Government of Ministry of Civil Aviation (Commission of Railway Safety)

SATISH KUMAR MITTAL Commissioner of Railway Safety, Southern Circle, No.7 Seshadri Road, Gandhinagar, Bangalore –560 009

No.T.11017A/9/2011-2012/9 Dated: September 27, 2011

To, The Chief Commissioner of Railway Safety, Ashok Marg, Lucknow – 226 001

Sir,

Sub: Collision of 66017 Beach – Cantonment MEMU train with rear- end of 56007 - Passenger train between Arakkonam West Cabin and Chitteri stations at Km. 74/10-12 on the Down Line of Arakkonam- Katpadi Electrified Double Line BG section in Chennai Division of Southern Railway at about 21:23 hrs on 13.09.2011

--- I - INTRODUCTION 1.1 Preamble 1.1.1 In accordance with Rule 3 of the “Statutory Investigation into Railway Accident Rules, 1998” issued by the Ministry of Civil Aviation vide Gazette Notification No. GSR 257 dated December 26, 1998, I hereby submit the Preliminary Report pertaining to the above subject matter.

1.1.2 Unless otherwise apparent from the context, the terms “leading”/”trailing”, “left”/’right”, “front”/”rear” are with reference to the direction of the movement of Train no. 66017 Main Line Electric Multiple Unit Down Train. Henceforth, in this Report, this Train is referred to simply as “66017 MEMU” or “the colliding train”. The train No. 56007 Arakkonam-Katpadi Passenger is referred to simply as “56007 Passenger” or “the collided train”.

1.1.3 The station ‘Arakkonam West Cabin’ is also called ‘Melpakkam’ and has been referred as ‘Arakkonam West cabin” in the report.

1.2 Inspection and Inquiry

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1.2.1 On 13.9.2011 at 23.35 hrs, CSO/Southern Railway informed me about the subject accident. CSO conveyed that rear-end collision had taken place between Arakkonam West Cabin and Chitteri stations. He also told that there were deaths and injuries to passengers. I conveyed to him my intention of inquiring into the accident and advised him to arrange preservation of clues and arrange photography of site and affected trains.

1.2.2 Based on my instructions, notifications were got publicised by the Railway Administration in newspapers in Chennai area intimating members of public having knowledge related to the accident to tender evidence at the Inquiry to be held from 10.00 hrs. of 16.09.2011 till its completion on 17.09.2011.

1.2.3 I left Bangalore for the accident spot by 12608 Express on 14.09.2011. This train left Bangalore at 09.45 hrs instead of at 06.30 hrs. I reached Katpadi station at 13.55 hrs, and from there I was taken by road to Chitteri station.

1.2.4 I reached Chitteri station at 16.15 hrs. CSO, CSE, ADRM and other Officers of Southern Railway met me at the station. I went through the report of data logger of the station and then proceeded to site of accident. I inspected the site of accident and damaged coaches of the train between Arakkonam West Cabin and Chitteri Down line between 16.45 hrs and 17.30 hrs.

1.2.5 I visited injured passengers at General Hospital/Arakkonam from 17.45 to 18.15 hrs. on the same day. I was informed that 36 passengers were admitted there. I enquired from passengers whether they were satisfied with the medical treatment given and also sought to know if they could offer any clues or leads with regard to the accident. All the injured passengers admitted in General Hospital/Arakkonam were travelling in 56007 Passenger. Some passengers told that 56007 Passenger had stopped at signal. When it started moving to Chitteri station, they heard a loud sound and they were thrown off their seats.

1.2.6 Honourable Minister for Railways accompanied by Chairman, Railway Board, Member Engineering, Member Electrical and Additional Member (Signal) had visited the accident spot on 14.09.2011 and injured passengers in hospital.

1.2.7 I came back to Bangalore by 12007 Shatabdi Express on 14.9.2011.

Page 2 of 13 1.2.8 I reached Chennai on the morning of 16.09.2011 for conducting Inquiry. I visited the General Hospital/Chennai between 09.00 to 10.15 hrs, there I met injured passengers and enquired about their well-being, their satisfaction about medical treatment and also if they could give any clues to arrive at result of inquiry. I was accompanied by CSO, DRM, ADRM and other Officers during hospital visit.

1.2.9 The Inquiry commenced at 10.30 hrs of 16.09.2011 in the DRM’s Conference Hall, Chennai. I inspected the site of accident again from 17.00 to 18.00 hrs. and carried out footplate inspection of Arakkonam West Cabin-Chitteri block section by a MEMU train between 19.00 to 19.30 hrs. to check the visibility of signals. Visibility of all the signal was good.

1.2.10 The Inquiry continued from 09.00 hrs to 13.30 hrs of 17.09.2011.

1.2.11 Total 47, out of which 36 were railway witnesses and 11 were members of public, witnesses were examined. The following SAG Officers from Southern Railway HQ attended the inquiry proceedings:

Shri S. Mohan … Chief Safety Officer Shri Dani Thomas … Chief Track Engineer Shri M. Sivanandam … Chief Traffic Planning Manager

Shri B. Shanmuganandam … Chief Rolling Stock Engineer Shri S.P. Vavre … Chief Electrical Loco Engineer Shri N.K. Gupta … Chief Electric Traction Engineer Shri T.G. Osuru … Chief Signal Engineer Shri S. Anantharaman … Divisional Railway Manager/Chennai Shri John Thomas … Additional Divisional Railway Manager/ Chennai

1.2.12 Notices about the Statutory Inquiry had been published in English newspapers i.e. “The Times of India”, “The Hindu” and other Vernacular Newspapers like Dinamalar, Dina Thanthi, Malai Malar on 15.09.2011.

Page 3 of 13 1.2.13 Preservation of clues:

Photographs and video of site and damaged coaches relevant to the cause of accident were arranged by Railway Administration. Observations of the site and both the trains had been got recorded. Records of data loggers of Arakkonam, Arrakonam west cabin and Chitteri stations, MEMU maintenance, speedometer charts and control office records had been preserved by the Railway and these were produced in the Inquiry.

1.3 Brief description of the Accident

1.3.1 66017 MEMU train started from Arakkonam at 21:15 hrs (01:28 hrs late). It passed through Arakkonam West Cabin. The train was on its way to Chitteri station when it collided with rear end of 56007 Passenger train in the mid-section at km. 74/10-12 at 21.23 hrs.

1.3.2 Driving motor coach and 3 trailer coaches of the 66017 MEMU train derailed and were lying at km 74/12-16. Front cabin of driving motor coach 13007 was smashed, leading bogie was riding over the bogie of mangled coach SLR 92727 of 56007 passenger.

1.3.3 2 rear coaches of 56007 Passenger derailed. Guard compartment of last coach SLR 92727 was crushed; body severed from underframe and was lying at km 74/14-16 on UP line. The 2nd from last, coach SRGS88442 capsized towards right and rested on side body between UP and DN lines at km 74/16-18.

1.3.4 Sketch of the accident site is enclosed in annexure – 1.

1.3.5 Due to the accident OHE tripped. Movements of trains on Up line and Down lines was stopped by the Control.

1.3.6 I regret to report that as a result of the accident, 10 passengers, including the Guard of 56007 Passenger, were killed. 24 passengers, including Motorman of 66017 MEMU train, suffered grievous injuries and 66 passengers sustained simple injuries.

1.3.7 The Railway Administration has estimated the actual occupancy of 56007 Passenger as 656 passengers. Carrying capacity of this train was 656.

Page 4 of 13 The 66017 MEMU train had carrying capacity of 618 passengers. At the time of accident, it was estimated to be carrying about 465 passengers.

II – RELIEF MEASURES

2.1 Intimation

First information of the accident was conveyed by the Loco Pilot of 56007 Passenger Train to the Station Masters of Chitteri, Arakkonam West Cabin and TLC / Chennai at 21.25 hrs (control timing) through his mobile phone. Control informed TPC to switch off OHE power supply and informed Divisional Officers.

2.2 Medical attention and relief

2.2.1 ARME/Chennai Central was ordered at 21.29 hrs. It left at 22.00 hrs and reached accident spot at 23.55 hrs. By that time, injured persons had been taken to General Hospital/Arakkonam with the help of ambulances provided by 108 State Service, Apollo Hospital and L&T Cement factory located nearby.

2.2.2 ARME/Renigunta was ordered at 21.40 hrs. It left Renigunta at 22.45 hrs. and arrived Arakkonam West Cabin at 23.59 hrs. ARME/ was ordered at 22.20 hrs. It left Jolarpettai at 22.52 hrs. and arrived station at 01.55 hrs next day.

2.2.3 Injured persons were first admitted in the General Hospital/Arakkonam and were later referred to General Hospital/Chennai and Divisional Railway Hospital/Arakkonam. They expressed their satisfaction about medical attention during my visit to Hospitals.

2.2.4 Ex-gratia payment of Rs.5,00,000/- each was paid to the next of kin of the dead. Rs.1,00,000 was paid as ex-gratia to 12 grievously injured passengers and Rs. 25,000/- was disbursed as ex-gratia to 51 passengers with simple injuries.

2.3 Restoration

Page 5 of 13 2.3.1 ART/Chennai Central was ordered at 21.29 hrs. It left at 22.15 hrs and reached accident spot at 2.40 hrs. ART/Jolarpettai ordered at 22.30 hrs. It left at 23.05 hrs. and reached accident spot at 2.30 hrs. ART/Renigunta was ordered at 21.40 hrs. It left at 22.45 hrs and arrived Arakkonam west cabin at 23.59 hrs. ART/ was ordered at 22.25 hrs. It left at 23.55 hrs and arrived Arakkonam at 1.39 hrs. Site of accident was restored with the help of ART of Chennai and Jolarpettai.

2.3.2 As a result of collision, through rail communication was disrupted on Up and DN lines. Up line was restored for traffic at 13.30 hrs on 14.09.2011. Down line was restored for traffic at 17.45 hrs.

2.3.3 As a result of accident, 2 trains were cancelled, one terminated and 7 trains diverted on 13.9.2011. On 14.9.2011, 23 trains were fully cancelled, 13 diverted, 3 terminated and one train partially cancelled.

III – THE TRAINS

3.1 Composition and marshalling order of the trains:

3.1.1 66017 MEMU ‘the colliding train’

This was an electrical multiple unit train. It had eight coaches. First and eighth coaches were motor coaches in following marshalling order;

Sl.No. Coach No. Body Type Year Built Last POH Date of Return from engine 1 MC 13007 ICF 2002 30.11.10 01.06.12 2 13273 ICF 2002 06.12.10 07.06.12 3 13271 ICF 2002 30.11.10 01.06.12 4 13274 ICF 2002 29.11.10 30.05.12 5 13275 ICF 2002 26.11.10 27.05.12 6 13272 ICF 2002 03.12.10 04.06.12 7 13276 ICF 2002 02.12.10 03.06.12 8 MC 13008 ICF 2002 07.12.10 08.06.12

Page 6 of 13 The leading motor coach no MC13007 was manufactured by ICF in the year 2002. It was commissioned on 12.8.2002. Headlight, speedometer (ESMON), automatic flasher light, dead man’s handle and hooter were provided and were in working condition. Airbrake (electro pneumatic and auto brakes) was provided and was in good working order. This motor coach had logged 103534 kilometers after last POH on 30.11.2010. It had undergone its last trip inspection schedule on 10.9.2011 at Avadi and was not due for any maintenance schedule.

3.1.2 56007 Passenger ‘the collided train’

3.1.2.1 Locomotive

This train was hauled by a WAG5HA AC locomotive no. 23376. It was manufactured on 02.07.1989. Headlight, speedometer, flasher light were provided and were in working condition. Air brakes were provided and were in working condition. The locomotive had logged 1,73,952 Km after its last POH. It had undergone its last major inspection schedule on 10.9.2011 and was not due for any maintenance schedule.

3.1.2.2 Coaches

This train consisted of eight coaches marshalled in the following order:

S.No Coach No. Body Year Last POH Date of from Type Built Return engine 1 97787 SLR ICF 1997 01.08.11 03/13 2 88467 GS ICF 1988 21.01.11 08/12 3 92521 GS ICF 1992 13.08.11 03/13 4 00461 GS ICF 2000 22.11.10 06/12 5 97697 SCZ ICF 1997 14.07.11 02/13 6 96612 SCZ ICF 1996 01.03.11 10/12 7 88442 GS ICF 1988 08.02.11 09/12 8 92727 GSLR ICF 1992 30.04.11 12/11

3.2 Length and Weight of trains a) 66017 MEMU train: The train weighing 320.9 tonnes was 177.686 m. in length. All the coaches were air-braked. The brake power available was 100%.

Page 7 of 13 b) 56007 Passenger train: The train weighing 413.48 tonnes, including the engine, was 198.35m in length. The formation was air-braked and was having 100% brake power.

3.3 Damage & disposition

3.3.1 66017 MEMU ‘the colliding train’

Driving motor coach no 13007 of 66017 MEMU suffered heavy damages. Front cabin was smashed, underframe, bogie frame, couplers and roof heavily damaged. Roof of the coach, pantograph and circuit breakers were damaged. Coach nos. 13273, 13271 and 13274 suffered minor damages. After the accident, the coaches were lying at km 74/12-16 on DN line.

3.3.2 56007 passenger ‘the collided train’

3.3.2.1 Two rear coaches of 56007 Passenger derailed. Guard compartment of last coach SLR927727 was crushed, body severed from under frame and the coach had capsized at km 74/14-16 on UP line. Both the bogies disintegrated and cluttered were lying on adjacent UP line.

3.3.2.2 Coach no SRGS88442, 2nd from last, capsized towards right and was resting on its side. Rear bogie wheels had separated and were lying under scattered bogie components. The coach was lying between UP and DN lines at km 74/16-18.

Several electrical equipments of coach nos. SLR 92727, GS 88442 and SCZ 96612 were also damaged.

3.3.3 Cost of damages to coaches was assessed as Rs. 2,44,20,000/-

3.3.4 Damage to track ( P.Way)

The track was damaged for a length of 200 m. 400 sleepers and fastenings were damaged. Cost of damages was assessed as Rs. 45,20,000/-

3.3.5 Damage to signalling installations

Page 8 of 13 S&T assets like FRP TLD boxes, GI wire and Channel bond pin were damaged. Cost of damages was assessed as Rs. 25,000/-.

3.3.6 Damages to the OHE

There were damages to cantilever assembly of one mast, cadmium copper catenary - 33 m and in span droppers -20 nos. Cost of damages was assessed as Rs. 36,000/-.

3.3.7 Total cost of damages to the Railway assets as a result of Collision with break-up is given:

Coaches : Rs. 2,44,20,000/- Track : Rs. 45,20,000/- Signalling : Rs. 25,000/- OHE : Rs. 36,000/------Total : Rs. 2,90,01,000/-

IV –LOCAL CONDITIONS

4.1 The section and the site

4.1.1 The accident occurred at km. 74/10-12 on the Down line between Arakkonam West Cabin and Chitteri station in 25 kv AC Electrified double line in Tiruvallur-Arakkonam-Katpadi section. The site of accident falls in Vellore civil district in State.

The nature of country around the site is plain. The kind of soil is moorum. The direction of the track at the site is from east to west. The line is on a 0.3 degree right hand curve at the accident site. The height of bank at the location of collision is 3.5 m. It is located on a 1 in 889 rising gradient towards Katpadi.

4.1.2 Track consists of 60 kg. rails. The sleepers are 60 kg. PSC laid to M+8 density.

4.1.3 The line is provided with Automatic Block System provided with continuous DC track circuiting with four aspect multiple aspect colour light signalling. Arakkonam West Cabin and Chitteri are special class stations interlocked to Std. IIR. Stations have centralized operation of non-route

Page 9 of 13 setting type panels. Stations are provided with Data Loggers networked to the Control Office.

4.2 Headquarters and jurisdictions

The Divisional Railway Manager, Chennai, is the head of the Division. All the branch Officers are also headquartered at Chennai. The Control Office is also situated at Chennai. Maintenance of rolling stock i.e. MEMUs is being done by SSE/EMU at Avadi. Signals are under the supervision of SSE/Arakkonam. Signal maintainer posted at Chitteri looks after maintenance of signals between Arakkonam West Cabin and Chitteri. JE/Sholingur and SSE/P.Way/Walajah Road are incharge of permanent way.

4.3 System of working

The system of working in Arakkonam-Chitteri line is Automatic Signalling by continuous track circuiting.

4.4 Sectional speed, Permanent/Temporary speed restrictions

Maximum permissible speed for MEMU trains from Chennai central station to Jolarpettai station is 100 kmph except for the portion of line between Arakkonam and Chitteri where it is 75 kmph on down line.

4.5 Kilometrages of stations/locations referred to in the report

Kilometrages are reckoned from Chennai Central station. Kilometers of stations mentioned in the report are as follows:

Station Code Km. Chennai Central MAS … 00.00 Tiruvallur TRL … 41.65 Arakkonam AJJ … 68.48 Arakkonam West Cabin AJJ W/C … 71.00 Chitteri CTRE … 76.31 Walajah Road WJR … 104.74 Katpadi Jn. KPD … 129.37

V – SALIENT FEATURES

5.1 Arakkonam-Arakkonam West Cabin-Chitteri line is provided with Automatic Block Signals. There are 5 signals between Arakkonam West Cabin and Chitteri on the Down Line:

Page 10 of 13 Km. 71.000 - Centre line of Arakkonam West Cabin station Km. 72.159 - Starter signal No. 5 - Arakkonam West Cabin Km. 72.555 - Signal no. 7A (semi-automatic dispatch signal of Arakkonam West Cabin Km. 73.549 - Signal no. 734G (semi-automatic gate signal)

Km. 73/27-29 - LC no. 34 manned Km. 74.550 - Signal no. 744G (semi-automatic gate signal) Km. 75/14-16 - LC no. 35 manned Km. 75.556 - Home signal 1A of Chitteri station (semi-automatic signal) Km. 76.31 - Centre line of Chitteri station.

5.2 Data logger record at stations indicates log of activities of home signal and related track circuits. No data logger is provided for Automatic gate signal nos. 734G and 744G and the corresponding track circuits.

5.3 Rearmost point of drop was found to be located at Km.74.319. There was no point of mount. Front end of motor coach 13007 of the colliding train was at Km 74.463.

5.4 Speedometer recording in driving coach of the colliding train stopped at 90 kmph and that in trailing motor coach stopped at 63 kmph. Maximum speed achieved by this train in the block section was 97 kmph. Speeds recorded in the trailing motor coach every second in last 5 seconds of recording were 90 kmph, 87 kmph, 85 kmph, 76 kmph and 63 kmph.

5.5 The collided train had stopped at automatic gate signal no. 744G since it was at danger (red). The train started when signal turned yellow. The maximum speed of 31 kmph was recorded thereafter. Speeds recorded every second in last 7 seconds before stopping were 31 kmph, 27 kmph, 23 kmph, 18 kmph, 13 kmph , 8 kmph and 6 kmph.

5.6 Collision occurred between semi automatic gate signal nos 734G and 744G. Signal nos 734G and 744G were in ‘ON’ aspect after collision.

Page 11 of 13 5.7 Track circuits of signals 734(G) and 744(G) were tested jointly on 23.9.2011 by a team of supervisors. Signals have been found to be in working order as per signal sequence.

5.8 Weather was clear and the visibility was good.

VI – PROVISIONAL FINDINGS

6.1 After careful consideration of the factual, material and circumstantial evidence available with me, I have come to the conclusion that the “Collision of 66017 Chennai Beach – Vellore Cantonment MEMU train with rear-end of 56007 Arakkonam-Katpadi Passenger train between Arakkonam West Cabin and Chitteri stations at Km. 74/10-12 on the Down Line of Arakkonam-Katpadi Electrified Double Line BG section in Chennai Division of Southern Railway at about 21:23 hrs on 13.09.2011” was caused due to 66017 Chennai Beach – Vellore MEMU train passing semi-automatic gate signal no. 734G at ‘danger’ without stopping and then proceeding at more than prescribed speed.

6.2 The accident is classified under the category “FAILURE OF RAILWAY STAFF”.

VII – IMMEDIATE RECOMMENDATIONS

7.1 Following are my immediate recommendations:

7.1.1 Railway should conduct special drives and ambush checks to ensure that drivers follow prescribed rules while passing automatic signals at danger.

7.1.2 Data loggers should be provided for all automatic block signalling sections.

7.1.3 Clock of speed recorders of locomotives and driving motor coaches should be periodically synchronised with standard time.

7.1.4 Speed recorders of the trains should be checked regularly by shed incharges to detect violation of rules for passing of automatic signals at ‘danger’ and also that maximum permissible speed of sections are not exceeded. Violators should be disciplined. Yours faithfully,

Bangalore (SATISH KUMAR MITTAL) Date: September 27, 2011 Commissioner of Railway Safety, Southern Circle, Bangalore

Page 12 of 13 Encl: Annexure-I Copy forwarded for information and necessary action please to:

1) Secretary (Safety), Railway Board, New Delhi 2) General Manager, Southern Railway, Chennai.

(SATISH KUMAR MITTAL) Commissioner of Railway Safety, Encl: Annexure-I Southern Circle, Bangalore

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