Joint fact finding inquiry report in connection with Derailment and Lay down of Light Loco no.
604 NDM6 / SGUJ at KM 73/10-11 between Ghoom - DJ at about 14.38 hrs on 04.03.2023
SN Observation Remarks
Light Loco no. 604 NDM6,Long Hood, while returning from Ghoom to
1. Summary DJ, got derailed, capsized and lay down in RHS of track at KM 73/10-11
between Ghoom – DJ at about 14.38 hrs on 04.03.2023.
DRM/KIR has nominated for fact finding Inquiry committee at once of
above incidence. Inquiry Committee comprising of :-
Formation of (i) Sr.DSO/KIR cum Sr. DSTE (convener),
2.
inquiry committee (ii) Sr. DME/DSL/SGUJ,
(iii) Sr.DEN/III/NJP &
(iv) Director DHR
07 nos. Supervisors were called on 06.03.23 and cross examined for the
investigation and fact findings of above derailment.
Name & Designation are as under:-
List of witness
called for Cross (i) Sri Bikash Kumar, LP of Light Loco no. 604 NDM6.
3. examination at (ii) Sri Jitu Jena, ALP of Light Loco no. 604 NDM6.
Diesel Shed / (iii) Sri Bibhash Acharjee, Nominated CLI of LP
SGUJ. (iv) Md. Arshad Mansuri, SSE/P.Way/IC/KGN
(v) Sri Prahlad Chhetri, SSE/P.Way/DJ
(vi) Sri Suman Kumar, SSE/Diesel/SGUJ Maintenance Supervisor of Loco.
(vii) Sri Jay Dev Mandal, BD/ IC/TDH attending the Site.
(i) Light Loco no. 604 NDM6, booked for work from DJ to Ghum. After
completion of work, while said Light Loco was returning from Ghum
Descriptive
to DJ, got derailed, capsized and lay down in RHS of track at KM
4. account of the
73/10-11 between Ghum – DJ resulting infringement of Road Traffic.
accident
(ii) Light Loco no. 604 NDM6 was dispatched from Ghum on Paper Line
Clear Permit (Pvt. no. 30).
Officer Visited the ADRM/NJP, Sr.DME/Dsl./SGUJ, Sr.DSO/KIR, Director/DHR and
5
Site DME/SGUJ.
Officials Visited SSE/Diesel Mech./SGUJ, SSE/P.Way/IC/KGN, SSE/P.Way/DJ Sectional,
6
the Site TI/DHR, SS/DJ, SC/Traffic/KIR, SC/C&W/KIR.
7 Casualty Minor injury in Left Hand of ALP Sri Jitu Jena.
Loss of Railway Nil
8
property
Loco no. 604 derailed at KM 73/10-12 on 04.03.23 between Ghum – DJ at
about 1432 hrs due to sudden jump off the Track due to rolling Down of
Loco. Rolling down occurred due to sudden bursting of Air pipe resulting
9 PF Cause
failure in building up of BP as well as MR pressure.
BY:- ADRM/NJP at Site.
(i) Engineering:- NIL
(ii) Loco :- Nil
Cost of Damage …………………………………………………………………………
10
Total:- Nil
Brake Down /TDH was called at 15.00 hrs, Left from TDH at 15.20 hrs.
Arrived at Site at 18.10 Hrs. Restoration work started at 18.16 hrs.
Restoration work Completed at 23.20 hrs.
11 Restoration Work Re-railed Loco no. 604 moved from site to Ghum with Loco no. 600
NDM6 at 23.50 hrs.
Brake Down /TDH left from Site at 00.05 hrs of 05.03.23 and arrived
TDH Shed at 03.15 hrs.
Considering all the facts and evidences and ongoing cross examination, it
is the fact that:-
(i) Loco was equipped with Air Brake System. Derailment occurred
due to MR Pressure & BP Pressure become “Zero” and braking
system got failed.
(ii) Sri Vikash Kumar, LP of the loco, replied in answer of Q. No.07
that the loco was going from GHUM to DJ in DN gradient in long
hood condition. He was applying the brake continuously to control
the speed within permissible limit. At Km 73/8-9 he heard a sound
of air leakage. He immediately applied the brake (SA-9) and loco
was stopped for about 02 minutes in which he along with ALP
tried to find the source of the leakage. But suddenly, loco started
rolling down and speed started to increase following which the
loco was derailed at km 73/10-11 between GHUM and DJ and
Remarks and capsized. Hence, derailment and capsizing of loco occurred due to
12
reason for findings sudden failure of Air Brake system.
(iii) Sri Jitu Jena, ALP of Light Loco no. 604 NDM6 confirmed the
LP’s statement during interrogation.
(iv) As per speedometer chart, the maximum speed of the loco was 27
KMPH before derailment at 14:38:25 hrs. which shows that the
Speedometer chart is matching with the statement of the Loco
Pilot Sri Vikash Kumar.
(v) As per statement of SSE/P.Way/IC/KGN and SSE/P.Way /DJ all
the parameters of the track are within permissible limit and it can
also be seen from Speedometer Chart that train was running fine
till Loco comes to dead stop before derailment. Also after given
Track Fit by SSE/P.Way/DJ at 23.35 hrs, train operation was very
smooth. Hence derailment due to any abnormality in Track, is
ruled out.
Considering all the facts and evidences and going through the cross
examination, we the undersigned have come to the conclusion that
derailment & capsize of Loco no. 604 NDM6 was occurred at about
13 Findings 14.38 hrs on 04.03.2023 due to Poor Maintenance (bursting of Air
Brake pipe) of the loco causing sudden failure of Air Brake System
resulting increase of speed of the loco up to 27 kmph which was beyond
the Maximum permissible speed of 15 kmph.
14 Mechanism of The ferrule joint of BP connecting pipe to DV got opened and continuously
accident leaking making BP to 0 kg/cm2. Loco came to dead stop due to brake application
due to sudden leakage. But due to the leakage, MR then is sending air so as to try
to keep BP to 5 kg/cm2 thereby exhausting the whole train pressure quickly.
Finally, after full exhaustion, loco rolled down and capsized.
LP/ALP while on hauling in gradient section, consistent braking was done through
SA9 to keep the train within permissible speed limit. When the leakage occurred
which was acknowledged by LP/ALP by the sudden explosive air leaking sound,
they tried to identify the location of leakage for further action. SA9 was in
applied condition. But due to draining of air from the MR, loco started to roll
down.
Had the LP/ALP applied Emergency from A9 handle to avoid MR dropping and
hence draining of MR would not occur as MR3 would not supply air to keep
BP=5kg/cm2 and exhaust itself. The inherent leakage in BC would have been
easily overcome without any problem as Compressor was running satisfactorily
to keep MR pressure.
Primary :-
(i) Sri Suman Kumar, SSE/D/Mech./SGUJ:- for poor maintenance of the
loco during schedule maintenance.
Secondary:- NIL (i)Shri Vikash Kumar, LP :- a. for not trying to secure
the train with the wooden wedges when loco was dead stop in DN gradient
Responsibility section.
15
b. For Not applying Emergency Brake to avoid MR dropping and avoid
roll down
(ii) Shri Jitu Jena, ALP :- a. for not trying to secure the train with the
wooden wedges when loco was dead stop in DN gradient section.
b. For Not applying Emergency Brake to avoid MR dropping and avoid
roll down
(i) LP brought the loco to dead stop condition using SA9 brakes and
then, tried to find the root cause of air leakage but within 2 minutes
both BP and MR pressure reduced to zero and loco started rolling
down as there was down gradient in the section. The situation was
simulated the next day and it was found that the accident could be
averted had the LP/ALP applied the emergency brake A9. As the
loco was already in dead stop condition and LP/ALP couldn’t get
enough time to secure the loco with wooden wedge or to think about
applying emergency brake A9 as emergency brakes are usually
applied during movement/running of loco. So, it is recommended to
issue working instructions in this regard and all LP/ALP should be
Suggestions and
counseled to apply emergency brakes in adverse situations also
16 recommendation
especially while working in higher gradient.
(ii) Manual hand brake should be provided in NDM6 locos.
(iii) All the locomotives should be upgraded with new compressors.
(iv) Pneumatic circuit design to be simplified all air braked locos as in
loco no. 600.
(v) Moisture absorbing filter to be fitted in pneumatic line of NDM6
locos.
(vi) MR 3 pressure gauge to be introduced in cab.
(vii) Measuring kits to measure the Wheel Tyre profile to be procured
for NG locos.
(viii) LPs / ALPs to be counseled about System of Braking in NDM6
Loco.
(Manish Kumar) (Satish Jyoti) (Priyanshu) (Lt. Gaurav Rajpal)
Sr. DME/D/SGUJ Sr. DEN/III/NJP Director/DHR Sr.DSO/KIR
(Convener)
