Utkal Tragedy: Rail Reform Must Be Put On The Fast Lane Now

At about quarter to six in the evening of 19 August, as the sun set, the Kalinga Utkal Express derailed in the crowded town of Khatauli near Muzaffarnagar, throwing 14 coaches off track. At least 23 persons died and over 100 people sustained injuries. This figure is set to rise given the extent of damage witnessed.

The second National Democratic Alliance (NDA) government inherited a system which was already running on steroids and was greeted by a devastating train accident near Gorakhpur on the very day Narendra Modi took the oath of office of the Prime Minister.

The spectre of accidents which affected Indian Railways during the first NDA government was squarely faced when Nitish Kumar, instead of blaming the system and officials, called for an honest assessment of what went wrong. On the basis of a recommendation made by a high-powered railway safety review committee led by Justice Khanna, the government created a non-lapsable Special Railway Safety Fund of Rs 17,000 crore in October 2001 to wipe out arrears of overaged assets within a fixed time frame of six years. A Corporate Safety Plan was created and a commitment made that no arrears would be allowed to accumulate in asset replacement. Unfortunately, such bold mid-course correction, where the government squarely looked into the eye of the problem, was squandered. The past decade has been a time when the fruits of this bold input were, in the words of Lalu Yadav, ‘milked’ to the fullest.

In fact, this is what Professor G Raghuram of IIM wrote about it, in 2007, albeit in praise of Lalu.

The first United Progressive Alliance government inherited a robust network which was progressively improved as the monies from the Special Railway Safety Fund were spent. This naturally resulted in lesser failures. Then came the bold decision to legitimise the endemic overloading problem of rakes – the so-called CC+2 regime (CC stands for the ‘carrying capacity’ of a wagon; two more tonnes of load over CC was legitimately permitted).

Members of the Railway Board, in charge of tracks, bridges and rolling stock, raised a red flag of accelerated ageing but were overruled. The worry of these senior and experienced officers was this – as more traffic picks up, where is the physical time to maintain and upgrade? Where is the money for upgrading the assets? A simple Right to Information (RTI) plea can reveal the extent of resistance which was put up.

The chickens have come to roost perhaps.

What led to this accident?

The information which has filtered in leads one to believe that this is a systemic failure of colossal proportions. If the responsibility gets fixed at the level of junior people or one department, it would be a travesty. Based on the preliminary information available and information shared on the internal WhatsApp group of the railways, it is reported that in the station area, the sequence of events was triggered by the failure of what is known as a glued joint. This is used in track circuits to detect the presence of a train and is used to ensure that a train is not directed on an occupied route.

Glued joints are in the station area, and this brings the assistant station master (ASM) into question, one who gets to see all the information on his signal panel (this is the white board with a layout of tracks and the occupancy status, provided in the chambers of ASM on railway platforms). It is technically not possible that the ASM was oblivious to the failure and the work being done as reported here. It was also reported that a 20-minute block was demanded as the track was deemed unsafe by those who maintain it. A glued joint cannot be replaced in 20 minutes; however, a temporary arrangement can be provided in this period and the information available indicates that this is what was aimed at and also that preparations for repair were made before this block was demanded. Without putting up banner flags, the work was started perhaps on the premise that permission would be granted. But as came to light subsequently, much oversight occurred at once as railway operations are guarded by multiple tiers of protection.

That the station authorities under the operating department were not aware, as reported in the media, does not add up. How could the ASM have been oblivious to the failure which was staring at him in his face? When work is being done in the station area, how is it that the ASM lost situational awareness? The idea of employing operating staff at stations from a different department is to avoid such mishaps (otherwise the ASM should ideally be with the signal department as he operates the signals).

Systemic rot

Due to the excessive pressure which gets piled up as maintenance staff does not get authorisation for blocks to even do emergency repairs, unsafe practices have crept in inside all infrastructure departments. Another issue is the high-pressure environment in which the maintenance staff works to avoid asset failure and minimise punctuality losses. This has made statistical lying an art which gets rewarded and, as a consequence, the train operations get reduced to a roll of dice. Margins in the system ensure that most of the trains pass safely, but then sometimes, the inevitable happens and there is a knee-jerk reaction across the board.

When all walkie-talkie communication from the station area was heard on a common channel, how did the ASM not know about what was going on? It has been reported that a crack in the fishplate of the glued joint was detected mid-day. Also, it is reported that the failure of a block instrument was logged because track work was ongoing. Even if the track maintainers were working without authorisation, that there was work being done on the track was known to Delhi Control, senior operating officers and senior track engineering officers. As is the practice in the railways, many such works are done routinely, but evidence points to a complete breakdown of teamwork and communication.

What is intriguing is that the ASM signalled the green light to the ill-fated train despite the fact that he was aware of the failure and the work (even if unauthorised). The sun set in Muzaffarnagar area at 5.49pm on 19 August; how can a red banner flag be visible as the rider sees at least four green signals? In such cases, detonators are put on the track, which obviously in this case were not placed. This also represents poor working practice, which cannot spring out of nowhere in a day.

In fact, a look at the history of railways would reveal that it is the same approach which leads to different forms of tragedy. One of the biggest rail accidents in the history of Indian Railways was the Firozabad disaster in 1995. This is what an India Today report had said about it then:

Remedy

As noted in the safety review done during NDA-1 on 28 September 2002, manuals cannot be given a go-by. The railways need to bring back the culture where speaking the truth is not seen as impractical. The Railway Ministry must first accept that there is a long overdue need to instil truthfulness. It must reward truthful staff and officers and not penalise them. The ministry must understand that punctuality is an outcome of a process and not the end result. Excessive pressure has resulted in the fudging of data and a tendency to manage and handle failures without reporting them. This must be acknowledged by the government. (Though this is not their creation, this aspect needs urgent acknowledgment.)

Since the past decade, branch officers who are at the helm of train operations are routinely deployed for cleanliness drives, variety of inspections outside their direct area of responsibility, examination duties, night inspections in fog, pantry inspections and so on. Manuals mandate rigorous inspections. With the system running on maintenance arrears, perennial shortage of materials and multiple aggressive unions, officers can only be diverted at the cost which has just been paid. How could multiple layers of supervision fail? The track maintenance people did the mistake, but how could such a work culture get instituted in the first place? Why did the ASM fail to understand the gravity of the glued joint failure? Frontline staff are also continuously taken away from their core task to take care of multiple overlapping inspections called for by the divisions/headquarters.

It is a regular complaint that station control and section control refuse to take memos; this stirs up tension among the staff as the practice has become widespread. If nothing is on paper, there is no responsibility as in this case. Just fixing responsibility on track engineers would be akin to offering paracetamol without proper treatment – the problem will manifest again, maybe in a different department.

Poor working practices cannot be laid at the doorstep of a divisional railway manager, who only comes in for a limited time. Who can give frontline staff the confidence to speak the truth? When the entire system has been routinely rewarding those who manage things somehow and not those who are honest, can things be set right by just a few officers of one department? Can safety be predicated on personal relationships? Where is the professionalism?

The ministry has taken strong measures like the taming of unions and decentralisation of powers to general managers, but the top leadership has failed to instil truthfulness and has failed to understand the reasons behind the unsafe practices.

The practice of begging, so to speak, on a daily basis for blocks so that routine and emergency maintenance takes place has corroded the organisational discipline as non-technical people sit in judgement on the safety aspect of engineering asset failure. (Would you trust a dentist to read your brain scan?) Here and here, one can listen to the conversation in the station with the section controller. One can note how initially a 20-minute block is first regretted and then a 15-minute block is also turned down. Unprecedented action has been taken where the complete chain from the local unit up to the member (in charge of civil engineering) has been sent on leave or suspended. But no action has been taken on that chain which was responsible for running the train at full speed while knowing about the failure. What has led to the acceptance of unsafe practices? Why is there a perception that by following the rules, the train operations would come to halt?

The minister has initiated major reforms, but they must be hastened. He has touched only the rolling stock but has left other departments which, incidentally, are the participating departments in this accident. There is urgent need to train and induct officers and staff coming in from the armed forces into positions in the station and section operations to introduce professionalism. One is reminded of the devastating accident of the Purushottam Express (see box), which happened by overlooking the safety recommendation at the altar of operational convenience of shunting and delayed upgrade. The trouble with ICF coaches is well-known – they are utterly unsafe; their climbing, telescoping and non-monocoque designs contributed to the death toll and devastation. Linke Hofmann Busch design coaches are available since 2000; yet ICF till recently was allowed to pump thousands of unsafe coaches into the network.

The Research Designs & Standards Organisation (RDSO) must be given the mandate right away to do an exhaustive audit of practices and come with clear answers as to why fudging data has become the norm; a general manager-level officer runs RDSO and is a person who has extensive field experience. He must be asked to move his team to clinically examine the network. They must devote to an audit of maintenance practices and why there is a growing perception that a highly educated staff is not able to cope with the century-old maintenance practices depending on manual hard labour. Is there a case where the Indian Army can be requested to recruit people for the railways on the basis of their physique and not on education for frontline track jobs?

Senior management can learn from other organisations like the Border Roads Organisation which have the provision of sending officers for a fortnight to take charge of another unit and thereby audit while being in the executive chair. This is more hands-on than the current railway practice of pro forma inspections.

The ability of the Railway Board to lead and instil confidence in lower formations should be urgently looked into; sending a member responsible for track upkeep on leave is just scratching the surface. The Railway Board is already in a state of flux with major reallocation of powers with executive powers shifted to the chairman, who incidentally is on extension. Should people like Ashwani Lohani be brought in from Air India? Such matters should be given an urgent thought.

Disclaimer: This piece is based on prima facie information. Traditionally, the reports of the Commissioner of Railway Safety do a more exhaustive job.