In a damning revelation, the Commissioner of Railway Safety (CRS) has pinpointed severe lapses at multiple levels that culminated in the tragic Kanchanjunga Express accident involving a goods train.
The June 17 incident in West Bengal's Darjeeling district, which resulted in the loss of 10 lives including the loco pilot of the goods train, has been described by the CRS as an "accident waiting to happen."
The CRS's exhaustive probe report has not only shed light on the systemic failures but also recommended the urgent implementation of the Automatic Train-protection system (KAVACH) to prevent such incidents in the future.
The CRS report disclosed that the accident was primarily due to the issuance of incorrect paper authority (T/A 912) to the loco pilot of the goods train. This document, which allows trains to cross defective signals, lacked crucial speed instructions, leading to a catastrophic misunderstanding.
Reflecting on the events, the CRS noted, "Due to improper authority and that too without adequate information, such an incident was an 'accident-in-waiting'."
Further investigation revealed that the defective signals were crossed by five other trains on the day of the accident. Despite the same authority being issued to these trains, they followed different speed patterns. Only the Kanchanjunga Express adhered to the norm of moving at a maximum speed of 15 kmph and stopping for one minute at each defective signal, while the rest, including the goods train, did not comply.
This discrepancy highlights the confusion and lack of clear instructions among loco pilots regarding the proper protocol when T/A 912 is issued. "The absence of proper authority and that too without adequate information created misinterpretation and misunderstanding about the speed to be followed," the CRS report stated.
Classifying the accident under the "Error in Train Working" category, the CRS highlighted the "inadequate counselling" of loco pilots and station masters about train operations in automatic signaling territories. The report emphasized the need for improved training and clearer communication to prevent such misunderstandings.
The CRS also raised concerns about the high number of signaling failures in automatic signaling territories. Between April 1, 2019, and March 31, 2024, there were 208 cases of Signal Passing at Danger (red signal overshooting), 12 of which resulted in collisions. This alarming statistic underscores the limitations of current preventive measures and the urgent need for the implementation of the KAVACH system.
"The occurrence of as many as 208 cases of Signal Passing at Danger, out of which 12 resulted in collisions, highlights the limitations of preventive measures taken by zonal railways," the report said.
The Commissioner of Railway Safety recommended exploring non-signaling-based systems, such as Artificial Intelligence-based detection and GPS-based anti-collision systems, to enhance safety in locomotive cabs across Indian Railways.
The report also pointed out a shortage of critical safety equipment, like walkie-talkies, in the Northeast Frontier Railway (NFR) Zone, where the accident occurred. This shortage meant that the goods train crew was not issued essential safety equipment, further compounding the risks.
In instances of multiple signal failures, the CRS identified three options for the rail administration, none of which were followed correctly in this case.
The first option involved loco pilots following a general rule to stop for one minute at a defective signal and then proceed with caution.
The second option was issuing a T/A 912 form with a caution order specifying the speed, which was not done in this instance.
The third option was to treat the situation as a "major signal failure" and follow the Automatic Block System, allowing only one train to enter between two stations at a time.
On the night of the accident, the CRS report found that the signaling control office was inadequately staffed. Instead of being manned by a Senior Section Engineer, a Junior Engineer, and a helper round-the-clock, it was managed by a technician. "It is not possible to manage such a major signaling failure by a staff of technician level.
The response of higher officials at the divisional level was lacklustre, as none of them attended the control office despite being informed of the serious failure," the report criticised.
Since the introduction of automatic signalling in January 2023, the Commissioner of Railway Safety prioritised the necessity of implementing all applicable rules at the field level, however, the widespread misinterpretation of these rules indicates towards a lack of a proper system of checks and balances.
The CRS concluded with a stark warning: "The large number of signaling failures in automatic signaling territory is a cause for concern and should be addressed urgently to improve the reliability of the system."
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