LESSONS LEARNT ON THE
BASIS OF
ACCIDENT INQUIRY REPORTS
of CRSs
(Other than Engg Dept)
Sri Ram JanmIRSE, SrDEN/I/Izzatnagar/NER
Sri B. VenkateshwarluIRSE, DyCE/CN/P&D/BNC/SWR
Sr Professional (PWay) Course no. 621
Derailment Investigations
Why?
Derailment costs money, anguish to users and possible loss
of life. Preventive & Corrective efforts. Investigation of
factors in itself a facet of accident mngt
How?
Obvious causes; Otherwise investigate in detail & impartially; TrackVehicle system dynamics; Immediate record of R/S & track
particulars, operating features, then analyse evidence logically &
systematically.
Other than Engg Dept -- Categories:
• Sabotage, Convulsion of Nature, Failure of Rly Staff,
Failure of Equipment, Failure of Both
Our Task:
• Analyse 16 CRS reports having such causes
Case #1
Derailment of 288Dn in Guntakal Division on SCR,
23.05hr 07.10.02; 3 injured; On unusual sound, Driver
applied brakes;
Loco and next 3 coaches derailed (2capsized)
Cause: Sabotage, Rail piece removed by outsiders, None responsible
Reasoning:
• RH rail laterally displaced by 20mm in the approach of
Br1084 with dog spikes removed on Br
• LH rail connections removed
• Wheels off track, went past bridge and fully derailed
CRS Recommendations:
Patrol with dog-squad, Better communication, Front Guard-van w/o
guard to be padlocked, GWI to be as per RB
Case #2
Derailment of 231 Up in Bangalore Division on SR,
06.16hr 23.10.03; 4 dead and 23 injured
Driver felt heavy jerk with high dropping of BP.
4 coaches from rear capsized and the 5th derailed
Cause: Failure of Rly Eqpt, Fracture of wheel disc in the last coach,
None responsible; Inspecting authority/DSP blameworthy.
Reasoning:
• Sudden derailment with no point of mount, evidence of unusual
sound from last coach for about 204min before.
• LH wheel of last wheel-set of last coach broke; combined effect of
thermal cracks due to braking & deficient metallurgy (0.64% C vs.
reqd max 0.52%)
CRS Recommendations:
USFD of rim of wheels @ POH; RDSO to fix threshold limits of
allowable cracks on wheel rims.
Case #3
Derailment of MSP-17 Dn EMU local in Chennai Division on
SR, @19.49hr 09.02.04; 1 dead & 7 injured; Sudden jerk,
Driver applied emergency brakes;
Train stopped having derailed, infringing up main line.
Cause: Eqpt failure; Freak unintended operation of point contactor unit
resulting in wrong operation of point42A while train in motion, S&T dept of
Division & HQ
Reasoning:
• First 3 coaches on right track, 4th derailed taking 2 routes
and rear 4 coaches took wrong route.
• Pt 42A got commanded electrically to go to reverse
position, when in between wheels.
CRS Recommendations:
P/s to Pt m/c only for short while; Review magnetic stick relays; Overload
protection to Pt circuitry; Crank-handle be interlocked; Automatic flasher
lights; speed recorders; Pt reconditioning under block only
Case #4
Derailment of Dn E-POL goods and subsequent side collision
with Up BCX goods in Delhi Division on NR, @02.47hr
31.03.03; 2 injured.
Dn goods derailed and 46th and 53rd TOH fouled upline, and
Driver of Up goods had no time to stop despite emergency
braking before side collision; loco and 11 BCXs derailed.
Cause: Failure of Eqpt & Staff; Poor enginemanship of Dn goods Driver
combined with weak track, Failure to protect. Down Goods Crew responsible.
Reasoning:
• 30kmph SR; Empty 4wheeler Tank wagons of Dn goods;
Sudden reduction in speed on Dn grade; No Point of mount,
only drop; Poor record of Driver ; Dn crew did not switch on
flasher lights; side collision could be averted.
CRS Recommendations:
Selection/Promotion/training policy of Safety/running staff; s/w for easy
extraction of speed data; ZMF gangs; Encroachments be cleared.
Case #5
Derailment of 8033Dn in Nagpur Division on CR,
@03.59hr 09.07.92; 15 dead & 28 injured;
Severe jerk, Driver applied emergency brakes;
Loco and next 9 coaches derailed (5capsized)
Cause: Sabotage, Buffer rails removed by outsiders, None responsible
Reasoning:
• RH buffer rail joints opened, ERCs removed for 130m
length; Emergency sockets damaged
• No derailment marks & OK track. Free rail jumped and
pierced through 8th Coach and traveled upto 8th coach.
CRS Recommendations:
Eliminate buffer rails & joints from LWR; Security patroling; Burring
of bolts; Portable phones to Guards; All Rly staff leave/duty to get
involved if on train; RDSO to develop anti-sabotage fittings; Rake
integrity; Gang absenteeism.
Case #6
Derailment of EPT-10 goods (Up line) leading to side collision with
3201Up (Middle line) in Mumbai Division Ghat section on CR,
@09.40hr, 25.11.96; 1 injured.
Goods Driver Felt jerk, noticed vacuum drop & train stopped. 4 wagons
derailed & dragged (one capsized, infringing Middle line). 3201Up driver
could see only late, applied brakes ; side collision; 5 coaches derailed.
Cause: Failure of Staff; Goods Driver mismanipulated Braking controls
Reasoning:
• 31st Wagon of goods jumped wheels – differential buffing due
to wrong combination of dynamic/vacuum brakes; Side
collision could not have been avoided—close timing & speeds.
CRS Recommendations:
Suitable speed recorders & Monitoring of speedometer working; Ghat
driver excess working hrs; Intensive counseling & monitoring on braking;
Regrading of track as several accidents.
Case #7
Derailment of 8478Up on Jhansi Division on CR, @ 19.23hr,
04.05.96; 4 injured;
On severe jerk, Driver applied emergency brakes;
Train derailed & dragged for 580m, 5 coaches derailed.
Cause: Failure of Staff & Eqpt; Combination of excess speed, Versine
variation 3.2deg curve, defects in undergear of 3rd coach from engine;
Secondary responsibility: Driver, CPWI, HTE
Reasoning:
• Speed 98kmph against PSR of 90kmph;
• Versine variation of 33mm on required 32.4mm;
• 3rd coach: broken oil in the main axle box of leading trolley, Missing
swing-link on left bolster of rear trolley, 3mm Wheel dia variation in
trailing axle of rear trolley.
CRS Recommendations:
Defective speedometers be rectified; Red cards for drivers; Sr-most to
ensure Jt observations; Neutral train Examiners @ POH
Case #8
Derailment of 7491Dn on Jabalpur Division on CR, @ 17.17hr, 22.05.97;
24 injured.
On seeing buffaloes on track, Driver applied brakes though
late; Loco dashed into, cattle guard entangled with Pt rod, bending it causing
gaping tongues; Coaches behind loco took 2 routes; Loco/9 coaches derailed.
Cause: Failure of Eqpt; None responsible, Mech dept blameworthy.
Reasoning:
• Cattle-guard fixture getting damaged, entangling with Pt-rod of
turnout leading to 2 road condition.
CRS Recommendations:
Cattle-guards to conform RDSO design; RDSO to make stronger
anchorage for Cattle-guard; GS&R to have supplementary instructions for
drivers to slow down on seeing cattle ahead.
Case #9
Derailment of A-14 Up EMU local on Bombay Division on CR, @
08.31hr , 15.05.92; 6 dead & 14 injured.
Local derailed between Diva & Mumbra, 4 coaches went off rail, Bolster of
5th coach fell, dragged and stuck up in V-rail of diamond, wheel following it
rode over it & jumped off track.
Cause: Failure of Eqpt & staff; Bolster assemby of motor coach fallen due
to broken hangers and caused obstruction to movement;
Primary: RITES inspection unit/Calcutta, Matunga W/S; COS: blameworthy
Reasoning:
• Bolster bottom spring-plank worked out and fallen due to
missing/broken hangers, then got entangled with V-rail.
CRS Recommendations:
• POH schedule be restored to 12m, 100% replacement of hangers, Nildefect certificate.
• Hangers from RDSO-apvd firms only; suitable strap for bolster assembly,
RITES to ensure detailed inspection at every stage of manufacture
Case #10
Derailment of 1057Dn on Bhusaval Division on CR, @ 05.46hr, 31.08.03;
No casualty.
Asst saw sparks from wheels of 6th/7th coaches, driver got heavy pulling,
Guard heard continuous hissing from DV; stopped,brake released & restarted;
Affected coach derailed.
Cause: Failure of Eqpt; Breakage of wheel due to brake-binding and higher
C (0.75% against max 0.52%)
Primary: Mech Directorate of Rly Bd; Blameworthy: Asst & Guard
Reasoning:
• Brake-binding present on all wheels of culprit coach: DV functioned
erratically due to CI body & Indian rubber components.
• Wheel broke due to excess heat & High C %.
CRS Recommendations:
• Imported reliable rubber kits in DV, Air dryers in locos.
• Train crew be trained in identifying rejectable/defective wheels.
Case #11
Derailment of N-45 Dn goods on Mumbai Division Ghat section on CR,
@ 02.29hr, 29.03.2K; 1 dead & 10 injured.
Brake van got derailed, then was re-railed and train started again, Again
derailed along with the BRH ahead, hitting & uprooting OHE.
Cause: Failure of Staff; Mismarshalling of light 4-wheeler brakevan
between 2 bogie-stocks.
Primary: Operating Dept of HQ/CR; Secondary: Guard
Reasoning:
• The force on 4-wheeler brake-van between BRH & Banker
considerable as upto 82.5t, Little lack of coordination between driving
& banking loco would have lifted brake-van due to buffing.
CRS Recommendations:
• RDSO to prescribe limiting parameters for plying 4-wheeler stock in ghats.
Case #12
Derailment of 2723 Dn on Bhopal Division on CR, @ 01.01hr, 16.06.97;
7 injured.
Driver crew saw discontinuity, applied brakes; Engine & 12 coaches derailed.
Cause: Sabotage; Discontinuity due to removal fish-plates and rail in
advance of SEJ; Unknown persons found responsible
Reasoning:
• 7m LH rail found tilted 40cm away, with no dent/grazing. So, left
wheel of loco derailed, along with 12 coaches derailed;
• left portion of cattleguard entangled with left rail ahead and uprooted
it, creating further discontinuity.
CRS Recommendations:
• Patroling when political agitations; Adequate gang strength with temporary
recruitment; No joints in LWR
• Guard & Driver found w/o full complement of T&P, CSO to ensure.
Case #13
Derailment of 2619 Dn on Ratnagiri-Madgaon of KRCL, @ 01.45hr,
10.03.2K;
3 dead & 20 injured.
Driver saw obstruction@ 100m ahead, applied full brakes, dashed into mount
of boulders/loose rocks; Loco & 6 coaches derailed.
Cause: Sudden Convulsion of Nature; Failure of East side slope of Bordave
cutting for 15m resulting in obstruction of traffic;
RDSO & KRCL found blameworthy.
Reasoning:
• Geography of Bordave cutting: top 6-8m highly weathered Laterite
and bottom 12-14m is weathered /closely jointed basalt strata.
• Undermining of bottom soft rock strata and subsequent slip of
overhanging strata onto track.
CRS Recommendations:
• KRCL & RDSO to review characteristics of cuttings, steps for slopestabilisation & protection.
• Disaster Mngmt trng for KRCL staff.
Case #14
Derailment of 287 Up on Guntakal Division (MG section) on SCR, @
02.08hr, 06.07.03;
1 dead & 9 injured.
Heard unusual sound, Driver was thrown out of Loco; Asst dead, Loco & 3
coaches derailed
Cause: Sabotage; track tampered by outsiders; Unknown persons found
responsible.
Reasoning:
• Boulder between checkrail & running rail @ LC.
• LH Wheel mounted on checkrail, RH wheel off rail; landing rail got
moved and track disturbed.
CRS Recommendations:
• No unguarded Boulders/Rly material in midsection.
• Better communication system.
• LCs with low TVUs to be closed & checkrails removed.
Case #15
Derailment of 2391Up on Danapur Division on ECR, @ 03.24hr,
01.06.03;
1 dead & 19 injured.
Running 419min behind schedule, Loco & 14 coaches derailed (4 capsized).
Cause: Sabotage; Discontinuity due to cutting & removal of cess-side
running rail; Unknown persons found responsible
Reasoning:
• 4.775m LH rail piece cut & removed, hack-saw blades & iron filings
found.
• LH Wheels dropped in discontinuity traveled on sleepers; on braking
track got uprooted.
CRS Recommendations:
• Patroling; Anti-sabotage fittings necessary; Rakes to be given full
maintenance time at Depots.
• Upgrade intelligence network, Coordinate properly with state govt; if
needed, stop trains in the sensitive areas at night
Case #16
Derailment of Up Material train on Mumbai Division (Neral-Matheran
NG section) on CR, @ 18.30hr, 11.10.99;
1 dead & 10 injured.
Driver lost control of engine on Falling grade on 71degree curve.
Cause: Failure of Staff & Eqpt; Combination of factors of over-speeding
beyond SR of 8kmph, Poor braking power, non-application of full
brakes;
Driving crew for secondary responsibility.
Reasoning:
• 30-35kmph against PSR of 8kmph on 71degree RH curve. Train ran
out of control.
CRS Recommendations:
• Full braking power must on NG section; Locos with speedometers &
speed-recorders.
• Air brakes from locos on NG section.
• No grass on track.
Analysis
• 63% of the sample-set contributed by Failures of staff & Eqpt.
• Necessary to improve the reliability of staff & Eqpt
Accidents due to Other than Engg Dept.
Sample base- 16 CRS reports for such causes
Convulsion of
Nature
6%
Failure of both
Sabotage
Eqpt and Staff
31%
25%
Sabotage
Failure of Equipment
Failure of Rly Staff
Failure of both Eqpt and Staff
Failure of Rly
Staff
Failure of
13%
Equipment
25%
Convulsion of Nature
Conclusion
• Selection/promotion/trainings of safety/running staff; Neutral
Examiners; USFD of wheels @ POH; Speed recording & s/w.
• Publicity drive to enlist public vigilance & reporting of unusual
track-vehicle system behavior.
• Anti-sabotage devices & practices – a must.
• Security patrolling with dog squads within 24hrs of intelligence,
withdraw train services if no cooperation from State Govts.
• Study of CRS reports help in better & quick awareness of faults in the
system and would help in placing better practices/technology in the
Rly system.
THANKS