SOUTH CENTRAL RAILWAY HEADQUARTERS SAFETY ORGANISATION BI-MONTHLY SAFETY BULLETIN – July & August 2017 **** DETAILS OF UNUSUALS AND ACCIDENTS THAT TOOK PLACE DURING JULY & AUGUST 2017

1. Brief of the incident (Yard Derailment): On 9th July 2017 at 09.25 hours, BT Special while movement at Mamanduru station of GTL Division from Ballast to UP Mainline, derailed at facing point at a speed of 8 KMPH infringing UP direction traffic via mainline. Cause: Due to improper setting and clamping of Point. The arrangement of cotter pin and bolt is improper and clamp was found loose as a result the trailing loco taken two routes and resulted in derailment.

Staff held responsible: Primary: a. Guard for not ensuring proper setting and tightness of clamp and violated G&SR which stipulate that all the points for the departure of a train from non- signalled line are set and facing points are properly locked. b. Pointsman for violating the same rules as mentioned for Guard Secondary: NIL Blameworthy: NIL. Matters brought to light:

a. SWR has not been updated / corrected as per the changes in BT Siding and not signed by Sr.DEN/S/GTL. b. TI/SWR failed to go to the concerned station to compare with approved signalling diagram and actual layout before finalising and submitting the SWR for signature. Suggestions & Recommendations:

a. Position of cotter pin hole and bolt for locking in hand operated point should be checked by SSE/P.Way at regular intervals. It should be properly greased and oiled in rainy reason to ensure perfect housing and setting.

b. SWR/MRM has to be updated and redundant clauses to be removed as per the updated yard layout and should be signed by Sr.DEN/S/GTL. 2. Brief of the incident (Yard Derailment): On 10.7.2017 at 18.45 hours, shunt movement was given for BOST’N’ Goods from Road-5 to Road-4 of Krishnapuram station of GTL Division. After passing Shunt Signal by train engine + 5 wagons, the train was stopped by the LP on the alert given by Dy.SS that unusual sound heard in the train formation. After stopping and noticing, it was noticed that one wagon rear truck by one pair of wheels derailed (17th wagon from train engine). Cause: Collapsed coping stones of Goods Shed platform fallen on causing the derailment of wagon. Heavy capacity Cranes and trailers worked close to the train formation for loading 4T electrical cables from Goods Shed platform into trailers. Staff held responsible: Primary: GSR/HX for not taking the undertaking from the Consignee or his authorised representative in regard to movement of Cranes / trailers and failed in exercising safety at unloading / loading area by allowing the party to work closer to the Goods Shed platform edge. Secondary: NIL Blameworthy: SSE/Works/HX failed to conduct joint inspections with SMR, CGSR, SSE/Electrical and RPF Personnel and violated the JPO of 6.8.2014 for safe working at Goods Shed premises issued by PCE & CCM. Matters brought to light: a. Periodical joint inspection not conducted by CGST, SMR, SSE/Works, SSE/Electrical and RPF Personnel since beginning. b. As per RB letter No. 2007/PL/25/1 dated 05.6.2007, Annexure II, Sl. No.3 consignments handling by Cranes are to be dealt only at rail level platforms along Siding whereas at KPU station, it was handled by Cranes on high level platform. c. Undertaking from Consignee not obtained in regard to movement of lorries / cranes. Suggestions & Recommendations: a. Mechanised loading is to be stopped as the high level Goods Shed platform is not permitted for mechanised loading. b. Enforcing mandatory periodical joint inspections among SSE/Works, GSR (Commercial), SSE/Electrical, RPF (Security) as per JPO 1/2014. c. Ensure obtaining undertaking either from the Consignee or his authroised agent in regard to movement of lorries by the GSR and making the consignee responsible for in any untoward incidents. d. Monitoring the loading / unloading activities by authorised railway representative for the safety of the Goods Shed platform while loading / unloading activities. e. It is difficult to conduct GLP check and also releasing of formation of train on Road- 5 as it is berthed in between platforms.

3. Brief of the incident (Yard Derailment): On 11th August 2017, at about 10.15 hours, FRM Machine while moving from Siding KL Point to 1st Loop of Thimmapur station of HYB Division, derailed on Point No.7 since the point was not clamped and padlocked before permitting movement on that point from Siding. Cause: SM failed to follow the correct procedure during unsignalled movement which is taking place from Siding KL Point to 1st loop and altered the Point No.7 without ensuring complete arrival of the FRM Machine on to 1st loop. The Pointsman who is also aware of the movement failed to clamp and padlock before PHS to the FRM Machine Operator. Staff held responsible: Primary: SM on duty Secondary: Pointsman Blameworthy: SSE/TM/BMO Suggestion & Recommendation: a. Shunt Signal may be provided for KL Siding. b. All Operating, Engineering Staff, Track Machine Operators and Loco Running Staff should be sensitized the procedure to be followed during unsignalled movements.

4. Brief of the incident (Yard Derailment): On 24th July 2017 at SC station lower yard of SC Division at 13.00 hours, when shunt movement was in progress, loco along with coach moving from L4 lower yard towards shunting neck on Point No.11 trailed through the point and without noticing this, they backed on the trailed through point which resulted in derailment. Cause: The on duty Shunting Staff failed to ensure the correct setting of points which resulted in trail through of point. Subsequently, by backing on the trailed through point, the derailment occurred. Staff held responsible: Primary: Pointsman Secondary: LP/Shunter, another Pointsman and Dy.SS/Lower Yard/SC. Suggestions and Recommendations: a. Point No.11 being the entry / exit point of non-interlocked SC lower yard, that point should be manned exclusively for ensuring correct setting and locking of the point by the YM. b. Feasibility of of Point No. 11, 12 & 13 with yard Cabin or RRI should be examined since heavy movements takes place over these points daily.

5. Brief of the incident (Yard Derailment): On 23rd July 2017 at about 15.40 hours, AC coupled engines while performing shunting at Kondapalli station of BZA Division for pulling out seven sleeper carrier loads from Line No.3 to Line No.1 towards to clear Point No.105 for attaching it to BV, the LP/Shunter driven the loco from rear cab instead of leading cab and late application of brakes resulted in overshooting of buffer stop (duly damaging) and travelled 30m on track and derailed 6 wheels of front three axles beyond the track portion. Cause: Derailment occurred due to LP/Shunter driving loco from rear cab and not observed the buffer stop and stop board on OHE mast resulted late application of A9 brakes which hit and damaged the buffer stop and derailed after passing 36m beyond the track. Staff held responsible: Primary: LP/Shunter who driven the loco from rear cab instead of leading cab coupled with late application of brakes. Secondary: Driving Inspector who failed to monitor LP/Shunter properly. Suggestions and Recommendations: Clear instructions to be passed for shunting staff to operate loco in leading cab when moving towards dead end.

6. Brief of the incident (Derailment): On 15.7.2017, at about 17.45 hours. While Train No.TNVR/CONCOR Goods while rolling into Singarayakonda station of BZA Division on to loop line, 13th wagon from BV leading trolley derailed on UP Loop line of SKM station and through traffic is not disrupted. Cause: Overall length of turnout between Pont No.19B & 19A (1 in 12) is more than 14m than the designed. Coupled with this, poor maintenance of track at points and crossings in respect of gauge and versines (kinks due to bad versines) resulted in derailment of one wheel set of wagon.. Staff held responsible: Primary: SSE/P.Way who failed to maintain track parameters at points and crossings as per IRPWM.. Matters brought to light:. a. The versine readings are not jointly recorded before restoration work started at the site of accident. b. LC No. 187 is passing through the turnouts which is to be avoided as per the checklist issued by Headquarters for points and crossings. c. As per ESP, change of grade is indicated at the location of turnout which is not permitted as per checklist issued by Headquarters. Suggestions & Recommendations: a. LC Gate is passing through the turnout portion. Possibility of shifting the LC may be explored. b. All loop lines where the speed potential has been increased from 15 to 30 KMPH by converting from 1 in 8 ½ to 1 in 112 turnout may be checked one time by the Engineering Officials for correct alignment. 7. Brief of the incident (SPAD): On 27th July 2017 at about 07.35 hours, LP of 17479 Express (Puri – TPTY) passed UP Starter and UP Advanced Starter Signals of Tarigoppula station of BZA Division at ‘on’ at a speed of 82 KMPH and entered in to the block section and in fact reached next station. Cause: Disregard of signals by both LP & ALP..

Staff held responsible: Primary: LP & ALP for disregarding the aspect of the signals (UP Starter and UP Advanced Starter Signals). Secondary: NIL

Matters brought to light: SM/TGU shouted on VHF set but not heard by the crew of PURI – TPTY Express may be due to defective walkie-talkie sets. Suggestions & Recommendations: a. There is no sand hump at TGU station and it is having the non-standard layout. b. All crew lobbies should ensure the proper working of walkie-talkie sets, its clarity of voice before issuing to crew.

1.0 Irregularities noticed in the working of Operating Department: a. During the safety audit inspection of RDM station in SC Division, it was noticed on 30th August 2017 that when the block instrument is installed at Bye-pass Cabin, why the PLCT books (T/A 1425 and T/D 1425) are issued and kept sometimes with Dy.SS/PF sometimes and sometimes by CASM/B Cabin? b. In the SWR of RDM station, it was noticed on 30th August 2017 that date of issue is 22.8.2012 and brought into force on 19.3.2016 subsequent to the introduction of the third line after 3 years 7 months. BPAC resetting procedure is given for double line block instrument. However, no mention is made about the third line i.e., single line block during BPAC failure under Para 9.0 (vi). Relay Rooms: As per Appendix ‘B’ – The SWR did not specify about the presence of two relay racks behind Dy.SS/PF Mini-Panel. Subsequent to the incident of rear collision at RDM GDK Siding on 21.6.2017, many shortfalls were noticed in the Siding related instructions and accordingly, the Division has issued suitable amendments to SWR. It was noticed that Dy.SS/Goods Cabin and Dy.SS/FCI Siding are exchanging PNs before dispatching a Pilot Goods from RDM to FCI Siding or vice-versa. The PN written in the authority given to the LP was cross checked and observed that it is not the same PN as received from other end. c. During the rear-window inspection by KCG – Egmore Express on 5th July 2017 by CSO, it was noticed at Falaknuma station of HYB Division that Point No.16KL at KM 14/10-12 was found taking ‘off’ from DN Main line to Temporary Ballast siding. It is appropriate for the Division to interlock this point. As per SIP of FM station, a speed board of 15 KMPH is provided on DN Home Signal No.1. Even on the panel of FM station, 15 KMPH board is shown on the DN Home Signal. Physically, it is confirmed with station Authorities that 15 KMPH board is not available on the Home Signal which is in violation of SIP of FM station. As per the Caution Order copy given to the LP of 17652 Egmore Express on the day of rear-window inspection, it was noticed that a permanent SR of 30 KMPH is imposed in “Falaknuma Yard” for the reason that entering from double line to single line. However, there is no Speed Indication board either near the facing point or at the trailing point location. Then, from where this 30 KMPH is to be observed by the LPs? Secondly, the Caution Order do not specify the KM from where to where; instead it is mentioned ‘Falaknuma Yard”, Yard of a station is not defined in any Manual. Hence, it is appropriate to justify the instructions of SIP of the station or modify it with proper procedures.

2.0 Irregularities noticed in the working of Engineering Department: a. During the safety audit inspection of RDM station on 30.8.2017, it was noticed that S&T bond wires are connected to CMS crossing by Exo-thermic weld which is not permitted. On some turn-outs, paint marking for sleeper spacing/numbering is not done. RH SKV weld at ahead of Point No.17B (UP Main line) is done by construction organization during triple line work on 12/2015 but Weld is not tested by USFD and not protected by joggled . Checked alignment with 7.2m chord and 18mm kink is noted. At exit sleeper no.1E & 2E, spacing/ squaring needs to be adjusted. Weld is very close to exit sleeper no.2E against the requirement of suspended weld joint. Sag in long chord at Point No.17A to be attended. Triple line work is completed on 12/2015 by Construction Organization but not handed over to open line till date. 3rd line between MMZ-RGPM (except MCI-PPZ) has been handed over to Open Line on 22.8.2017 stating that the records pertaining to maintenance will be handed over in due course. Regarding this, the total data has been verified by both Open Line and Construction Organisation and some corrections were also suggested by Open Line. However, till now for 3rd line, the sectional data is not entered into TMS for facilitating inspection reports. It is found that the 3rd line SEJ & LWR boards are missing. The works left over by the Construction Department while handing over the 3rd line should be taken up duly taking funds from the Construction Organization. b. During rear-window inspection by KCG – Egmore Express on 05.7.2017 by CSO, it was noticed that at Malakpet station of HYB Division, on UP line, platform extension work was found in progress and one JCB was working. In this connection, SR 30 KMPH and stop if required is imposed but no Railway Official with hand signals was found to alert the moving trains, if necessary. c. During rear-window inspection by KCG – Egmore Express on 5th July 2017, it was noticed by CSO that heavy vegetation is found on DN line before Huppuguda station and no cess is available in HYB Division. d. It was also noticed in the rear-window inspection by CSO on 5th July 2017 between KCG – MBNR stations of HYB Division that doubling work is in progress executed by RVNL under MMTS Phase-II from between FM-UR stations, however, barricading is only by a rope and at many locations it is dismantled (KM 16 to 27). As per Railway Board letter No. 2015/CE-II/TK/14 dated 30.12.2015, “sturdy fencing is required”. Even Para 826 in Chapter VII of IRPWM specify the same. Division to ensure the sturdy barricading before any unusual takes place. e. Also, it was noticed that in KCG-MBNR section of HYB Division, sharp curves are available and visibility is poor to LPs of approaching trains and no whistle boards are provided at 600m ahead of the curve locations as per Para 815(2) of IRPWM. This is essential to ensure the safe trolley working apart from Trackmen working on track.

3.0 Irregularities noticed in the working of S&T Department: a. During safety audit inspection of RDM station of SC Division on 30th August 2017, it was noticed at ‘A’ Cabin that in Route Cancellation Register, entries are made in four parts i.e., two for super emergency (UP & DN) and two for regular cancellation (UP & DN). The concept behind the super emergency is not understood and not legislated in the SWR. In Super Emergency Cancellation counter Nos. from January to July 2017, only on hand number is brought forwarded i.e., 000036 and 000091 before and subsequent to the cancellations., How it is checked when the next incremental number is not changed? Secondly, the feature of super emergency is not seen anywhere written in the SWR or followed by other Divisions. b. It was also noticed at ‘A’ Cabin RDM on 30.8.2017 that one redundant wooden box having veedor counters of various S&T gears is available in the Cabin. These veeder counters are now covered with a paper. However, when the SM key visible on the box was operated, the VDU operation is affected and buzzer started buzzing. It shows that the SM key on the wooden box is not disconnected from the VDU control. It is necessary to delink and remove the arrangement at the earliest. c. At ‘A’ Cabin/RDM as noticed during the safety audit inspection on 30th August 2017, S&T Officials maintenance schedule as per IRSEM is not followed from April 2017 to August 2017. d. At B” Cabin Relay Room of RDM Station in SC Division, it was noticed on 30th August 2017 that smoke detectors are not provided in Relay Room, Battery Room and Data Logger Room. Ventilators are filled with dry grass by birds making it prone for fire hazards. e. At Bye-pass Cabin of RDM in SC Division - S&T Officials inspection / maintenance schedules of various S&T gears such as Crank Handle – 1, 2 and 3, Calling-on Route Cancellation Counter No.11, 12, 13 & 14; UP BPAC (RGPM - RDM), Block Instrument (Double Line) (RDM – RGPM), Block Instrument (Single Line) (RDM – RGPM), DN Advanced Starter Signal (Double Line) Axle Counter Reset Register, DN IBS BPAC, UD line BPAC, Relay Room Key Register, Route Cancellation Register RC – 1, 2, 3, 4, 5, 6, 7 & 8 not followed from April to August 2017. f. During the inspection of GTL Division on 6th July, 2017 it was noticed that on 7th May 2017 at 14.05 hours, PIL – KCI block instrument failed due to ‘premature TOL’ at KCI station. Failure memo was prepared by SM/PIL but not taken / acknowledged by S&T Official and no remark is passed for not accepting. Failure entry is made in the Signal Failure Register. Train passing document PLCT was crosschecked and found correct. However, ESM did not sign and did not pass any remark against the failure entry. JE/Signals/MPL passed a remark that “on arrival of 57546 at PIL, the block restored”. Cause for failure is not analysed. On enquiry with SM/KCI, it is seen that ESM/PIL acknowledged the failure memo given by SM/KCI on the subsequent day i.e., 8th May 2017 at 09.00 hours after a lapse of 19 hours of failure.

4.0 Irregularities noticed in the working of Electrical Department: a. During rear-window inspection by KCG – Egmore Express on 5th July 2017 by CSO , it was noticed that at many locations, between KCG – FM on both UP & DN directions, muffing of OHE masts were found either buried or broken.

5.0 Irregularities noticed in the working of Mechanical Department: a. At RDM station of SC Division, it was noticed during the safety audit inspection on 30th August 2017 that on GL-2, BOBY wagons were stabled and the bottom doors were in ‘open’ condition. It is not desirable to allow the doors in ‘open’ condition which may lead to unsafe condition / derailment in points zone in the course of movements. These wagons are also not secured with skids on either side of the formation which is necessary. b. DEMU rake stabled on Road No.3 (PF-3) of RDM station in SC Division was found in energized condition at both end and cabs were in unmanned condition. It is unsafe to keep it in energized condition in unmanned condition. Doors and windows of vendor portion, passenger portion of Power Car are ‘open’.

ATTENTION …….. LOCO PILOTS / ASISTANT LOCO PILOTS Ensure that you have proper LR of the section as per SR 3.78 which you are booked to work the train.

ATTENTION …….. OPERATING STAFF Do ensure to work the trains as per SWR rigidly

ATTENTION …….. S&T Officials Do ensure to maintain the block instrument maintenance schedule of once in a fortnight by ESM, once in a month by JE/Signals and once in a quarter by SSE/Signals as per IRSEM

ATTENTION …….. Engineering Officials Ensure that S&T bond wires are not connected to CMS crossing (by Exo- thermic) weld.