusual occurrences and accidents, as laid down in GSR, Switching on the flasher light by the driver should not be considered as having protected the train.

10. ARME should be reached the accident site at the quickest. In the electrified sections such trains may be worked with powers not requiring electric current of the OHE as OHE is generally switched off, in which case electric locomotive is require to be replaced by diesel locomotive.

11. TTEs in the train must check each and every coach of the train, even if there is shortage of TTEs, and look for inflammable and dangerous goods being carried by the train passengers in addition to their other duties.

12. TTEs must remain at the accident site to render assistance to the stranded and injured train passengers unless and otherwise permitted to leave the accident site by the DRM/ADRM.

13.  A comprehensive Manual on the train lighting and air condition should be made out by the Ministry of Railways.

14. New trains should be introduced only when it is certified by the concerned officers of Division and Headquarters of the Railway.

15.  HRC fuses should be used as battery fuses.

16.   No modifications, additions and alterations in the designs issued by RDSO should be made by the production units unless these are approved by RDSO.

1.32   DASHING OF MINIBUS WITH 5657 UP-KANCHANJUNDHA EXPRESS AT UNMANNED LEVEL CROSSING BETWEEN STATIONS  SURAJKAMAL-KANKI ON KATIHAR DIVISION OF NORTHEAST FRONTIER RAILWAY ON 27/02/2004.

a)   CAUSE Due to Gross negligence of Mini Bus Driver.

b)   CASUALTIES    KILLED 10 (Outsiders), GRIEVOUS-31 (Outsiders) SIMPLE 06 (Outsiders).

c)   COST                -   Rs.25,000/-     

d)   CATEGORY    -    Failure of persons other than Railway Staff.

RECOMMENDATIONS :

1.Initially, TVU figures at LC SK 333 was reported as 3642 units as per census in 1998. However, the same as per traffic census in 2003 stood at 70.857X127.78=9054 units. Fresh traffic census after the accident as per instruction laid is recommended.

2. Local residents demanded immediate manning of LC as there are a number of schools in the area. A cyclist was reportedly run over at LC in the past. Railway however could not produce details of accidents at the LC in the past. Railway should upgrade the LC based on traffic census and arrange its manning.

3.  Railway should examine and provide grade separation with road-under-bridge as a long-term measure.

4.  Railway should ensure road surface and gradients at LCs within the gates in terms of Annexure-9/1 para 904. Item 15 of IRPWM.

5.  Whenever feasible, providing grade separation at rail-road crossings by way of Road-Under-Bridges while pursing/execution of Projects e.g. Doubling or Gauge conversion involving considerable investment in the area can enhance safety. It is recommended to spell out clearly such safety enhancing provisions/directions in Terms of reference for such Projects so that Project executing Authority work to that end and safety enhanced and ensured.

6. While Railway reported TVU as per last traffic census in 2003 at LC SK-333 as 70.857 X 127.78 = 9054 units. However, Railway had no proposal for manning the LC Vehicle units at LC being <180. Railway considered the LC as not qualified for manning in terms of the Revised Policy instructions issued under Bds No.2003CE-I/LX/59 dated 11.06.2003. It is recommended that amendment/clarification be issued to the Railways in this context.

7.   Mishap revealed poor state of enforcement of provisions of Section 123 and 131 of MV Act, 1988. State Civil Authorities should be pursued for effective enforcement of provisions of MV Act so as to ensure safety at rail road crossings.

8.  It is recommended that crew and station staff be trained in handling/managing during accidents/disasters.

9.  It is recommended that Railway execute MOU (Memorandum of Understanding) with Hospitals/Nursing Homes available in the area for mobilization and providing fast relief and medical attention to those injured in accidents.

10. Railways should be delegated suitable powers for reimbursement of medical aid/services provided by Private Hospitals/Nursing Homes to the persons grievously hurt in similar cases.

1.33    DERAILMENT OF 406 B UP BISHRAMPUR-BILASPUR PASSENGER BETWEEN STATIONS DARRITOLA-UDALKACHHAR BLOCK SECTUION ON BILSAPUR DIVISION OF SOUTH EAST CENTRAL RAILWAY ON 05/03/2004.                                                                                          

a)  CAUSE Discontinuity in the right hand rail on the approach of Bridge No.85 (Over river Halfali).

b)   CASUALTIES    KILLED 02 (Passengers), GRIEVOUS-13 (Passengers) SIMPLE 11 (Passengers).

c)   COST                -   Rs.1,26,50,000/-

d)   CATEGORY    -    Failure of Persons other than Railway Staff

RECOMMENDATIONS :

1.  In view of large number of miscreant/antisocial activities in Anuppur-Bishrampur section since 13.03.2002, the potential threat to the safe running of trains in this section has to be realized at all level of Railway Administration and appropriate action needs to be taken particularly by the Divisional Standing Committee for monitoring sabotage prone areas in terms of Member Engineering, Railway Boards DO No.2002/E-II/TK/19 pt.1 dated 14.07.2002.

2. On all important and major bridges including approaches, the fish plated joint should be provided with two anti-sabotage nuts and bolts or two bolts should be burred in terms of Railway Boards letter No.2002/CE-II/TK/10, dated 08.10.2002 irrespective of whether it is sabotage/miscreant prone area or not.

3. The fixing arrangement of channel sleepers with the girders needs to be reviewed as it was noticed that the derailed coaches could not pass over the bridge, being guided by the guardrails.

4.  The wooden sleepers at SEJs should be replaced by PSC sleepers early.

5.  Before a Group D train passing staff is posted at a station with independent charge, he must be tested by Station Master and acknowledgement of the staff should be recorded in the Assurance Register.

1.34          INCIDENT OF BOMB BLAST IN TRAIN NO.2303 UP POORVA EXPRESS BETWEEN FATUHA AND BANKA GHAT STATION ON DANAPUR DIVISION OF EAST CENTRAL RAILWAY ON 23.03.2004:- 

a) CAUSE Due to blast of explosive of material country made bomb.

b) CASUALTIES     KILLED NIL, GRIEVOUS 01 (Passenger),SIMPLE 02 (Passengers).

c)  COST           -   Rs.15,000/-

d)  CATEGORY      Failure of Persons other than Railway Staff.

RECOMMENDATIONS :-

1. Government Railway Police and State Police may be approached by the Railway Administration to intensify random checks by searches and deploying dog squads etc. to deter the antisocial elements from carrying explosive material in the trains.

2.  Traveling Ticket Examiners and other escorting staff should be trained to handle passengers during fire on trains, train accidents or any other disaster in passenger trains till the medical relief train arrive at site. 

3.  East Central Railway to please ensure that the speedometer graph of passenger trains involved in accidents in seized and submitted to the commission at the earliest opportunity without fail.

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