An investigation into a major train accident that left 17 people dead and 34 others injured in the Vizianagaram district of Andhra Pradesh last year has concluded that the accident was caused due to “error in train working”, adding that the collision could have been averted had the crew and operating staff followed the rules.
The inquiry by Pranjeev Saxena, Commissioner of Railway Safety of the North East Circle, has also exposed lapses on the part of the railway administration; the National Disaster Response Force’s lack of expertise in handling relief and rescue operations after train accidents; and systemic safety lapses, including the failure of anti-telescopic features in the coaches of both trains and the malfunctioning of an automatic signalling system.
These findings come at a time when Indian Railways is promoting a ‘Safety First‘ culture across its network, amidst an increasing number of accidents and instances of trains passing signal at danger.
Editorial | Safety first: On the lessons from the train accident in Vizianagaram, Andhra Pradesh
Pilot errors
A locomotive pilot’s decision to overshoot a signal in danger and his assistant’s failure to apply the emergency brakes even in the face of the approaching collision were the primary reasons why Train No. 08504 Visakhapatnam-Rayagada Passenger smashed into the rear of Train No. 08532 Visakhapatnam-Palasa Passenger at a speed of 82 kmph on October 29, 2023, according to the final CRS report. The accident occurred between Kantakapalle and Alamanda railway stations in the Waltair Division of East Coast Railway.
The Loco Pilot and Assistant Loco Pilot of Train No. 08504, and the Train Manager (Guard) of Train No. 08532 were among the 17 people who died in the accident.
‘Badly drafted rules’
Despite the failure of three automatic signals on all the three lines, the Signal & Telecommunication staff did not indicate actions or precautions to be taken by the station and control staff. Badly drafted rules led to ambiguity on what was to be done in case of automatic signal failure, the report said.
For some reason, the Station Masters started informing the crew of approaching trains over wireless communication about the failed signals, which encouraged them to bypass the prescribed precautions. In violation of all rules, the Station Master of Kantakapalle issued a Private Number authorising the Loco Pilot of Train No 08504 to proceed.
“This was the penultimate action leading to the accident. Overwriting in the Private Number book on the number, claimed failure of the Train Manager to hear the conversation between the Loco Pilot and Station Master of Kantakapalle (over walkie talkie) and “stolen” Train Manager journal indicate that an assurance of some sort was given to the Loco Pilot/Assistant Loco Pilot of this train to proceed at sectional speed,” Mr. Saxena wrote in the 60-page investigation report accessed by The Hindu.
‘Anti-telescopic features failed’
The probe also revealed that the coaches of the two passenger trains lacked certain safety features that could have minimised loss of lives and grievous injuries of passengers. The anti-telescopic features of the coaches, designed by the Integral Coach Factory (ICF), failed to work in both the trains.
The ICF coaches with screw coupling were designed with weak structural elements in the toilet portion located at the ends of the coach body. These elements were meant to be crushed and absorb kinetic energy through the deformation or collapse of the plastic parts in case of collisions if the impact speed exceeded 30 kmph, thus protecting the passenger sections of the coaches from the impact at relatively lower speeds.
Modified coaches
However, over a period of time, ICF had modified the design to address sagging and corrosion issues. It strengthened certain structural elements, including those elements originally meant to collapse and absorb kinetic energy by plastic deformation or breakage. This modification was identified as the reason why the anti-telescopic feature failed to work.
Analysing the modifications made to the structural elements in comparison to the original specifications, Mr. Saxena said that all the coaches involved in the accident were modified. “Had these coaches been with original design, death and grievous injuries would have been significantly less,” he said.
The CRS said that the Research Designs and Standards Organisation, Rail India Technical and Economic Services, and Transport Technology Centre Inc, United States, had developed and tested two crash-worthy coaches using the ICF design and a centre buffer coupler to absorb energy at a relative velocity of 60 kmph, using a collapsible aluminium honeycomb structure behind the draft gear. It had modified bogies and bogie-body connections to withstand the impact of the collision.
The coaches also had secondary energy absorbers in place of side buffers which came in contact after the honeycomb started collapsing. The actual crash test was carried out on February 21, 2006, where the relative speed was 65 kmph. The results indicated that the design could be implemented with some modifications.
Crash-worthy coaches
Mr. Saxena suggested that at least the last two coaches of every passenger-carrying train should have such crash-worthy and injury-free features. The layout of Seating-cum-Luggage Rake (SLR) coaches should be modified to shift the luggage portion to the two ends of the coach so that the collapsible portion is in the luggage area only.
He added that the guard’s section could be shifted with the provision of a rear view camera and speedometer to allow better monitoring of train speed. “All future specifications of coaches/train-sets must have crash-worthy and injury free features,” the CRS report said.
Double impact
The investigating officer also noted that a dead locomotive had been attached next to the main locomotive in one of the trains. This caused higher casualties in the train ahead, as the locomotives were stiffer and heavier than the coaches, leading to much higher kinetic energy of the rear train. “This aspect should be studied by a team of experts and revised orders issued to decide where to place a dead locomotive in a train,” he said.
With regard to disaster relief, the CRS quoted the NDRF team commander as saying that the force was not given any training to deal with railway accidents. Mr. Saxena recommended that the NDRF be given training to handle issues specific to railway accidents, including how to access capsized coaches, precautions related to working under live overhead electrical wires, adjacent running railway lines, and work on bridges.
