Spotlight

New Delhi, 2 December 2023

‘Not Necessarily By Accident’?

By Rajiv Gupta 

The nation celebrated the rescue of 41 workers from the Silkyara Bend–Barkot tunnel in the Uttarkashi district of Uttarakhand. Once the euphoria of successful effort settles, it will be time to ask whether the tunnel collapse was preventable. The utility and impact of the answers will depend on the questions we ask. Our conduct of post-accident inquiries into its causes has been less than satisfactory. A discussion of how we have dealt with railway accidents will illustrate this. 

On October 29, 2023, there was a terrible train accident involving a collision between the Vishakhapatnam-Palsa passenger train, and the Vishakhapatnam-Rayagada passenger train between Alamanda and Kantakapele in Andhra Pradesh which resulted in the death of 14 and several more injured. 

On June 02, 2023, over 290 passengers lost their lives while around 1000 were injured in the train crash, involving the Bengaluru-Howrah Superfast Express, the Shalimar-Chennai Central Coromandel Express and a goods train. 

Such accidents are published on the front pages in newspapers and are on the national television news for a few days and then lapse into a collective national apathy until the next catastrophe. The process has become a ritual where politicians at local and national levels announce payments to the families of the deceased and to the injured. This is followed by a decision to initiate an enquiry into the causes of the accident. And then we happily move on with our lives. 

An inquiry conducted by the Commissioner of Railway safety (CRS) regarding the second accident highlighted that the rear-collision of the train caused due to the lapses in the signalling-circuit-alteration. It pointed that these lapses resulted in wrong signalling. Consequently, seven officials were suspended and proceedings were initiated against them. This probably would be the last thing about the accident in the media. 

The payment to the families is justified as compensation for the lapses on the part of the railways. However, the findings of the inquiry by the CRS as well as the ensuing action against seven officials merits discussion. 

There has been significant amount of research analysing human errors that result in accidents in a variety of situations from healthcare, to aviation, and nuclear power plants. Some of the most respected work has been done by James Reason and Charles Perrow. They have suggested that errors are of two types: active errors and latent errors. Active errors occur at the level of the frontline operators, and their effects are felt almost immediately. An example of active error could be the failure of the signaling system. Latent errors tend to be removed from the direct control of the operator and include things such as poor design, incorrect installation, faulty maintenance, bad management decisions, and poorly structured organisations. 

Active errors are related to the act of omission or commission that may have been occurred when and where the accident happened. They do not tend to affect any other area of the system at any other point in time. Latent errors are prevalent throughout the system. They can, and do, lead to errors in different parts of the system at different points in time and hence are more consequential than active errors. In general, any inquiry that is constituted after an accident tends to focus on active errors and not on latent, or systemic errors. 

There could be a variety of reasons for this. Latent errors are not easily discernible. They typically involve the acts of omission and or commission by higher level officials, and there could be a tendency to avoid confrontation with powerful officials. It is much easier to pick an operator’s mistake than to question the policy makers of the organisation. The end result is that the underlying problems remain embedded in the system and will result in future accidents and the same analysis would be repeated. 

An audit report by the Comptroller and Auditor General of India on Derailment of Trains in India for the years 2017-2021 makes for some very interesting, as well as alarming, reading.  In fact, after reading the report, it would appear fortuitous that the number of accidents is not higher than what are observed in practice. Some key points from the report will be discussed in this article.

The report looked at several aspects of the operation and maintenance of the rail system. One aspect deals with the inspection of tracks with the help of Track Recording Cars (TRCs). The Indian Railway Permanent Way Manual (IRPWM) provides that the Broad Gauge routes should be monitored by TRCs as per prescribed frequencies dependent on the type of track. The audit found that the shortfall in conducting the inspections varied from 30 to 100% across different zonal divisions. The best performing zonal division could only perform 70% of the prescribed inspections. In 14 out of 18 divisions the inspections performed were half, or less than half the prescribed requirements, and in four divisions no inspections were carried out at all. 

The report also mentions that a derailment of Seemanchal Express occurred in February 2019. The TRC inspection over the section was overdue by four months, which could have given vital inputs for defects in the track which could have averted the accident. This is a clear example of a latent error leading to an accident. An initial investigation revealed that the accident was due to a fracture in the track, an active error. But there has been no mention in the media about the lack of inspection, which could have prevented the tragedy. The accident was waiting to happen. 

Several examples of latent errors are presented in the audit report. Some of these include shortfall in manpower, shortfalls in training for maintenance personnel, lack of adequate safety equipment such as helmets, torches, gloves for maintenance staff, non-adherence to recommended methods of welding for tracks, non-completion of recommended track renewals, etc. The Rashtriya Railway Suraksha Kosh (RRSK) was announced by the Ministry of Finance in 2017-18 for safety related works of renewal, replacement and augmentation of railway assets. 

An analysis by the CAG revealed a reducing trend of fund utilisation for track renewals, repairs, etc, while there was a growing misuse of funds for non-priority areas such as purchase of crockery, passenger amenities (lifts, escalators, extensions of platforms), salaries and bonuses, etc. The report found that out of 1129 derailments during 2017-18 to 2020-21, 289 derailments (around 26%) were linked to track renewals. This amply suggests the lack of safety focus on the part of the Railway management. 

Over the four-year period covered by the report (2017-2021), there were 217 consequential and 1800 other accidents. While derailments formed the largest percentage of both categories of accidents (65-70%), the second biggest cause of consequential accidents was fire. Despite about 9% of consequential accidents being due to fire, it was found that no fire extinguishers were provided in 62% of the coaches. 

The government is moving ahead with ambitious plans for high-speed rail connecting the cities. While we should be celebrating these plans, nevertheless there is sufficient cause for concern regarding our ability to maintain the existing railway assets, let alone the newer, more sophisticated systems. We should not fall into the trap of thinking that we can automate ourselves out of this mess. What is needed is better management at the ground level and a real commitment to passenger safety from the government and the top management of the railways. Until that happens, perhaps it might be better to slow down. And it may be instructive to repeat the audit after a few years to see to what extent the Railways have heeded the suggestions.---INFA 

(Copyright, India News & Feature Alliance)