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1 GOVERNMENT OF INDIA MINISTRY OF CIVIL AVIATION (COMMISSION OF RAILWAY SAFETY) (T.11016 / 1 / 2011-12 / NFC) From: Commissioner of Railway Safety, Northeast Frontier Circle, 14, Strand Road, 12 th Floor, Kolkata – 700 001 To: The Chief Commissioner of Railway Safety, Ashok Marg, Lucknow. Subject: Side collision of 14055 UP Brahmaputra Mail with Brake Van of UP DC 13189 NRPA at about 05:45 hours of Jan, 11 th 2012 while passing through platform line (Line No. 1) at Karanpurato Station at km 209/5-6 within station section on Tinpahar Jn (TPH) – Sahibganj (SBG) Broad Gauge Single Line Non-Electrified ‘B’ Route Section of Malda Division, Eastern Railway. I INTRODUCTION 1.1 Preamble In accordance with Rule 3 of “Statutory Investigation into Railway Accidents Rules, 1998” published by the Ministry of Civil Aviation, I have the honor to submit a Brief Preliminary Report of my Statutory Inquiry into side collision of 14055 UP Brahmaputra Mail with Brake Van of UP DC 13189 NRPA at about 05.45 hours of Jan, 11 th 2012 at Karanpurato Station on Tinpahar (TPH) – Sahibganj (SBG) Broad Gauge Single Line Non-Electrified ‘B’ Route Section of Malda Division, Eastern Railway. 1.2 Inspection and Inquiry 1.2.1 I came to know about the accident at 07:49 hours, on January, 11 th 2012 from Chief Commissioner of Railway Safety, Lucknow who called me on my mobile when I was at residence and directed me to take up the inquiry into the accident. The accident took place at Karanpurato Station on Malda Division of Eastern Railway that falls in the jurisdiction of Commissioner of Railway Safety, Eastern Circle. 1.2.2 Chief Safety Officer, Eastern Railway came in contact at 0804 hours. I enquired and asked him to make arrangement for movement to the Site for my inspection of site in the afternoon. He informed that he was proceeding to site and that Chief Engineer / Track Machines shall accompany me to the site. 1.2.3 Divisional Railway Manager, Howrah Division when contacted informed that a Special Train for my movement from Howrah to site shall be ready at about 1000 hours. 1.2.4 I left Howrah by the Special Train made ready at about 1100 hours of the same day i.e. on 11 th January, 2012 and reached Karanpurato Station at 1545 hours. 1.2.5 Inspection of Site On 11-01-2012 on arrival at Karanpurato Station at 1545 hours by Speacial Train from Howrah, I first inspected the accident site of side collision of 14055 UP Brahmaputra Mail with Brake

Side collision of 14055 UP Brahmaputra Mail with Brake Van

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GOVERNMENT OF INDIA MINISTRY OF CIVIL AVIATION

(COMMISSION OF RAILWAY SAFETY) (T.11016 / 1 / 2011-12 / NFC)

From: Commissioner of Railway Safety, Northeast Frontier Circle, 14, Strand Road, 12 th Floor,

Kolkata – 700 001 To: The Chief Commissioner of Railway Safety, Ashok Marg, Lucknow.

Subject: Side collision of 14055 UP Brahmaputra Mail with Brake Van of UP DC 13189 NRPA at about 05:45 hours of Jan, 11 th 2012 while passing through platform line (Line No. 1) at Karanpurato Station at km 209/5-6 within station section on Tinpahar Jn (TPH) – Sahibganj (SBG) Broad Gauge Single Line Non-Electrified ‘B’ Route Section of Malda Division, Eastern Railway.

I INTRODUCTION

1.1 Preamble

In accordance with Rule 3 of “Statutory Investigation into Railway Accidents Rules, 1998” published by the Ministry of Civil Aviation, I have the honor to submit a Brief Preliminary Report of my Statutory Inquiry into side collision of 14055 UP Brahmaputra Mail with Brake Van of UP DC 13189 NRPA at about 05.45 hours of Jan, 11th 2012 at Karanpurato Station on Tinpahar (TPH) – Sahibganj (SBG) Broad Gauge Single Line Non-Electrified ‘B’ Route Section of Malda Division, Eastern Railway.

1.2 Inspection and Inquiry

1.2.1 I came to know about the accident at 07:49 hours, on January, 11th 2012 from Chief Commissioner of Railway Safety, Lucknow who called me on my mobile when I was at residence and directed me to take up the inquiry into the accident.

The accident took place at Karanpurato Station on Malda Division of Eastern Railway that falls in the jurisdiction of Commissioner of Railway Safety, Eastern Circle.

1.2.2 Chief Safety Officer, Eastern Railway came in contact at 0804 hours. I enquired and asked him to make arrangement for movement to the Site for my inspection of site in the afternoon. He informed that he was proceeding to site and that Chief Engineer / Track Machines shall accompany me to the site.

1.2.3 Divisional Railway Manager, Howrah Division when contacted informed that a Special Train for my movement from Howrah to site shall be ready at about 1000 hours.

1.2.4 I left Howrah by the Special Train made ready at about 1100 hours of the same day i.e. on 11th January, 2012 and reached Karanpurato Station at 1545 hours.

1.2.5 Inspection of Site

On 11-01-2012 on arrival at Karanpurato Station at 1545 hours by Speacial Train from Howrah, I first inspected the accident site of side collision of 14055 UP Brahmaputra Mail with Brake

2

Van of UP DC 13189 NRPA at Karanpurato Station (KPTO) of Malda Division, Eastern Railway, the culprit Brake Van and derailed S -9 Coach (14th from engine) of 14055 Up Brahmaputra Mail as a result of the collision off-tracked and rolled down the formation kept / available at site and Karanpurato Station.

1.2.6 Having inspected the site and Karanpurato Station, I left Karanpurato Station by the Special Train at 1648 hours and reached Sahibganj Station (SBG) at 1740 hours. I visited the Loco Shed at Sahibganj and inspected the 2 (two) coaches 12th & 13th from engine of 14055 UP Brahmaputra Mail detached and kept.

1.2.7 After visiting site, I decided to hold inquiry on 13th January, 2012 at Malda and accordingly directed Railway to issue press notification to this effect. Railway was also asked to preserve clues and details regarding the accident as well as to make arrangement for holding inquiry on 13th January, 2011.

1.2.8 I also met Additional General Manager, Principal Chief Engineer and Chief Signal & Telecommunication Engineer Eastern Railway, Kolkata available at Sahibganj.

1.2.9 After site visit I left Sahibganj at 1845 hours by the Special Train and reached Howrah at about 24:00 hours on 11th January, 2012.

1.2.10 During my site inspection, I was accompanied by:

(i) Divisional Railway Manager, Eastern Railway, Malda (ii) Chief Safety Officer, Eastern Railway, Kolkata (iii) Chief Motive Power Engineer, Eastern Railway, Kolkata (iv) Chief Engineer / Track Machines, Eastern Railway Kolkata

1.2.11 As per First Information AXXR of the Railway dated 11-01-2012 received through FAX at 11:43 hours, 5 (five) got killed and 09 (nine) persons suffered injuries as under-

Killed : 05 (five) 04 Passengers 01 Un-identified person. Grievous : Nil Simple : 09 (nine) 06 Male 03 Female Trivial : Nil

1.2.12 All injured passengers were first rendered first aid at site and then shifted to Sahibganj Railway Hospital where preliminary treatment was provided to the injured passengers and then finally shifted and admitted in Divisional Railway Hospital at Malda.

4 injured were discharged on Jan 12th 2012 and rest 5 injured were discharged after giving proper treatment on Jan 13th 2012 as indicated in in CMS / MLDT’s Report.

SN Particulars Details of injury Nature of injury

Treatment Disposal

1 Sabnam, F-03 D/o Jafar Khan,

Cut 1” on right parietal region.

Simple Cut stitched.

X-Ray Skull (A/L) at Rly Hospital, Malda

Discharged on 13.01.2012

2 Jamila Khatoon.

Cut ½“ on dorsal aspect of right wrist.

Simple Three stitches given.

Discharged on 13.01.2012

3

SN Particulars Details of injury Nature of injury

Treatment Disposal

F-30

W/o Jafar Khan

2” cut on temporal region.

X-Ray skull (A/L)

X-Ray right wrist (A/L) at Rly Hospital, Malda

3 Kunj Bihari,M-34

Right hand injured.

Simple First aid given. Released after first aid.

4. Falu Mia, M-3

S/O Jainaluddin

Cut injury on forehead.

Injury on right thigh inner side.

Multiple abrasion on right leg.

Swelling of right elbow.

Simple 5” stitched.

CT Scan of brain done.

Discharged on 13.01.2012

5. Falani F -25

W/o Jainaluddin

Cut injury left thigh 4“ Blunt injury on chest.

Simple X-Ray left thigh (A/L)

Discharged on 13.01.2012

6. Naresh Yadav, S/o Ram Yadav

M-

Punctured wound right thigh.

Lacerated injury on left foot.

Abrasions on forehead.

Simple X-Ray right thigh (A/L)

X-ay left ankle (A/L)

X-Ray pelvis (A/L)

Discharged on 12.01.2012

7. Satish Kumar

M-32

Trauma.

Left middle finger.

Simple First aid given. Released after first aid.

8. Tushar Yadav M-10

S/o Robindra Kr. Yadav

Injury on face. Simple First aid given. Released after first aid.

9. Md Jakir Hussain M-30

Cut injury (Lacerated) 4” on left foot sole,

Simple CT Scan of brain.

X-Ray left foot

Discharged on 13.01.2012

4

SN Particulars Details of injury Nature of injury

Treatment Disposal

left foot sole,

Cut in the web of great toe & 2nd toe.

Cut on occipital region - 1”

(AP,LAT) 13.01.2012

1.2.13 A press notification was issued in leading News Papers of the area (both in English and in Regional Languages) inviting members of public, local people and passengers having knowledge relating to the accident to tender evidence at the inquiry in the Office of Divisional Railway Manager (DRM) at Malda on 13th Jan, 2012 or write to my office at 14, Strand Road, 12th Floor, Kolkata-700 001.

1.2.14 Sr. Divisional Safety Officer, Eastern Railway Malda Division under his Office letter No. RB-3/2011-2012 dated 12-01-2012 made reference to the following to depute their representative during the inquiry.

(i) District Magistrate, Sahibganj District, Govt of Jharkhand. (ii) Superintendent of Railway Police, Dhanbad, Jharkhand (iii) Superintendent of Police, ,Sahibganj District, Govt of Jharkhand (iv) OC/GRP, Sahibganj District Jharkhand

1.2.15 As per the scheduled program of holding inquiry, I commenced my inquiry from 10:00 hours of 13th Jan, 2012 and completed at 1800 hours.

1.2.16 The statutory inquiry on Jan, 13th 2012 was attended by the following officers of Eastern Railway:

(i) Shari Harsh Kumar, Divisional Railway Manager, Eastern Railway, Malda (ii) Shri S.K. Singh, Chief Safety Officer, Eastern Railway, Kolkata (iii) Shri A. Dutta, Chief Motive Power Engineer, Eastern Railway, Kolkata (iv) Shri A. Nigam, Chief Engineer, Eastern Railway, Kolkata (v) Shri M.G. Chugh, Chief Signal & Telecommunication Engineer (Planning),

Eastern Railway, Kolkata

1.2.17 In all 30 (Thirty) persons registered their statement out of which 07 (seven) were non-railway and remaining 23 ( twenty-three) were Railway Officials as under-

Non Railway:

(i) Inspector, Railway Police / Sahibganj (GRP) - 01

(ii) Inspector of Police Station, Sahibganj, Rajmahal (State Police)- 01

(iii) Sub Inspector, Sahibganj, GRP - 01

(iv) Injured passengers - 04 Railway: - 23

Total - 30

1.2.18 Preservation of clues

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(i) Derailed coach NR 04292 WGSCN (S-9) positioned 14th from engine of 14055 Up Brahmaputra Mail as a result of the side collision with brake van SC 15269 BVZC of UP DC 13189 NRPA that rolled back down the gradient obtaining in the Karanpurato Station Yard passed beyond outside the fouling mark at Barharwa end causing infringement and side collision with coaches 12th to 14th from engine of 14055 Up Brahmaputra Mail while the same was entering and passing through Karanpurato Station Yard via platform line (Line No. 1), detached and off-tracked on left right side of the forma tion was available at the site.

(ii) Derailed brake van SC 15269 BVZC of UP DC 13189 NRPA that rolled back down the gradient obtaining in the Karanpurato Station Yard passed beyond outside the fouling mark at Barharwa end causing infringement and side collision with coaches 12th to 14th from engine of 14055 Up Brahmaputra Mail while the same was entering and passing through Karanpurato Station Yard via platform line (Line No. 1) detached and off-tracked on left right side of the formation was available at the site.

(iii) Coach NR 03230 WGSCN and NR 16669 WGSCN positioned 12 th & 13th from engine of 14055 Up Brahmaputra Mail hit by brake van SC 15269 BVZC of UP DC 13189 NRPA that rolled back down the gradient obtaining in the Karanpurato Station Yard passed beyond outside the fouling mark at Barharwa end causing infringement and side collision with coaches 12th to 14th from engine of 14055 Up Brahmaputra Mail while the same was entering and passing through Karanpurato Station Yard via platform line (Line No. 1), detached were available in Loco Shed at Sahibganj.

(iv) The relevant station records were seized by officers of Malda Division.

(v) Still photographs of damaged coach and other relevant features of the accident site were taken.

(vi) Sketch of the accident site including joint notes were recorded and prepared.

(vii) All the records pertaining to train operation maintained in Divisional Control at Malda as required were seized / sealed and preserved by the Railways.

1.3 The Accident

1.3.1 On 11.01.2012, UP DC13189 NRPA comprising of 42 BCN (loaded with stone chips)+1 MT hauled by WDG3A 13189 was passing through Karanpurato Station at 00: 10 hours through main line (Line No. 2). Due to the failure of the Loco (attributed to malfunctioning of the Fuel Booster Pump) which had partly crossed the starter signal, the train was suitably brought back and stabled on Main Line (Line No. 2) of Karanpurato Station.

1.3.2 14055 UP Brahmaputra Mail hauled by Diesel locomotive no. WDP4 20049 on its run from Dibrugarh to Delhi was passing through the platform line (line No. 1) at Karanpurato Station at about 05:44 hours when UP DC13189 NRPA with dead loco started rolling back towards TLJ side on the down gradient obtaining in the at Karanpurato Station Yard beyond and outside the fouling mark causing infringement and brake van SC 15269 BVZC grazing & scrubbing the coach No. NR 03230 WGSCN positioned 12 th from engine in the portion after the rear door, entire length of coach No. NR 16669 WGSCN (13th from engine) knocking down the doors and pressed its side all along the length puncturing and shearing the side of NR 04292 WGSCN (14 th from engine) and causing the coach to derail by all wheels and mounting on the same.

1.3.3 At the time of side collision speed of the 14055 UP was 15 Kmph.

1.3.4 There was no injury to the passengers in 12th and 13 th coach. However, as because the brake van pressed / punctured and caused shearing of the shell of 14 th coach, 5 (five) passengers got killed whereas 9 (nine) passengers were inflicted simple injuries.

1.3.5 The passenger occu pancy in the train was around 1524 against the capacity of 1636 passengers.

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1.3.6 As a result of the side collision, in all 14 (fourteen) persons sustained injuries as categorized below.

(i) Killed - 05 (Five) 05 Train Passengers (ii) Grievous - Nil (iii) Simple - 09 09 Train Passengers (iv) Trivial - Nil

1.3.7 The weather was fair and visibility was clear at the time of accident.

II RELIEF MEASURES

2.1 Intimation

2.1.1 1st information of the occurrence was conveyed by the Guard of 14055 Up Brahmaputra Mail to on duty Assistant Station Master (ASM), Karanpurato Station at 05:50 hours.

Assistant Station Master, Karanpurato Station immediately informed the Section Control / Malda at about 05:55 hours. In turn Control informed all concerned.

2.1.2 Railway, Civil Authorities, other Govt. Officials and Non-Government Organization moved to the site on receiving the intimation as under-

SN Particulars Arrival time

1 Sr.DMO / SBG along with AME / SBG by ARMV / SBG 07:13 hours

2 Local police with other Railway staff 08:15 hours

3 CMS/MLDT, along with four Railway Doctors by ARMV/MLDT 09:20 hours

4 DRM, Sr. DEN(C), Sr. DME, Sr. DEE(G), Sr. DSO, Sr. DSTE, DPO, DEN-I, DSC, AME / MLDT, AEN / NFK, SBG, AME / SBG, APO / III

09:20 hours

2.2 Medical attention and relief

2.2.1 On receipt of information about the accident from Guard of 14055 Up Brahmaputra Mail, on duty ASM / Karanpurato informed State Ambulance at 06:05 hours.

2.2.2 The movement of ARMEs based at Sahibganj and Malda Town are appended below

Particulars

ARME / SBG (Double exit)

ARME / MLDT (Double exit) Remarks

(a) Time of ordering 06:00 06:00

(a) Time of blowing the siren 06:00 06:00

(c) Time of arrival at bar 06:25 06:50

(d) Time of dispatch from station 06:30 07:00

(e) Time of arrival at the station immediately in the rear of the accident site, and at accident site

07:13

09:20

Delayed dispatch of ARME / MLDT due to exit point occupied by DN DC 13591 DHN BTPN

2.2.3 As per record, there was delay in the dispatch / departure and movement of ARME/MLDT.

7

Delay was stated to be due to the exit point of ARME / MLDT being occupied by DN DC 13591 DHN BTPN Load. After departure of DN DC at 06:28 hours ARME siding was cleared. ARME was dispatched at 07:00 hours after attachment of power at 06:50 hours.

2.2.4 Dr. B. K. Mandal, Sr. Divisional Medical Officer, Sahibganj rushed to site along with paramedical staffs by ARMV left SBG at 06:25 hours and reached site at 07:13 hours.

2.2.5 Traffic Inspector / SBG with other Railway staff reached accident site by ARMV / SBG at 07:13 hours.

2.2.6 All injured persons were shifted to nearest Railway Hospital at Sahibganj, by ARMV / SBG at 13:35 hours after first aid treatment at site.

2.2.7 CMS / MLDT with four other doctors and paramedical staff left for accident site by ARMV / MLDT at 07:00 hours and reached accident site at 09:20 hours.

2.2.8 After preliminary treatment at Sahibganj Railway Hospital all injured persons were shifted to Malda Railway Hospital, Malda for better treatment.

2.2.9 4 (four) injured passengers were discharged after first aid from Railway Hospital, Malda on 12.01.2012 and remaining 5 (five) injured passengers were discharged from Railway Hospital, Malda after proper treatment on 13.01.2012.

2.2.10 All 05 (five) bodies of dead were taken over by Local Police at 11:00 hours of 12.01.2012 from accident site.

2.2.11 The details of disposal of the injured / dead furnished by CMS, Malda are as under:

Nature of

injury

Persons injured (Nos)

Disposal of injured Status

(as on 13.01.2012)

Killed 05 State Police took over dead bodies at 11:00 hours of 12.01.2012

4 (four) injured passengers were first taken to Railway Hospital at Sahibganj after first aid treatment at site by ARMV / SBG on 11-01-2012 and then shifted to Railway’s Divisional Hospital at Malda.

Discharged from Railway Hospital, Malda on 12.01.2012.

Simple 09 5 (five) injured passengers were first taken to Railway Hospital at Sahibganj after first aid treatment at site by ARMV / SBG on 11-01-2012 and then shifted to Railway’s Divisional Hospital at Malda.

Discharged from Railway Hospital, Malda after imparting proper treatment on 13.01.2012

2.2.12 The Railway Administration initially disbursed ex-gratia amount of –

(i) Rs. 1,00,000/- each to passengers dead except two dead passenger. Out of which one was unidentified and relative of one dead passenger did not agree to receive the payment.

(ii) Rs. 10,000/- each passengers simple injured.

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2.2.13 None of the injured passengers undergoing treatment in Malda Railway Hospital had any complaint in regard to (a) payment of ex-gratia and (b) medical attention and care being received by them.

2.2.14 There was no complaint either from passengers or from public about loss of property / personal belongings of passengers or about any negligence on the part of the Railway Administration.

2.3 Restoration and interruption to traffic

2.3.1 The movement of Accident Relief Train (ART) based at Sahibganj and Malda Town are appended below

Particulars

ART / SBG (Double exit)

ART / MLDT (Single exit) Remarks

(a) Time of ordering 06:00 06:00

(a) Time of blowing the siren 06:00 06:00

(c) Time of arrival at bar 06:25 07:10

(d) Time of dispatch from station 06:55 07:20

(e) Time of arrival at the station immediately in the rear of the accident site, and at accident site

08:00

11:30

TPH 09:20

ART / MLDT returned from TPH.

2.3.2 All the stranded passenger of front 13 coaches were sent to Sahibganj along with the passengers of derailed coach. At Sahibganj, 12 th and 13th coach from train engine were detached and 3 GSCN and 1 SLR were attached to accommodate all the passengers comfortably.

2.3.3 Rear portion consisting of 9 (nine) coaches of 14055 Up Brahmaputra Mail were taken to BHW Station at 09:45 hours and were served breakfast. Passengers of these 9 (nine) coaches were served with lunch at Malda Town station free of cost through departmental means. This portion was dispatched from Malda for its destination Delhi via Katihar at 14.25 hours after attached one SLR.

2.3.4 Match truck and one damaged coach were off tracked and restoration work completed at 13:20 hours on main line with 10 Kmph for first train and thereafter with normal speed.

2.3.5 Junior Engineer / P.Way / BHW, at site issued track certificate at 13:20 hours with 10 Kmph for first train and thereafter with normal speed.

2.3.6 Loop line point clear and track fit certificate at 14:20 hours. First train HOD Special left via loop line at14:05 hours at KPTO station and passed accident site.

2.3.7 Details of delay, termination and cancellation of trains are appended below:

Trains terminated - 53021, 13409 Trains Cancelled - 53401.53402, 53403/53404,53063, 53022, 13410 Trains diverted - Nil Trains delayed - 15648 Up at TLJ – 308 min (05:55 to 11:03 hours) 14056 Dn at SBG- 142 Mts (09.50 hours – 12.20 hours) And 80 min in between BGP-SBG section.

III THE TRAIN

3.1 Composition and marshalling order of the train

3.1.1 Locomotives

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3.1.1.1 The loco WDP4 20049 that hauled 14055 UP Brahmaputra Mail was manufactured by Diesel Locomotive Works (DLW), Varanasi and commissioned on 25-01-2008.

3.1.1.2 The length and weight of the loco was 21.024 m and 126 t respectively.

3.1.1.3 The loco was provided with Headlight, Flasher Light, Vigilance Control Device, Speedo Meter and speed recorder. All were in working order. The loco was running with short hood leading.

3.1.1.4 The loco was having Air Brake with 100% brake power.

3.1.1.5 Brakes viz. A-9, SA-9, Dynamic Brake, Emergency Brake and Hand Brake were available with loco in working condition.

3.1.1.6 It earned 763154 Km after commissioning. Last trip examination was done on 13-12-2011. No schedule was overdue.

3.1.1.7 There was no damage to locomotive that hauled 14055 UP Brahmaputra Mail.

3.1.1.8 Position of the control handle regulator after accident is as under:

a) Sector handle position : Motoring b) Reversal Handle position : Forward c) A-9 Automatic Handle Position: Applied d) Throttle Handle Position : Idle e) Emergency Brake Valve : Normal

3.1.1.9 Position of brake valve after accident: Released condition.

3.1.2 Coaches

14055 UP Brahmaputra Mail comprised of 24 (twenty-four) coaches. The marshalling order of the train was as under:

SN (from

engine) Coach No. Body & type Year

built Last POH

Date of

return

Remarks

1 NR 02724 GSLRD Steel / RCF 2002 AMV 15-12-10 07/12 On Rails

2 NR 10451 GS Steel / RCF 2010 Built 2010 03/12

3 NF 03401 GS Steel / RCF 2003 NBQS 07-05-

11 12/12

4 NR 16313 GS Steel / RCF 1990 JUDW 22-12-10

07/12

5 NR 06415 GS Steel / RCF 2006 JUDW 24-10-11

05/13

6 NR 05290 WGSCN Steel / BEML

2005 JUDW 08-03-

11 10/12

7 NR 05222 WGSCN Steel / RCF 2005 AMV 04-02-11 09/12

8 NR 16512 WGSCN Steel / RCF 1989 JUDW 03-12-11

07/13

9 NR 12205 WGSCN Steel / ICF 1989 AMV 16-02-11 09/12

10 NR 07243 WGSCN Steel / BEML

2007 JUDW 27-08-11

04/13

10

SN (from

engine) Coach No. Body & type

Year built Last POH

Date of

return

Remarks

BEML 11

11 NR 10215 WGSCN Steel / RCF 2010 Built 2010 04/12

12 NR 03230 WGSCN Steel / RCF 2003 JUDW 31-05-

11 01/13

13 NR 16669 WGSCN Steel / RCF 1990 JUDW 14-05-

11 12/12

14 NR 04292 WGSCN Steel / RCF 2004 JUDW 21-09-

10 04/12 Derailed

by all wheels

15 NR 04801 WCB Steel / ICF 2004 JUDW 03-03-

11 10/12

16 NR 07879 WACCWN

Steel / RCF 2008 AIIW 20-12-11 07/13

17 NR 98122 ACCN Steel / RCF 1998 AIIW 29-08-11 04/13

18 NR 08940 ACCN Steel / RCF 2008 JUWS 31-05-11

01/13

19 NR 06885 ACCWN Steel / RCF 2009 AMV 26-08-10 04/12

20 NR 08222 WGSCN Steel / BEML

1990 JUDW 24-06-

10 01/12

21 NR 16624 WGSCN Steel / RCF 2008 JUDW 11-05-11

12/12

22 NR 16306 GS Steel / RCF 1993 JUDW 21-10-11

05/13

23 NR 11916 GS Steel / ICF 1987 JUDW 09-11-

11 06/13

24 NR 13523 SLR Steel / BEML

1988 AMV 09-03-11 10/12

On Rails

3.1.3 Damages to coaches of 14055 Up

SN (from

Engine)

Coach No

Disposition Damage (Brief description)

12 NR WGSCN

On rail. North side from HWH end grazing / scrubbing mark observed over 12.150 mm. North end HWH end body

11

SN (from

Engine)

Coach No

Disposition Damage (Brief description)

03230 corner sheared off. North side HWH end 01 foot step broken.

13 NR

WGSCN 16669

Coupling entangled with derailed coach.

North Side over body grazing & scrubbing & also bent over length of 21337 mm & North Side both end body corner bent & sheared off. North side all footsteps bent & broken.

14 NR

WGSCN 04292

Derailed & coupling entangled with the adjacent coaches.

Side wall middle of coach above west rail sheared off & bent towards inside of coach, 4 (four) side lower and upper berth damaged badly, Delhi end bathroom damaged badly, All wheels of both the trolley derailed.

3.1.4 Length, Weight and Brake power of the train

The length and weight of the train were 535.124 m and 952.96 t respectively excluding the engine.

3.1.5 The train was fully air braked with 100% brake power.

3.1.6 The seating capacity of the train was 1636 while the actual occupancy was around 1524.

3.2 Composition and marshalling order of the Goods Train ( UP DC 13189 NRPA)

3.2.1.1 The loco WDG3A 13189 that hauled UP DC NRPA was manufactured by Diesel Locomotive Works (DLW), Varanasi and commissioned on 01-05-2005.

3.2.1.2 The length and weight of the loco was 19.126 m and 123 t respectively

3.2.1.3 The loco was provided with Headlight, Flasher Light, Vigilance Control Device, Speedo Meter and speed recorder. All were in working order. The loco was running with short hood leading.

3.2.1.4 It earned 33445 Km after commissioning. Last trip examination was done on 13-12-2011. No schedule is overdue.

3.2.1.5 Last trip examination was done on 13-12-2011.

3.2.1.6 Position of the control handle regulator after accident is as under:

a) Sector handle position : Motoring b) Reversal Handle position : Neutral c) A-9 Automatic Handle Position: Applied d) Throttle Handle Position : Idle e) Emergency Brake Valve : Normal

3.2.1.7 Position of brake valve after accident was in released condition

3.2.1.8 Locomotive neither got damaged nor derailed.

3.2.2 Wagons of UP DC 13189 NRPA

UP DC 13189 NRPA comprised of 43 (Forty-three) wagons with marshalling order as as under:

12

SN (from

engine) Wagon No. Last POH

Date of return

Remarks

1 CR BCNA M-1 973579 PWP 05-01-11 02/17

2 NE BCNAHSM-1 2753 PWP 25-04-09

05/15

3 SR BCNAM-1 46983 JHSW 23-03-

10 04/16

4 CR BCNM-1 153976 KTTW 18-01-

10 02/16

5 NE BCNM-1 5597 PWP 13-09-06

6 ER BCNM-1 50558 JUDW 19-10-06

01/13

7 ER BCNM-1 53093 RYPS 21-12-

10 01/17

One hand brake pull rod deft. but active

8 SE BCNM-1 05670 JUDW 03-11-

07 12/13

9 CR BCNM-1 153798 JUDW 11-12-

08 01/15

10 ER BCNM-1 52377 JSSW 20-12-

07 02/14

11 CR BCNM-1 50004 KTTW 25-06-

11 07/17

12 ER BCNM-1 50266 JUDW 30-03-

07 05/13

13 CR BCNAM-1 953605 RYPS 10-07-

09 08/15

14 ER BCNM-1 52746 JMP 04-07-09 07/15

15 SR BCNAM-1 40553 KGPW 06-05-

08 05/14

16 SE BCNAM-1 130449 JUDW 29-10-

11 12/17

17 SC BCNAM-1 35945 JUDW 28-10-

11 12/17

18 SE BCNAM-1 131407 JUDW 31-10-11

12/17 DV defective and inactive

13

SN (from

engine) Wagon No. Last POH

Date of return

Remarks

11 inactive

19 WR BCNAM-1 963149 YRPS 13-10-08

11/14

20 NR BCNAM-1

110685A JUDW 19-12-

05 01/12

Six Bk. Block deft. but active

21 SE BCNAM-1 108590 KTTW 25-06-

11 07/17

22 NR BCNAM-1 99783A NBQS 06-05-

11 06/17

23 NR BCNAHSM-1

114311 KGPW 14-01-

11 02/17

24 NW BCNAHSM-1 311105 / 41848

Not visible 06/12

25 NF BCNAM-1 71365A NBQS 06-05-

11 06/17

26 SW BCNAHSM-1 311504/ 21322

KTTW 18-04-11

05/17

27 NR BCNM-1 92092 JHSW 27-01-

09 03/15

28 SC BCNA 36202A JUDW 30-01-

07 03/13 One hand brake

deft but active

29 NF BCNAM-1 71777 JUDW 28-10-11

12/17

30 SE BCNAM-1 130140 JUDW 28-10-

11 12/17

31 SC BCNM-1 27766 JUDW 23-08-

07 09/13

32 NC BCNAHSM-1 311303/ 10318

BQS 05-02-10 03/16

33 SC BCNAM-1 35738A JUDW 13-03-

06 04/12

34 SE BCNAM-1 109186 KTTW 25-06-

11 07/17

14

SN (from

engine) Wagon No. Last POH

Date of return

Remarks

35 NR BCN 92129 JUDW 11-03-08

04/14

36 SR BCNAM-1 46996 JHSW 13-04-

10 05/16

37 CR BCNM-1 151157 PWP 05-04-06 05/12

38 WR BCNAM-1 973293 RWS 21-12-09 02/16

39 WR BCNAM-1 993549 JUDW 09-11-

11 12/17

40 SC BCNAM-1 39092 RYPS 09-01-10

02/16

41 SE BCNM-1 106359 KTTW 22-10-

07 11/13

42 ER BCNM-1 48151 JMPW 29-11-

10 12/16 Entangled with

brake van

43 SC BVZC 15269 JUDW 09-11-

11 12/13

Derailed. HWH end CBC of Brake Van entered into coach with an angle of 300

3.2.3 Damages & disposition of the wagons are appended below

SN (from loco)

Wagon No. Disposition Damages (Brief Description)

42

ER 48151 BCN M1,

P – JMPW 29-11-10,

R/D – 12/16,

B/Date – BESCO 1998.

Wagon entangle with brake Van

(i) HWH end brake pipe bent. (ii) HWH end centre pivot and

side bearer CC pad displaced,

(iii) End pull rod bent. (iv) HWH end north side 01 No.

outer spring displaced , (v) HWH end panel plate 100

mm x 460 mm cutting, (vi) Operating handle bent.

15

43

SC 15269 BVZC,

P – JUDW 09-11-11, R/Date – 12/13.

HWH end CBC of Brake Van entered into coach with a angle of 300 and derailed condition

(i) HWH end platform badly bent;

(ii) HWH end CBC bent and damaged;

(iii) All footstep of HWH end badly bent;

(iv) All the Spring were dismantled and scattered

3.2.4 Length, weight and brake power of the wagons:

The length and weight of the UP DC 13189 (Goods Train) were 637.48 m and 3458 t excluding the engine.

3.2.5 The UP DC 13189 (Goods Train) were fully air braked with 100% brake power

3.3.1 Signal & Telecommunication

Side collision of 14055 Up Brahmaputra Mail with Brake Van of UP DC 13189 NRPA at Karanpurato Stations caused no damages whatsoever to the S&T gears.

3.3.2 Permanent Way

Side collision of 14055 Up Brahmaputra Mail with Brake Van of UP DC 13189 NRPA at Karanpurato Stations caused no damages whatsoever to the P. Way.

3.3.3 Electrical

Following electrical equipment of the coach got damaged as a result of the collision:

(i) One FL fittings, (ii) Electrical wiring of light & fan switches of side berths of the said coach.

3.5 Approximate cost of damages

i) Locomotive (WDM2A 16847) & (WDG3A 13189) : Rs. Nil ii) Rolling Stock : Rs. 59,59,313.00 iii) Electrical : Rs. 6,13,203.00 iv) Permanent Way : Rs. Nil v) S & T : Rs. Nil

Total cost of damages : Rs 65,72,516/-

IV LOCAL FEATURES

4.1 The Sect ion and the site

4.1.1 The site of accident Km 209/5 -6 is located within Karanpurato Station Section limit on Tinpahar Jn – Sahibganjj Single Line Non-electrified ‘B’ Route.

4.1.2 Site is located in the Civil District of Sahibganj at a distance of 7.45 Km from Taljhari Station and 7.48 Km approximately from Maharajpur Station.

4.1.3 The alignment runs South to North direction in the section.

4.1.4 The nature of the country around the site is open on right side, undulated on left side, alignment having straight

4.1.5 Gradient in Karanpurato Station Yard

16

(i) ES and SI Plans indicate change in grade at a distance of 250.70 m outside the outermost point at MJP end of Karanpurato Station Yard with down gradient of 1 in 417 towards TLJ.

(ii) Index Section (corrected upto 31-03-2011) submitted indicate formation level rising from level of 30.398 m to 31.679 m at Km 209 with rising grade of 1 in 417 followed by rising grade of 1 in 526 to level of 34.605 m.

(iii) Levels and Gradients in Karanpurato Station Yard

Km Dist w.r.t

KPTO Level

Grade

Pt to Pt

Grade KPTO -Pt

Grade KPTO

300 MJP-720 TLJ

Grade KPTO 90 MJP - 630 TLJ

MJP end 570 102.75 -643 683

480 102.89 1125 492

390 102.81 692 436

? 300 102.68 310 392

210 102.39 414 442

90 102.1 486 486 FM 132.42

KPTO 210.14 0

101.915

90 101.79

5 750 750

210 101.51 421 519 451 505

300 101.32 474 504

420 101.12 600 528

? 510 100.95 529 528

630 100.67

5 436 508 FM 594.58

720 100.42 353 482

810 100.18 375

900 100.00

5 514

960 99.89 522

1020 99.72 353

1080 99.6 500

17

209 1140 99.48 500

TLJ end 1200 99.59 -545

4.1.6 The Permanent Way at the place of accident consisted of 52 Kg rails, 90 UTS laid in the year 1995 on mono-block PSC sleepers having density 1540 Nos. / Km (M+7) with elastic fastenings and ballast cushion of 250 mm (1.75 Cum / m).

4.1.7 Bank height is 2.5 m to 3.00 m with stable formation. The kind of soil is clay.

4.2 Signaling and System of Working

Karanpuato Station (KPTO) a ‘B’ Class Station is located on Tinpahar Jn – Sahibganj Single Line Section having Standard III interlocking equipped with MACL signaling worked on Absolute Block System of working with token-less single line block instruments with motor operated points controlled from Central Panel.

4.3 Headquarters and jurisdiction

4.3.1 Section is controlled from Control Office of the Division located at Malda.

4.3.2 Headquarter and jurisdiction :

4.3.2.1 Engineering Department

S N Official / Gang HQ Jurisdiction

1 Sr. Divisional Engineer / Co-ord Malda All over Malda Division 2 Sr. Divisional Engineer / II Malda Including MJP & excluding KIUL 4 Divisional Engineer / I Malda Excluding AJLE & MLDT- MJP (Excl) 5 Asst. Engineer Sahibganj MJP (Incl) & BGP (Excl) with MDLE

section. 6 Sr. Sectional Engineer / P.Way Sahibganj Km 105/03 – 172/3 7 Junior Engineer / P. Way Bahrarwa Km 129/0 – 150/9 8 Gang Km 144/0 – 150/9

4.3.2.2 Signaling & Telecommunication Department

S N Official HQ Jurisdiction

1 Sr. Divisional Signaling & Telecom Engineer Malda All over Malda Division

2 Asstt Divisional Signaling & Telecom Engineer SBG BHW-EKC

3 Senior Section Engineer / Sig SBG BHW-EKC

4 Section Engineer / Sig SBG TLJ-KRMA

4.4 Monsoon patrolling usually introduced during the monsoon period w.e.f. May, 16th to Oct, 15th as per the extant instructions was not in force.

4.5 Maximum permissible sectional speed is 100 Kmph .

No permanent / temporary speed restriction was in force in the vicinity of the accident site on the day of the accident in BHW-SBG Section. There was no temporary speed restriction in force in the vicinity on the day of the accident on the section.

18

4.6 The dates of last inspection of the track prior to accident are as below :

SN Official Date Inspection by

1 Divisional Engineer / I / MLDT 03-12-2011 Foot Plate Ex NFK –MJP 13409 MLDT-BGP I / City Ex

2 Divisional Engineer / I / MLDT 03-12-2011 Push Trolley MJP-TLJ

3 Asstt. Divisional Engineer / NFK 03-12-2011 Foot Plate Ex NFK –MJP 13409 MLDT-BGP I / City Ex

4 Sr. Divisional Safety Officer / MLDT 30-12-2011 Night Foot Plate BHW-BGP 13415 MLDT-PNBE I/City Ex

5 Asstt. Divisional Engineer / NFK 4-01-2012 Motor Trolley NFK -MJP

6 Asstt. Divisional Engineer / NFK 05-12-2011 Push Trolley TLJ -KPTO

7 PWI / BHW 08-01-2012 Night Foot Plate SBG-BHW 13134 Varanasi-SDAH Exp

During their inspection, inspecting officials found no defects.

4.7 Daily record of rainfall of 7 (seven) days prior to the accident reflected Nil rainfall.

4.8 Kilometerage of va rious stations / locations referred to in the report reckoned from the Khana (KAN) station are:

Station / Location Kilometer

Khana (KAN) 0

Barharwa Jn (BHW) 178.04

Tinpahar Jn 194.53

Taljhari (TLJ) 204.19

Accident Spot 209/05-06

Karanpurato (KPTO) 210.92 (WTT), 210.16 (ES & SI and Index Plan)

Maharahpur (MJP) 217.50

Sahibganj (SBG) 232.34

V SALIENT FEATURES

5.1.1 On 11.01.2012, UP DC 13189 NRPA comprising of 42 BCN (loaded with stone chips)+1 MT hauled by WDG3A 13189 was given through signal on Main line for UP through movement through Karanpurato Station (KPTO). Train was passing Karanpurato Station at 00: 10 hours through main line (Line No. 2).

5.1.2 Train stopped after the loco partly crossed starter signal. Loco Pilot noticed 0 (zero) Fuel Oil pressure.

5.1.3 The train was brought back by the Loco Pilot suitably to the rear of Starter Signal.

5.1.4 Loco Pilot found that Fuel Booster Pump was not working. While trying to find the reason for the Fuel Booster Pump not working, the loco shut down automatically.

5.1.5 Loco Pilot started the loco thereafter at 1:44:29 but the loco shut down again at 1:47:09.

5.1.6 As the Loco Pilot could not rectify the problem, he served failure memo to ASM on duty at Karanpurato who in turn relayed the same to MLDT Control.

5.1.7 On Control's message, Loco Inspector / SBG, Sri A.M. Yadav arrived by 13134 DN at 03:04:00 hours from Sahibganj. Loco Inspector / SBG started the loco again at 3:09:40 but it shut down at 3:09:44. Loco Inspector ruled that loco could not be rectified on line and confirmed the loco failure.

19

5.1.8 ASM / KPTO consulted MLDT Control whether Loco Crew and Guard should be spared and after receiving MLDT Control's go-ahead served the spare memo to Loco Crew and Guard at around 04:10 hours. Contents of Spare Memo are reproduced below-

‘ SM / KPTO,

To,

The Dr. and Guard of 13189 UP/DC

You are hereby spared to your HQ as per CNL/MLDT.

Sd/-

11/01/2012

Station Manager, Karanpurato

5.1.9 Loco Crew and Guard left KPTO Station by 13133 UP which passed via loop line of KPTO Station. This was at around 04:10 hours. Loco Inspector / SBG as well left KPTO by 13133 UP for SBG.

5.1.10 Trains that were worked through loop line ( Line No. 1) of Karanpurato Station after occupation of main line by UP DC 13189 NRPA were as under –

Train ?

Stns ?

UP

DC

131

89

NR

PA

?

5307

3 U

P ?

? D

N B

CN

(E

)

? 5

3044

DN

1302

3 U

P ?

1348

3 U

P ?

? 1

3134

DN

1340

3 U

P ?

1307

1 U

P ?

1313

3 U

P ?

? 5

3074

DN

1405

5 U

P ?

MJP 00:40 00:48 01:15 02:37 02:52 02:56 03:32 03:55 04:15 05:13

KPTO 00:10 00:30 01:05 01:24 02:31 02:44 03:04 03:25 03:45 04:10 A 05:23 D 05:24

05:45

TLJ 24:00 00:16 01:16 01:32 02:22 02:34 03:11 D 03:12 A 03:07

03:36 04:00 05:32 05:37

BKLE 23:00 04:0

0 04:1

0 04:1

5

BHW D 05:04 A 05:02

5.1.11 After departure of 13133 UP, 53074 DN arrived at 05:20 hours and left at 05:22 hours through loop line of Station. Thereafter, 14055 Up Brahmaputra Mail arrived and was passing through KPTO station when UP DC13189 NRPA with dead loco started rolling back towards TLJ side on the down gradient obtaining in the at Karanpurato Station Yard beyond and outside the fouling mark causing infringement and side collision at 5:44:35 hours collision occurred (as per download of event recorder in loco of 14055 Up) with brake van SC 15269 BVZC grazing & scrubbing the coach No. NR 03230 WGSCN positioned 12 th from engine in the portion after the rear door, entire length of coach No. NR 16669 WGSCN (13 th from engine) knocking down the doors and pressed its side all along the length puncturing and shearing the side of NR 04292 WGSCN (14th from engine) and causing the coach to derail by all wheels and mounting on the same.

5.1.12 Goods train UP DC 13189 had therefore been standing on main line of Karanpurato (KPTO) Station for more than 5½ hours before arrival and passage of 14055 UP Brahmaputra Mail through Karanpurato Station. During this time 10 (ten) trains (other

20

than 14055 Up), 6 (six) in UP direction and 4 (four) in DN direction passed via the loop without anything untoward.

5.1.13 At the time of side collision speed of the 14055 UP was 15 Kmph.

5.1.14 There was no injury to the passengers in 12th and 13 th coach. However, as because the brake van pressed / punctured and cause d shearing of the shell of 14 th coach, 5 (five) passengers got killed whereas 9 (nine) passengers were inflicted simple injuries.

5.1.15 There was no evidence of any kind of outside interference / tampering with the disabled loco and its trailing load or with the track.

5.1.16 Provisions contained in the General & Subsidiary Rules of Eastern Railway in regard to Securing of vehicles at Stations are reproduced below –

‘ 5.23 Securing of vehicles at stations. - The Station Master shall see that vehicles standing at the station are properly secured in accordance with special instructions.

‘ SR. 5.23. [i] Vehicles shall be secured when standing in sidings or on running lines, and at least one safety chain and padlocks used for every fifteen vehicles. Where there are brake-vans, the brakes shall be screwed hard on and in the case of goods vehicles all lever brakes shall be put down .

[ii] The new type of bogie wagons for example, BOX, BOBS, BOI, BRH, &c., are fitted with roller bearings and are liable to roll even on level formation . These wagons stand the same danger of rolling down on a gradient of 1 in 400 as ordinary 4-wheelers on a gradient of 1 in 133. Special care should, therefore, be taken to secure these wagons while standing in sidings or on running lines.

Following precautions are necessary when BOX wagons are stabled at a station.

[a] At least two safety chains must be used and locked. [b] The hand brakes whether side operated or end-operated must

be fully tightened. If a rake of BOX wagons is stabled, at least six wagons from each end must have their brakes put on tightly.

[c] The brakes should be operated by station staff, such as Porters, Shunt men or Points-men under the personal supervision of Guard or ASM.

5.1.17 Excerpts of the Joint Observations recorded by Senior Supervisors on arrival at Karanpurato Station are reproduced below –

‘(10) Hand brake of SC BVZC 15269 found in released condition.

(11) Hand brake of adjacent 10 Nos. wagons from BVZC and also from T/E were checked and found in released condition.’

5.1.18 Provisions contained in the General & Subsidiary Rules of Eastern Railway in regard to Duties of Staff viz Driver is reproduced below –

‘G. Duties of Staff on Arrival

4.55. Shutting off Power

21

In stopping a train, the Driver shall determine where to shut off power by paying particular attention to the gradient , the state of the weather, the condition of the rails, brake power and the length and weight of the train’.

4.61. Driver not to leave engine when on duty.-

No Driver shall leave his working locomotive or his self-propelled vehicle when on duty, whether at a station or on a running line, except in case of absolute necessity and after a competent railway servant has been placed in charge of the locomotive or self-propelled vehicle. In the case of a self-propelled vehicle manned by a Driver only, a Driver may leave it when necessary, provided he has locked the cabs and has put the vehicle in low gear with the ignition switch in the off position and has screwed down and locked the hand brake’.

5.1.19 Excerpts of the Joint Observations recorded by Senior Supervisors on arrival at Karanpurato Station are reproduced below –

‘(12) Loco of UP DC 13189 WDG 3A / ABR NWR found in dead condition.

(13) The position of SA-9 and A-9 of Engine No. 13189 found in application condition and the pressure of the gauges found in zero.

(14) No wooden wedge found in cab room and under the wheel of loco and load.

(15) UP DC 13189 which arrived at KPTO M/Line at 00:09 hours on 11/1/12 and found in same track till accident.

(16) Driver and DAD was not available in Engine and Guard in Brake Van.

(17) Load was not secured by chain and padlock.

(18) Failure memo given by Driver at 00:45 hours, then after LI/SBG arrived by 3134 Dn and attained 03:10 hours and Crews spared at 04/07 hours by ASM / KPTO.’

5.1.20 Instructions contained in Board’s No. 2012 / SAFETY – 1 / 3 / 1 (.) dated 11-01-2012 are reproduced below –

‘ GENERAL MANAGERS, NEW DELHI, DATED 11.01.2012

ALL ZONAL RAILWAYS.

NO. 2012/SAFETY-1/3/1 (.) A SIDE COLLISION OF A GOODS TRAIN WITH A MAIL TRAIN RESULTING IN LOSS OF HUMAN LIVES TOOK PLACE ON EASTERN RAILWAY DUE TO ROLLING DOWN OF GOODS TRAIN WHICH WAS STABLED ON THE MAIN LINE WHILE THE MAIL TRAIN WAS PASSING THROUGH LOOP LINE. THIS SEEMS TO HAVE HAPPENED DUE TO NON OBSERVANCE OF RULES FOR SECURING OF STABLED LOADS.

IT HAS BEEN DECIDED THAT A MONTH LONG DRIVE MAY BE LAUNCHED TO COVER THE FOLLOWING ASPECTS REGARDING SECURING OF VEHICLES AT STATIONS:

(i) WHENEVER VEHICLES / LOAD IS STABLED ON RUNNING LINES OR SIDINGS, IT MUST BE:-

(a) CHAINED AND PAD LOCKED; (b) SECURED BY USE OF WOODEN WEDGES / SPRAGS ETC.;

22

(c) COUPLED WITH OTHER VEHICLES.

(ii) HAND BRAKES OF AT LEAST SIX WAGONS FROM EITHER END MUST BE FULLY TIGHTENED. IN CASE COACHING VEHICLES ARE STABLED, GUARDS HAND BRAKES IN SLR / SLRS MUST BE APPLIED. THE HAND BRAKES SHOULD BE OPERATED UNDER THE PERSONAL SUPERVISION OF GUARD AND IN THE ABSENCE OF GUARD BY SM / ASM ON DUTY.

(iii) THE POINTS MUST BE SET CLAMPED AND LOCKED AGAINST THE BLOCKED LINE / LINES AND SCOTCH BLOCKS WHEREVER AVAILABLE SHOULD BE USED TO ISOLATE THE LINE / LINES AND THE KEYS KEPT WITH STATION MASTER.

(iv) STOP COLLARS MUST BE PLACED ON RELEVANT SIGNAL AND POINTS BUTTONS / LEVERS.

(v) REMARK TO THE EFFECT THAT ‘ LINE NO. IS BLOCKED' BE MADE IN TSR / SM DIARY.

(vi) AFTER ANY RAKE IS STABLED, THE STATION MASTER MUST INFORM THE SECTION CONTROLLER UNDER EXCHANGE OF PRIVATE NUMBER THAT ALL LAID DOWN PRECAUTIONS FOR STABLING HAVE BEEN TAKEN.

THE SECTION CONTROLLER MUST OBTAIN THIS ASSURANCE FROM STATION MASTER BEFORE ALLOWING THE NEXT TRAIN TO PASS THROUGH THE STATION.

(vii) AVAILABILITY OF ADEQUATE NUMBER OF SPAGS, WEDGES, CHAINS AND PADLOCKS SHOULD BE ENSURED AND THESE SHOULD BE OF STANDARD DESIGN.

THE FEEDBACK ON THE ABOVE SHOULD BE GIVEN ON DAILY BASJS SIMS WEBSITE.’

5.1.21 The weather was fair and visibility normal at the time of accident.

VI PROVISIONAL FINDINGS

6. Having carefully considered all the evidence tendered, records produced, observations, site inspection and circumstantial evidence, I have come to the conclusion that the side collision of 14055 UP Brahmaputra Mail with Brake Van of UP DC 13189 NRPA at about 05.45 hours of Jan, 11th 2012 at Karanpurato Station, on Tinpahar Jn (TPH) – Sahibganj (SBG) Broad Gauge Single Line Non-Electrified ‘B’ Route Section of Malda Division, Eastern Railway was caused as UP DC 13189 NRPA with its disabled dead Loco stabled on main line on up / rising gradient obtaining in Kara npurato Station Yard and not secured properly / adequately as per instructions rolled back towards Taljhari (TLJ) side beyond / outside the fouling mark at Taljhari end of Karanpurato Station Yard resulting in infringement and collision with coaches positioned 12 th to 14 th from train engine while 14055 UP Brahmaputra Mail was entering and passing Karanpurato Station Yard via platform line (Line No. 1).

Accordingly, the cause of the accident is attributed to and classified as – ‘Failure of Railway Staff’.

(B. SINGH) Commissioner of Railway Safety Northeast Frontier Circle, Kolkata

23

456. Guard to see that train is stopped clear of fouling marks.-

When a train comes to a stand at a station, the Guard shall see that, wherever possible, the last vehicle of his train has cleared the fouling marks of all points and crossings. If not, he shall inform the Station

4.60. Guard not to leave train till handed over.-

No Guard shall leave his train unti l i t has been properly handed over in accordance with special instructions.

SR. 4.60.- [a] No Guard shall leave the station at the end of his run without the Station Master's permission to do so. He shall also before leaving see that his train has been signed for by the outgoing Guard, or by the Trains Clerk . He shall furthermore have delivered all consignments, Way-Bills, Dispatches, &c. for that station and shall have made over those for stations beyond.

[b] Every Guard shall also hand over all journals and documents kept by him in connection with the running of his train to the Assistant Station Master on duty before leaving the platform at the end of his run, if a box is provided for the purpose such documents are to be placed therein.

24

[c] In the event of the train running over two or more Divisions the Guard shall submit separate train documents for each Division, and shall also sign his name on the roster before he leaves the station.