Writing about railway safety in the immediate aftermath of a major accident is a particularly unpleasant and challenging task for someone who has been part of the system for almost four decades. The derailment of the Patna-bound Indore-Rajendra Nagar Express between Pukhrayan and Malasa stations near Kanpur in the early hours of Sunday – leading to the death of over 146 passengers and injuries to more than 200 people – is surely one of the worst railway accidents in recent times. There can never be adequate compensation for the families of those who have lost their dear ones and those grievously injured. It is but natural that emotions are currently running high and there is palpable anger directed towards a system (and those who run it) that apparently seems to have learnt no lessons from repeated accidents in the past. One needs to understand and respect those sentiments. Yet, managing safety in a huge transport organisation like Indian Railways cannot be based on emotions. At times like this, there is need for calm thinking and objective analysis rather than knee-jerk reactions and dramatic gestures. Above all, there is a need to avoid a feeling of deja vu and letting things settle down to business as usual.
Every accident need not necessarily become a disaster. In this case, while the proximate cause is the derailment (due to cause yet to be finally established), the crushing/telescoping of the derailed coaches, leading to the large number of casualties, is a peculiar feature of this accident despite the fact that the derailment occurred on a flat section with no curve, bridge or embankment. In the past, there have been derailments involving several coaches that had capsized and yet the casualties were few, if any. This is an aspect which no doubt the Commissioner of Railway Safety inquiring into the accident will look into.
An interesting reaction from someone high up in the railway hierarchy immediately after the accident was that “those responsible will not be spared” – or something to that effect. It seemed it had already been concluded that it was a “who” and not a “what” that was responsible for the accident, apparently to soothe public sentiments. This is the natural outcome of a tradition where the majority of accidents (about 70 per cent) are attributed to staff failures. The motto seems to be ‘punish or perish’. Going by the number of staff who have been pulled up for accidents, by now Indian Railways should be one of the safest in the world. Since that is not so, the reasons lie elsewhere.
Accidents in any field are the result of the cumulative failures of procedures and systems over the past involving some “near misses”. At present there is hardly any systematic analysis in the Railways of such unsafe situations. The Railways has a bureaucratic organisational structure where information flow is strictly regulated along ‘departmental’ routes. Further, systems and procedures are used as a means of achieving greater consistency of human action. On the other hand, failures are not isolated events but the result of a combination of causes. Consequently the emphasis should be on reforming the system rather than firefighting. For this, there is a need to enable free flow of information from the lowest to the highest levels about any deviations from the accepted norms or practices so that corrective action can be initiated promptly. In fact, some years ago, British Rail had put in a system of online reporting of deviations from norms having a bearing directly or indirectly on safety. The objective was to get feedback from individuals regarding “near misses” or error-promoting conditions which would normally not be reported through usual channels, and to use this information to enhance safety. The confidentiality of the person making the report was maintained. It is time for Indian Railways to consider adopting similar measures to get honest real-time feedback to take immediate corrective action. With the vast improvements in communications and information technology, this should not be difficult. It needs emphasising that the aim should be to correct, not punish.
After any major train accident, the focus turns to investments in safety or the lack of it. There is very little discussion or analysis of the results of investments made in the past and whether any lessons have been learnt therefrom. For example, following the sanction of a Special Railway Safety Fund in 2001 amounting to Rs.17,000 crore (spread over five-six years) consequent to recommendations of the high-level safety committee under Justice H.R. Khanna, and the implementation of the Corporate Safety Plan in 2003, there was a perceptible reduction in the total number of accidents, particularly derailments, with the accident rate declining from about 0.44/million train kilometres in 2003 to about 0.13/million train kilometres by 2013. There is no analysis as to what went right. Unless such analysis is undertaken periodically, there can be no proper evaluation of the benefits arising out of the investments. Safety investments need to be linked to risk reduction.
There is then the lurking feeling amongst the lay public that nothing much is done after ordering enquiries into major accidents.
The accident enquiry reports are treated as confidential documents. There is no reason why the summary of the findings of major accidents and the follow-up action taken cannot be put in the public domain. The U.S. Department of Transportation regularly uploads its reports on train accidents on its website. A beginning could be made with the enquiries conducted by the Commissioners of Railway Safety, starting with Pukhrayan.
K. Balakesari is former Member Staff, Railway Board.