Case Study
OF
Rear collision of Coromandel Express
With Stabled Goods Train N/DDIP
Subsequent Side Collision with last two coaches of
12864 Express
At Bahanaga Bazar of KGP Division in SER
On 02.06.2023
IRIDM/Bangalore
CONTENTS OF THE PRESENTATION
• Details of the accident.
• Various relief and rescue activities.
• Pictures of the site.
• Cause of the accident explained with the sequence of events.
ACCIDENT LOCATION
• BAHANAGA BAZAR (BNBR) station
is in Kharagpur – Ranital section of
KGP division in SER on Howrah-
Chennai route.
• Section is DOUBLE LINE Electrified.
• Permissible speed 130 kmph.
• BNBR is a 4 line station consisting
of:
• Up loop line
• Up main line
• Down mainline
• Down loop line
• Shunting Neck
12841 Coromandal Exp.
●DAILY SERVICE from Shalimar to Chennai.
●Train leaves Shalimar 15:20 Reaches Chennai at 16:50 on
next day.
●Train formation consist of 23 LHB coaches.(LVPH-1, LSLR-1,
LGS-2, LSCN-5, LWCB-1, LACCN-9, LACCW-2, LFAC-1,
LWLRRM-1)
●BPC No.1256679 SRC Dated: 02.06.2023
●Loco No: 37334/SRC- WAP-7.
12864 SMVB - HWH Exp.
• Daily Service from SMVB-Bangalore to Howrah.
• Leaves SMVT at 10.35hrs and reaches HWH at 19:55 on next
day.
• Formation consists of 22 LHB Coaches LSLR-1, LGS-2, LWCN-
7, LWCB-1, LWACCN-8, LWACCW-2 and LWRRM-1
• BPC No. 1252425 SRC dtd. 30.05.2023
• Loco No. 37070 SRC.
BNBR -Just before the Accident
• One BCN Goods train received on DN loop line and
regulated at BNBR.
• Goods train N/DDIP ( BOX-N loaded with IRON ORE) received
on UP loop line at 18:14 hrs and regulated at BNBR.
• Both distant and home signal, starter and advance starter
cleared for 12841 for pass through.
• Train no 12841 approaching to BNBR at 18:49 hrs.
• Train no 12864 passing through down main line at 18:55 hrs.
BNBR -Just before the Accident
Stationary Goods Train BCN
12864 SMVT – HOWRAH Exp
Stationary Goods Train NDDIP
The Accident
• Train no. 12841 took route to UP loop line even when the signal
is cleared for UP Main line.
• 12841 collided with rear of N/DDIP Goods train at 18:55:52 hrs.
• The last coach of Train no 12864 passed the DN main line
berthing track at 18:55:59.
• After collision some coaches of 12841 derailed towards DN
main line and collided with last two coaches of 12864 at
18:56:01.
• Speed of 12841 exp was 128 kmph at the time of accident.
• Speed of the 12864 was 113 kmph.
Consequence
• Loco of 12841 mounted over the BV of N/DDIP goods train
and landed over the 4th wagon.
• Both trucks of loco worked out and got damaged.
• 15 coaches of 12841 exp got derailed.
• 6 Coaches of 12841 derailed, capsized and crushed…
• BV and 5 BOXN of N/DDIP goods got damaged.
• Last two coaches of 12864 derailed and capsized.
The Aftermath…….
• Death: 294
• Injury: 953
• Traffic Disruption for : 51 hrs
• Rolling stock : 58 crores
Rough Sketch
Visuals of the Accident Site
Consequence
The RESPONSE….
• SPARME/BHC ordered at 19.10 hrs., departed 19.20 hrs., arrived
site at 20.30 hrs., rescue work started 20.50 hrs on 02.06.23.
• SPARME/KGP ordered at 19.02 hrs., departed 19.22 hrs., arrived
site at 22.06 hrs., rescue work started 22.15 hrs on 02.06.23.
• ART/KGP ordered at 19.15 hrs., departed 19.36 hrs., arrived site
at 22.48 hrs., rescue work started 23.00 hrs. on 02.06.23
• ARME/SRC ordered at 20.19 hrs., departed 20.40 hrs., arrived site
at 00.55 hrs., rescue work started 01.00 hrs. on 02.06.23
• SPARME/KUR ordered at 19.45 hrs., departed 20.37 hrs., arrived
site at 01.30 hrs., rescue work started 01.30 hrs. on 03.06.23.
• ARME/TATA departed from TATA at 20:45 hrs and arrived site at
9.15 hrs on 03.06.23 with team of doctors.
RELIEF & RESCUE WORK
• Much help was received from the Army, Navy, AMC, NDRF,
ODRF and State Administration including police and medical
service along with NGOS, Local charities, volunteers and
local public.
• Rescue team of C&W provided all assistance for making
approach for rescue of passengers by NDRF, ODRF and AMC.
• Rescue and relief equipment’s of ART such as abrasive
cutter, Cutter, spreader, rod cutter, plasma cutting, gas
cuttings were used for rescue operation.
RELIEF & RESCUE WORK
• Rescue operation was continued up to 11:30 hrs of
03.06.2023.
• 16 hrs of continuous work.
• A combined work of Railways, NDRF, ODRF Army, Navy,
Armed Medical Corpse, State Administration including Police
and Medical service along with NGOS, Local charities,
volunteers and local public.
RESTORATION WORK..
• On completion of rescue operation and after police clearance,
restoration work started from 11.30 hrs on 03.06.23.
• 1 st capsized coach SE-191496(3rd from rear) of 12841 grounded
by POCLAIN machine at 11.40 hrs on 03.06.2023.
• Total 21 Coaches of Train No. 12841, 5 wagons + one brake van
from Goods Train N/DDIP and one locomotive were grounded
using 6 nos. POCLAIN machine. 2 nos. coaches of 12864 in the
rearmost toppled and grounded due to accident.
• DN Main line was made clear of infringement at 6.04 hrs on
04.06.23 for OHE fitment and track attention. Up Main Line and
UP loop line was made clear of infringement by 8.30 hrs on
04.06.23 for OHE fitment and track attention.
RESTORATION WORK…
• One DA and oxygen loaded lorry sent from KGP workshop to
facilitate restoration operation.
• Lighting Arrangements: For adequate lighting during night
time at site 13 DG sets and 550 Flood lights and other
outdoor lights of different wattage were provided at site.
Towers lights were provided for site illumination.
• Road Crane ordered 125 Tonnes
• 140 T crane of KUR tackled one LVPH coach of 12841.
• 3 nos. of 8W tower cars were used for OHE work.
RESTORATION WORK…
Odisha train accident: NDRF shares spine-chilling videos of rescue
operations in Balasore
FINDINGS
• The rear collision was due to the lapses in the signaling circuit
alteration carried out at North signal goomty in the past, and
during the execution of the signaling work related to replacement
of electric lifting barrier for level crossing gate no. 94 at station.
• These lapses resulted in wrong signaling to the train no. 12841
wherein the up home signal indicated green aspect for run
through movement on the up main line of the station, but the
cross over connecting to the up main line to the up loop line was
set to the up loop line
• The wrong signaling resulted in the train no 12841 traversing on
the up loop line and eventual rear collision with goods train
standing there.
Chronology of Events -On the Day of accident
(02.06.2023)
• S&T Staff were working at North Goomty for ELB
replacement work at LC 94.
• Disconnection taken at 16:20 hrs.
• At 16:20:53 point failure of crossover occurred for 17A/B UP
MAIN LINE. This failed at normal position.
• Reconnection done at 16:50 hrs.
• After reconnection work S&T staff were working at LC 94 for
road users signal.
On the Day of accident
(02.06.2023)
• Point machine at 17A and 17B were totally damaged after
the accident.
• From test room, it is known that indication of the crossover
17A/B was normal even after the accident.
UP Loop Line
17B
17A
UP Main Line
Down Main Line
Down Loop Line
North Signal Goomty
RELAY CONNECTIONS PROVIDED INSIDE GOOMTY
Original Wiring Diagram
From Point M/C 17
For LC For Spare
Cross over (normal)
F13 F14 F21 F22 F23 F24
17NWKR 2GFRR SP
30 Core Cable to Station Central Relay Room
Cable Defect in 2018
From Point M/C 17
Cross over (normal)
F13 F14 F21 F22 F23 F24
17NWKR GFR1 GFR2
Defective cables removed
from 17NWKR
Defective
Cable
17NWK1R Relay
30 Core Cable to Station Central Relay Room
Attention to Cable Defect in 2018
From Point M/C 17
Cross over (normal)
F13 F14 F21 F22 F23 F24 Connection took from
17NWKR and given to F23
and F24.
GFR1 GFR2 Necessary alteration made
17NWKR
in Station Central Relay
Room on the leads coming
from GFR2.
Now GFR2 also working as
17NWKR.
17NWK1R Relay But marking not changed
continued as GFR2.
30 Core Cable to Station Central Relay Room
ELB replacement of LC94 at BNBR on 02.06.2023
• LC 79 of BLS was closed some time ago.
• Planned to Reuse of Pre-wired Location Box of LC 79 of BLS
for ELB replacement of LC94 at BNBR
• Wiring Diagram of LC 79 supplied to BNBR
Actual Wiring scheme with LC79 of BLS
From Point M/C 17
From LC79 From LC79
Cross over (normal)
F13 F14 F21 F22 F23 F24
17NWKR 2GFRR 3GFRR
30 Core Cable to Station Central Relay Room
Boom Replacement of LC 94 on 02.06.2023
From Point M/C 17
Cross over (normal)
From LC 94
F13 F14 F21 F22 F23 F24
• Lead from 17NWKR to
F23 & F24 removed.
17NWKR GFR1 GFR2 • New cable from LC 94
connected to F23 & F24.
• Now supply Continuously
available to 17NWK1R
relay in Relay Room
• It will indicate 17 cross
17NWK1R Relay
over in normal, even if in
30 Core Cable to Station Central Relay Room reverse position.
On the Day of accident
(02.06.2023)
S&T staff on disconnected F 23&24 at
At 16.20:53hrs Unexpectedly Point failure of cross over
North goomty for ELB replacement
17A/B at normal
for LC 94
SM operated crossover AB through individual operation
Reverse circuit is not disturbed
from Normal to Reverse, it took normal time 14 seconds
SM operated crossover AB through individual operation At 16:22:19hrs, S&T staff connected
from Reverse to lead from LC 94 to F 23 & 24. Then
Normal, it took 37 seconds relay picked up
On the Day of accident
(02.06.2023)
Further Crossover 17A/B was set to Reverse from Normal at Reverse circuit is not disturbed, working
18:14:22 for reception of goods train to up loop line without any issue.
One goods train received subsequently Goods train N/DDIP Reverse circuit is not disturbed, working
received with same point setting and controlled at BNBR. without any issue.
Route released at 18:34:52.
Reverse to Normal individual command was initiated at
F 23 & 24 have supply from LC 94 always.
18:34:59 hrs.
Relay for Normal route in Central Relay
And its Normal indication appeared almost at the same
Room always in picked up position.
time
F 23 & 24 have supply from LC 94 always.
Even after 18:34:59hrs Panel of crossover 17A/B shows
Relay for Normal route in Central Relay
Normal, but it was in Reverse state
Room always in picked up position.
On the Day of accident
(02.06.2023)
At 18:36:21hrs 17NWK1R - Relay for Normal route in
S&T staff testing/operation of GFR switch
Central Relay Room Suddenly dropped and again picked up
at LC 94
automatically at 18:36:23 hrs
Route 1A was initiated at 18:52:16. the Home signal Off for Distant, Home, starter and Advance
the train no. 12841 starter signal is off
12841 Passed Home signal with green aspect entered in to
up loop line and collided with the Goods train N/DDIP ACCIDENT OCCURS
which was stabled there.
Responsibility
Lapses at multiple levels in the S&T Department
Issues, Shortfall & Suggestion
By
ACMS/KGP/SERly
SHORTFALLS NOTICED
Placement of ARMEs at unfavorable locations far away from the
accident site hindering smooth operations
Difficulties in data collection and compilation
Outdated and improper camping equipment resulted in lot of
difficulties in setting up and operation of first aid post & relief
booths as the rescue & restoration works lasted for more than two
weeks.
SUGGESTIONS AND FUTURE PLANNING
Enhanced co-ordination at higher levels with state authorities for
total Disaster Management
Restructuring of the ARME
Up gradation of the camping (quadrangular tents) should be
procured instead of the present triangular tents
As road connectivity has improved dramatically road mobile vans
with camping equipments in pattern of NDRF teams should be
thought of and available at stations where ARME scale-I is present.
Provision of ambulance at stations with ARME scale-II for easy and
quick access to accident site, if any. Ambulance can be GPS connected;
few of them should have 5G facility for telemedicine facility, critical care facilities.
SUGGESTIONS AND FUTURE PLANNING
Provision Of Laptops/Tablets With Printer In ARME Scale –I
To Facilitate Data Compilation And Dissemination.
Creation/Enhancement Of Cash Imprest To The Tune Of At
Least Rs.1.00 Lakh To Meet The Essential Expenditure,
Including Basic Food For Care Givers, At The Accident Site.
Deputation Of Able Bodied RPF , Engg, Mech, Med
Personnel To NDRF As In Territorial Army For Capacity
Building With Proper Incentives.
Problems & Suggestions
Sl. Problems Suggestions
No.
1 Duplication of Identification of Patients Fixed Identity tag must be attached to
each injured Passenger e.g . Bal/23/01
2 Details of data of Medical Department not Name, address, aadhar details to be
tallying with that of Ex Gratia Payment considered from Commercial data. Injury
details , nature of injury to be considered
from Medical Data
3 General Tickets to be aadhar linked Identity of Passengers
4 Local Help To facilitate urgent local help, round the
year communication with Local available
State as well as Private Health
Authorities should be maintained by
involving them in CMEs, Health
Programmes etc.
5 Identity of Dead bodies AI based identification process of
disfigured bodies, if technologically
feasible.
Problems & Suggestions
Sl. No Problems Suggestions
6 ARMEs are usually stationed far away from If ARMEs are to be utilized
actual accident site, leading to difficulty in properly,OT should be replaced
transportation of the injured passengers. by dressing room, as operation in
Often injured passengers are shifted from ARME is very rare nowadays..
accident site prior to arrival of ARME.
7 Difficulty in data collection , compilation and Liasoining excercisesat the highest
onward transmission to Rly Bd level and MOUs between Rlys and
state govts to be undertaken.
8 Better Treatment for Injured passengers Ayushman Digital Health Card no.
may be submitted at the time of
Reservation and Ticketing.
Problems of transportation of patients Station building should be
9
designed in such a way that it can
be changed into make shift
hospitals, if feasible.
THANK YOU
Contacts
IRIDM/Bangalore
Director
Indian Railway Institute of
Disaster Management
Bangalore 560074
Email-
[email protected]
[email protected]
