CRS blames human error for Odisha triple rail disaster 2023

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04-July-2023 6:51 pm IST, New Delhi

S. Rameshwar Rao. (2023). CRS blames human error for Odisha triple rail disaster 2023
Zenodo. https://doi.org/10.5281/zenodo.8113870

This research paper analyses the conclusions of the CRS investigation.into the evening of June 2 2023 when three trains — Kolkata-Chennai Coromandel Express, Bengaluru-Howrah Superfast Express and a goods train — were involved in one of the worst railway tragedies in the country in the last three decades that left at least 293 dead and nearly 1,100 injured in Balasore.

1. Introduction

On June 2, a tragic train accident occurred near Bahanaga Bazar station in Balasore, Odisha, which led to a substantial loss of life and injuries. This incident serves as a painful reminder of the critical importance of ensuring safety in railway operations. The objective of this research report is to conduct a comprehensive investigation into the causes and contributing factors of the accident and present recommendations to prevent similar incidents from happening in the future.

2. Accident Investigation Process

The accident investigation was conducted by the Commission of Railway Safety (CRS), an independent body responsible for conducting investigations into railway accidents. The investigation process involved meticulous on-site inspections, data analysis, interviews with relevant personnel, examination of maintenance and operational records, and consultation with experts in the field.

3. Findings and Analysis

3.1 Faulty Connections in the Automated Signalling System

Faulty wiring in the level-crossing location box was identified as the primary cause of the train accident in Odisha. The investigation revealed that the incorrect labelling of wires in the location box had remained undetected for several years, leading to the faulty connections. This critical issue compromised the communication between the trains and contributed to the collision.

3.2 Maintenance Work Mix-up and Ignored Red Flags

Further investigation uncovered a mix-up in the maintenance work performed on the signalling circuit, which ultimately led to wrong wiring during the repair process. The workers conducting the repair were misled by incorrect lettering on the terminal and circuit, resulting in the improper reconnection of wires. Additionally, red flags indicating abnormalities in the automated signalling system were ignored by the station master from the operations department, contributing to the accident.

3.3 Responsibility of the Signal and Telecommunication Department

The investigation report highlighted lapses at multiple levels, primarily placing responsibility on the Indian Railways' Signal and Telecommunication department. Non-compliance with standard operating procedures during repair work, inadequate supervision, and insufficient guidance for the repair team were identified as key factors that contributed to the incorrect wiring and subsequent accident.

3.4 Inadequate Documentation and Communication

The investigation also revealed deficiencies in the documentation and communication practices within the Signal and Telecommunication department. The completion signalling wiring diagrams, which provide crucial guidance for maintenance work, were found to be outdated and inaccurate. Furthermore, the approved circuit diagram for replacing the electric lifting barrier was not provided to the signalling staff, leading to a lack of proper guidance during the repair process.

4. Comparative Analysis with Previous Rail Accidents

4.1 Gaisal Train Disaster, 1999

The Gaisal Train Disaster, which occurred on August 2, 1999, was one of the deadliest train accidents in India's history. The accident took place near Gaisal, a town in West Bengal, when the Brahmaputra Mail collided with the Awadh Assam Express on the same track. The collision resulted in a devastating fire, leading to the deaths of over 290 people and injuring several others. The accident was primarily attributed to human error, with negligence on the part of the signalmen and lack of communication between stations being key contributing factors. Investigations revealed deficiencies in the signaling system and inadequate implementation of safety protocols.

4.2 Khanna Rail Accident, 1998

The Khanna Rail Accident, which occurred on November 26, 1998, was a tragic collision between the Amritsar-bound Frontier Mail and a local train near Khanna, Punjab. The accident resulted in the loss of approximately 200 lives and left many injured. Investigations revealed that the accident occurred due to the failure of the signal system, as the signal turned green for both trains simultaneously, leading to a collision. Additionally, inadequate maintenance of tracks and signaling equipment was identified as a contributing factor. The incident shed light on the importance of regular maintenance and upgrading of railway infrastructure to ensure passenger safety.

4.3 Kanpur Train Derailment, 2016

The Kanpur Train Derailment, also known as the Indore-Patna Express derailment, occurred on November 20, 2016, near Pukhrayan, Kanpur, in Uttar Pradesh. The accident resulted in the tragic loss of more than 140 lives and left numerous passengers injured. Investigations revealed that the primary cause of the derailment was a fracture in the railway tracks due to an undetected crack. Additionally, the lack of regular inspections and maintenance of tracks, coupled with excessive train speed, contributed to the severity of the accident. The incident highlighted the need for improved track maintenance practices and enhanced safety measures to prevent such derailments in the future.

5. Recommendations

5.1 Updating Completion Signalling Wiring Diagrams and Documentation

Based on the findings of the investigation, it is crucial to update the completion signalling wiring diagrams and other relevant documentation. This includes ensuring that the diagrams accurately reflect the correct reconnection of wires after maintenance work. The Indian Railways' Signal and Telecommunication department should take immediate action to review and update these diagrams, incorporating any changes made since 2015. This will help prevent confusion and minimize the risk of faulty connections in the future.

5.2 Correct Labelling of Signalling Circuits

To address the issue of incorrect labelling of wires in the location box, it is recommended that the lettering of signalling circuits at the site be revised. The Signal and Telecommunication department should implement a comprehensive review and re-labelling process to ensure accurate identification of wires and circuits. This will help prevent confusion among the signalling staff and minimize the chances of incorrect connections, contributing to enhanced safety and efficiency of the signalling system.

5.3 Compliance with Standard Operating Procedures

In order to avoid lapses and improve safety during repair work, strict compliance with standard operating procedures is essential. The Indian Railways' Signal and Telecommunication department should reinforce the importance of adhering to established protocols and guidelines. This includes conducting repair work in the presence of an officer who can oversee the process, provide necessary guidance, and ensure that proper procedures are followed at all times. By enforcing compliance, the risk of errors and faulty wiring can be significantly reduced.

5.4 Testing and Verification of Signalling Circuits

To ensure the reliability and functionality of the updated signalling circuits, it is recommended to assign a separate team specifically dedicated to testing and verifying the circuits and their functions. This team should consist of qualified personnel who can thoroughly inspect the circuits, identify any potential issues or malfunctions, and conduct rigorous testing procedures. By implementing a comprehensive testing and verification process, any discrepancies or faults can be detected and rectified before the signalling system is put into operation, thereby minimizing the risk of accidents and ensuring the safety of railway operations.

6. Conclusion

In conclusion, the train accident in Odisha was a result of faulty connections in the automated signalling system, primarily caused by incorrect labelling of wires in the level-crossing location box. The investigation identified lapses at multiple levels, with the Signal and Telecommunication department of Indian Railways being primarily responsible for the incident. The report highlights the importance of updating completion signalling wiring diagrams, correct labelling of circuits, adherence to standard operating procedures, and thorough testing and verification of signalling circuits to prevent similar accidents in the future.

7. References

  1. "1999 Gaisal train disaster." India Today, August 2, 1999
  2. "Probe points to signalmen's negligence." The Times of India, August 4, 1999
  3. "Railway collision death toll passes 290." BBC News, August 2, 1999
  4. "Khanna rail mishap: Signal failure or human error?" Rediff.com, November 29, 1998
  5. "Probe blames maintenance for Khanna mishap." The Tribune, December 2, 1998
  6. "Khanna Rail Accident." The Indian Express, November 28, 1998
  7. "Kanpur train accident: Fractured track suspected cause." Hindustan Times, November 21, 2016
  8. "Indore-Patna Express derailment: Safety lapses led to worst train tragedy in years, finds probe." The Indian Express, December 29, 2016
  9. "Kanpur train derailment: Track repair work was pending since 2010." India Today, November 21, 2016
  10. "Odisha train crash: Faulty signal connections caused deadly accident, finds CRS probe" WION News. July 4 2023
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