Brief of TASK FORCE report.

                               GOVERNMENT OF INDIA MINISTRY OF RAILWAYS

                                    REPORT OF TASK FORCE ON SAFETY

Ministry of Railways (Railway Board) on 06.12.2016 constituted a Task Force to suggest system and process to improve the safety performance of Indian Railways with the following officers:

1. Mr. ArunSaxena, General Manager/NC Railway,Chairman

2. Mr. Shubranshu , CSO/Central Railway Member

3. Mr. Satishkumar AGM/Eastern Railway Member

4. Mr. Anantharaman, COM /Southern Railway Member

5. Mr. John Thomas, CEE/South Central Railway. Member

The terms of reference was

1) To conduct data analysis, analysis of sample of previous investigation reports, field interviews etc to develop a factual view on potential solutions

2) To identify 4-5 big actionable interventions across each area to improve safety performance i.e. Rolling stock, Track, OHE, Points and crossings , Organizational interventions etc

3) For each of the intervention, to develop an implementation plan, clearly laying out who needs to do what by when.

They submitted their report containing 77 pages altogether on 10.01.2017.Extract from the report pertaining to Loco Running Staff issues are appended herewith for a detailed study. Many of the recommendations of the Task force are in favour of our demands and representation. Whereas there are recommendations in the contrary. So we have to study the report in depth and raise our voice to get all the positive recommendations implemented and to fail the adverse ones.

1.Accidents – Broad Statistics:

While it is true that train accidents have come down in absolute numbers, Indian Railways,as a public carrier, must ensure safety of very high standards. While accidents cannot possibly be brought down to nil, deaths and injuries should certainly be considered unacceptable, whether in a running train, on LC Gates or at the work-place. Some of thekey derivatives from the accident statistics are as follows:

1.1. Even though there has been a significant reduction in train accidents over the last 10-15years, recent years see a plateuring of figures at around 100-120 Consequential Accidents.(Annexure – 1)

1.2. Incidences of derailments constitute over two-thirds of all accidents followed byUnmanned Level Crossing Gate Accidents.

1.3. Failure of Railway Staff is the biggest cause (50-60%) of all accidents.

1.4. Derailments cause maximum deaths and injuries (357 in 2016-17, 136 in 2015-16, 369 in2014-15) (Annexure – 2)

1.5. Asset Failures (Track defects such as Rail Fracture, inadequate maintenance, trackgeometry etc.) remain the single largest contributor as a cause of accidents. This isfollowed by failure of Mechanical Assets. (Annexure – 3)

This report addresses the underlying causes and proposed solutions, both organizational and technical.

4. A Completely ICF-Design-Free Regime:

4.1. In order to completely eliminate ICF coaches, a design older than seventy five years, itis necessary to take a holistic view of passenger vehicles. Self propelled vehicles should be used more and more for short distance services. These trains have higher seating capacity, benefit from better acceleration, do not need engine reversal and therefore de congest platforms and yards enhancing safety all around. They also have the advantage of having EP Brakes, which ensures uniform braking, shorter braking distance and time, thereby improving average speeds.

4.2. Even the LHB is a four-decade old design and cannot be relied upon for serving ourlong term needs, which must increasingly be served by train-sets or self propelled stock.

4.3. Recommendations:

4.3.1. All short distance trains, up to 500km, should switch to self-propelled stock.

[Railway Board to issue policy: six months, Implementation: ten+ years]

4.3.2. The existing capacity of ICF or RCF may not be able to provide enough self-propelled stock and certainly not of a contemporary design. Hence, it is necessary that a fresh look at the product-mix of the proposed Kanchrapara Factory be given quickly. This may be aimed at relieving ICF, RCF and MCF to manufacture only or largely LHB. KPA should be exclusively a high-speed/semi-high-speed self-propelled coach manufacturer. [Mechanical Coaching Directorate: three months]

7. Wagon Design:

7.1.4. Goods Guard Vans must be made user-friendly with lights, fan and comfortable furniture. A rechargeable battery of adequate capacity too should be provided to cover prolonged halts. This battery may also power the EOTT Device. This shouldbe completed within one POH Cycle, i.e. four years. (CSP 7.22) [Mechanical Freight Directorate: four years]

7.1.5. IR must eventually plan to do away with guards completely. [An action plan to be prepared by the Traffic Transportation Directorate: six months]

9. Ancillarisation of Workshops:

9.6. Recommendations:

9.6.1. Each Department (Directorate in The Railway Board) that controls Workshops

(Mechanical, Electrical, S&T and Engineering) will identify non-core activities that should be outsourced on a long-term basis. (Kh I 2.17 and K 2.11.5)[Mechanical Workshop Directorate to coordinate: three months]

9.6.2. A separate schedule of powers for outsourcing and terms and conditions for such long term contracts will be prepared for uniformity. CWMs will be fully empowered to enter into such contracts. [Mechanical Workshop Directorate to coordinate: three months]

9.6.3. Similar delegation of powers should also be done for SrDMEs and SrDEEsin-charge of Train Maintenance, Coaching Depots, Car Sheds, DEMU Sheds andLoco Sheds. [Concerned Board Directorates: three months]

10. Locomotives:

10.1. Locomotives require best maintenance attention compared to other rolling stock since they are smaller in number and are homed in a shed, headed by a senior officer. Yet,safety issues spanning diesel and electric traction need to be addressed in a holistic fashion. Uniform design of loco cabs has been attempted for years. This idea needs to be revisited and uniformity of loco cabs, separately across Diesel and Electric Locomotives should be studied afresh. Electric Locos may require further division between conventional locos and 3-phase ones.

10.2. It is important that location of various safety devices used by the loco pilot – like the A9,SA9, Speedometer, VCD reset button, Assistant’s Emergency Braking Switch, Hand Brake Operating Device, Various Cutout Cocks are at identical locations in one type oflocomotives.

10.3. Recommendations:

10.3.1. Loco and Motor Cabs should be equipped with Audio-Visual Recorders like the cockpit. LPs and ALPs should be provided with noise-cancellation head phones for communicating with each other. [Electrical RS and Mechanical Traction Directorates: two years]

10.3.2. If the VCD of a loco fails, the loco should be declared dead after clearing the block section. [Electrical RS and Mechanical Traction Directorates: one month]

10.3.3. All loco cabs should be air-conditioned. New locos should be turned out with

Air-conditioning and old ones should be retrofitted within one POH Cycle.(Tripathi 9.75) [Electrical RS and Mechanical Traction Directorates: four years]

10.3.4. An ergonomic design for the seats of Loco Crew and of Motormen should be developed with international standards and installed within next one year.[Electrical RS and Mechanical Traction Directorates: one year]

10.3.5. Crew Friendly Cab has been an on-going exercise. All locos that have not been provided with crew-friendly cabs should be modified within next five years. (CSP4.3 and 7.19) [Electrical RS and Mechanical Traction Directorates: five years]

10.3.6. A final view on uniform design of loco cabs must be taken within three months and policy directives issued. All cabs should be converted into the standardized ones within the next POH cycle. (K 6.4) [Electrical RS and Mechanical Traction Directorates: five years]

22. Automatic Train Protection (CSP 4.6):

22.1. The issue is important enough to be discussed separately from the para on Signaling. No modern train system in the world operates without an ATP System in place. (Kh I 2.12, K3.5.1 and K Suppl. 3.2)

22.2. In spite of frequent SPADs in Europe there have been no casualties. (K Suppl. 3.2)22.3. Each country has developed its own version of ATP and most of these meet the ETCS-Ilevel stipulations. (K Suppl. 3.2)

22.4. Recommendations:

22.4.1. IR should now lay down a roadmap for introduction of ATP on its network. This should be done within next six months. [Signal Directorate: six months]

22.4.2. An India specific ATP system, matching at least ETCS L-1 standards should be developed. The endeavor should be to ensure significant indigenization of the hardware and software and full indigenous support. This should be finalized within a year. [Signal Directorate: one year]

22.4.3. TCAS should be developed as a sub-set of the ATP. Necessary upgrades and changes in the TCAS system should be done to ensure this simultaneously.[Signal Directorate: one year]

22.4.4. Assured Funding should be provided for the ATP System so that ATP on all A&B Routes can be provided by March 2022. [Finance Directorate: four years]

23. Communication Backbone (K 4.4.4 and CSP 5.17):

23.1. Wireless is the way forward. With increasing number of devices, portable radios, othercommunications systems, on-board equipment and Trackside installations, DistributePower (Locotrol), EOTT etc. it is unavoidable that IR sets up a secure, irrepudiable andrecordable communication system as the step towards “Internet of Trains”. It is also thesine qua non for a robust Automatic Train Protection System (ATP).

23.2. A Mobile Train Communication System based on Radio and GSM-R is the need of anymodern railway system. This provides for communication so secure that even trainpassing, gate operations, operation of blocks etc. can be based on it through suitablechanges in GR and Operating Rules.

23.3. Recommendations:

23.3.1. A clear roadmap for Communication Backbone including Mobile Train Radio

Communication should be drawn within next six months. (K 8.6) [Telecom directorate: six months]

23.3.2. Mobile Train Radio Communication should be installed on Routes A and C within next three years. B and D Routes should be covered in another three years thereafter. (Kh I 2.11.1 and Kh II 3.2.2) [Telecom directorate: three and six years]

23.3.3. A detailed plan for Communication Based Train Control (CBTC) in Suburban

sections should be created within next one year and implemented in five years.(K 8.5) [Telecom Directorate: one year]

23.3.4. A pan-India license for radio frequency (spectrum) should be taken centrally by the Railway Ministry to enable communication between wireless devices. This should be done within next six months. [Telecom Directorate: six months]

24. Signal Passing At Danger (SPAD):

24.1. SPAD is a worldwide phenomenon and a lot of research is being done to control, if not eliminate it altogether.

24.2. Analysis of SPAD (Annexure – 10) indicates that majority of incidences happen after“home rest” (HQ Rest) or full rest or leave. This is counter intuitive, but points us towardsa need for not only counseling, but also to a scientific approach to the problem. This isdue to the fact that quality rest is missing during such long home-station rest as the locopilot is preoccupied with attending to personal and family matters.

24.3. SPAD by departmentally promoted crew is much higher as compared to directlyrecruited crew through RRB and stands at 9.91 and 3.85 per thousand crew in eachcategory respectively. (Annexure – 11)

24.4. SPAD is directly related to fatigue.

24.5. Enquiries into SPAD are perfunctory and only indicate who was guilty, not why ithappened. (Kh II 5.5.4)

24.6. Recommendations.

24.6.1. SPAD should be classified accordingly to the distance of overshooting. Cases of SPAD should be dealt differently upon whether the LP, after committing SPAD,has stopped within the signal overlap or crossed the overlap. This should also decide the penalty imposed on the erring crew. In ATP/AWS Territory this differentiation will not, however, apply. (Kh II 5.5.4) [Safety Directorate: three months]

24.6.2. All new Loco Crew should be recruited with minimum qualification of Diploma.Even departmental candidates should fulfill this criterion. (K 6.3)

24.6.3. All Running Rooms should be air-conditioned and made noise-proof regardless of their geographical location.

24.6.4. There should be a separate Plan Head for Running Rooms, Lobbies and Crew Rest Rooms. (Tripathi 7.5.3)

24.6.5. Loco Pilots coming to duty after availing a periodic rest or after a leave should be made to take a mandatory rest of 6 hours in the running room before being booked for a train.

24.6.6. Loco Crew should be called to duty not before 08:00 hrs. after availing leave till the previous day. (K 6.6)

24.6.7. Breathalyzers and Bio-Metric Identification should be integrated into the CMS across all Lobbies within six months.

24.6.8. Loco Inspectors and Officers on footplate should be provided with portable breathalyzers to test the crew on the run. (Kh II 3.10.3)

24.6.9. Loco crew should be mandatorily provided with accommodation in their Headquarters and required to stay in them.

24.6.10. A study should be commissioned with expert outside help within next threemonths on Alertness Management and Fatigue Mitigation. IIT-Kharagpur has done work on fatigue in Airlines Pilots. They must be consulted. (Kh II 5.4)[Mechanical Traction Directorate: six months]

24.6.11. There is a need to revise and update the Psychological Tests for running crew.Vienna Test System, an acclaimed testing methodology may be consulted for this purpose. [RDSO: six months]

24.6.12. There is a need to lay down that maximum speed for crossing a signal at cautionshould not be more than a maximum specified. Provision for speed control already exists in GR 3.07, but no limit has been set by any Railway. This is also in line with maximum speeds prescribed after passing a signal at caution in AWS territory. [Safety Directorate: Three months]

24.6.13. Cell phone jammers should be installed in Loco Cabs to prevent use of Mobile Phones by Loco Crew, a known cause of SPAD and collisions. [Electrical and Mechanical Directorates dealing with Locos and Self Propelled Stock: six months]

24.6.14. LPs/ALPs found guilty of SPAD should never be put back on running duty, iftaken back after removal. Establishment Rules need to be changed to enable their posting in other categories. [Establishment Directorate: three months]

24.6.15. The ALP should be tested and certified for application of Assistant’s Emergency Brake operation on the driving simulator by the trainer by simulating a condition where the LP doesn’t react to an unsafe situation. [Zonal Railways: Immediate]

24.6.16. There is not direct supervision of ALPs as available for LPs and LP Shunting.There needs to be an LI for every 50 ALPs for better monitoring and mentoring.[Establishment Directorate to issue yardstick: three months]

24.6.17. During categorization of LPs as A, B or C, the present system of 1 or 0 mark for each of the hundred attribute results in most of the LPs getting categorized as A.This needs to be reviewed and better system designed. [Mechanical Traction Directorate: six months]

24.7. Supervision of Loco Crew: Loco crew are counseled and monitored largely by Loco Inspectors and occasionally by the CPRC/CTLC/CCC. There is a need to ensure that experienced and competent staff is selected to these posts.

24.8. Recommendations:

24.8.1. Loco Inspectors must not only be experienced, but also drawn from senior levels ofthe cadre. We must revert to the pre-2009 norms for selection of Loco Inspectors.All Loco Inspectors must be experienced Mail/Express Drivers. [Mechanical Traction Directorate: three months]

24.8.2. CCC/CPRC/CTLC should be drawn from the cadre of LIs. This will ensure correct counseling and monitoring of crew and meaningful interaction with the respective Branch Officers. [Mechanical Traction Directorate: three months]

25. Train Operations:

25.1. Several devices have been under deliberations for years. Enough trials have beenconducted successfully. There is a need to induct them on full scale.

25.2. End of Train Telemetry of EOTT: This enables guard less operations of trains as it checks for air pressure continuity and train integrity. If provided with features of brake application, it will also apply brake from the rear end of the train, thus improving braking performance.

EOTT also enables elimination of the Guard Van or the Brake Van, which are prone to derailments. It also enables addition of an extra wagon in place of the Brake Van, thus increasing revenue. Even if we do not eliminate the Guard and the Brake Van, the EOTT, by itself, provides additional safety.

25.3. Recommendations:

25.3.1. EOTT trails should be concluded and policy issued to begin installing the EOTT device in Freight Trains. [Mechanical Development Directorate to conclude trail:six months, Traffic Transportation Directorate to issue policy: one year]

25.4. Distributed Power (DP) or Locotrol: DP is required not only for long haul trains, but is immensely useful for a normal length (59-60 wagons) freight trains. (CSP 4.4)

25.4.1. Wherever double heading or a “multi” is required, Locotrol can be fruitfully

deployed. It enables elimination of the Brake Van, thus permitting an additional wagon. It eliminates possibilities of derailments of Brake Vans. Locotrol also allows brake application from both ends of the freight train, thus improving braking performance and safety.

25.4.2. Locotrol eliminates need for shunting for engine and Brake Van reversal, reduces coupler forces, prevents wheel-burns and train-parting thus making operations simpler and safer. (K 4.10.3)

25.4.3. Locotrol saves about 8-10% of energy as well.

25.5. Recommendations:

25.5.1. Distributed Power Systems should be installed on Locomotives, where the samehas been adequately proven. [Electrical RS and Mechanical Traction Directoratesto install first five hundred DPs each in electrical and Diesel Locos: two years]

25.5.2. Inter operability between various makes of DP should be ensured by creating anIR Standard for the same. [RDSO: three months]

25.6. Retro reflective Boards: All Boards meant for guidance of loco crew, such as SpeedRestriction and Termination Boards, Signal Sighting Boards, km Stones, Boards on OHEMasts, Boards on Signal Posts etc. should be retro reflective. This should be done within ayear. [Zonal Railways: one year]

35.5. Recommendations for Training and Certification of Loco Crew:

35.5.1. Each LP and LP must undergo a refresher course of one week every two years,which should include GR&SR, Safety Rules and instructions and a SimulatorTest. A three-yearly refresher course is inadequate. (Kh II 5.3.1)

35.5.2. The current practice of issue of Competency Certificate to loco crew by the Branch Officer needs to be backed by actual foot-plate test by a Loco Inspector specifically nominated for this purpose.

35.5.3. Each loco pilot training centre, at least one in each Zonal Railway, should be

equipped with a full scale in-motion driving simulator for each generation ofLocomotive, EMU/MEMU/DEMU. [Training and MPP Directorate to issue policy: three months]

35.5.4. These simulators are to be used for testing and certification. If a loco pilot fails the simulator test, he/she should be treated as having failed in the training program and made to repeat the entire training again. [Training and MPP Directorate to issue policy: three months]

35.5.5. Each major crew booking, at least one in each Division, should be equipped

with a table-top driving simulator. These are low cost machines, but are capable of giving a loco pilot a quick refresher in areas he needs. A countrywide Rail net based network and a central database of running crew should be prepared. Thiswill have specific training needs of each loco pilot, as noted by the LI orOfficers-in-Charge. Each loco pilot, once in a month, upon signing off, will be required to undergo a 1-2 hour long simulator training session specifically determined for him. (K 6.7 and CSP 7.16) [Training and MPP Directorate to issue policy: three months]

35.5.6. Simulators should also be procured for EMU/MEMU and DEMU motormen. (CSP 7.16) [Training and MPP Directorate to issue policy: three months]

35.5.7. There should be a system which ensures that errors in the field are communicated to Training Institutes to create a case-study based learning technique. [Safety Directorate: three months]

41. FOG Operations

41.1. Fog, during winter, not only disrupts train operations, many accidents have happeneddue to poor visibility in fog.

41.2. There is no known technology, not even for air-operations, that enable vision in fog.Only assistive technologies exist, which combine various cameras to project an imageof the road ahead.

41.3. Recommendations:

41.3.1. Modified Automatic Signalling, as already adopted, must continue.

41.3.2. Fogpass has undergone several refinements. It must be made SIL 4 compliant,its locational accuracy enhanced and then inducted in adequate numbers to provide assistance to crew during fog. To be done within next one year. [Mechanical Traction Directorate: six months]

41.3.3. Trials with Composite Camera based technologies, which use optical, radio andinfrared wavelengths to create a workable image of the path ahead, should be started in right earnest. [Mechanical Traction Directorate: six months]

41.3.4. If found successful these Fog vision Cameras should be installed in locomotivesand Motor Cabs in Fog Prone areas. [Electrical RS and Mechanical Traction Directorate: six months]

41.3.5. As an interim measure retro-reflective Zigma Boards should be provided on all masts for five masts in rear of stop signals in electrified territory to indicate to the loco pilot about an approaching stop signal. Similar arrangements should be done for non-electrified territory. [Zonal Railways: six months]

42. 42. Accident Reporting and Enquiry

42.1. The ground reality is that Accident Enquiries, in most/many cases, do not reveal the realcause of accident, not even the proximate cause, such as whether it was a track defect ora Rolling Stock defect. Enquiries often get mired in departmental fights and end upeither being compromised or delivering a finding, which is incorrect.

42.2. There is an immediate need to organise Accident Enquiries on the lines of that done by the National Transportation Safety Board (NTSB) of USA. At least the CRS levelenquiries should adopt this methodology. (Kh II 5.6.1)

42.3. Departmentalism is the root cause that prevents honest accident enquiries.

Departmentalism starts from the daily chore of logging and de-logging of punctualitylosses. Copious documents are written and acrimony generated that hits the generalharmony in the Divisional working.

42.4. “A new management ethos should be evolved which will encourage and aid honestyeven in admission of failure”. (Kh I 2.15.9)

42.5. Recommendations:

42.5.1. An honest and transparent system of capture of accident and safety related datashould be put in place with a so that no comparison with past statistics would bemade as two sets would be incompatible. Reporting of unsafe acts andaccidents, howsoever minor should be encouraged. (Kh I 2.15.8) [Safetydirectorate: immediate]

42.5.2. Equipment failure, as reported first in the Control Office Application by the

Controllers, should be taken as sacrosanct. Any subsequent intervention islikely to vitiate the truth. (Kh I 2.15) [Safety directorate to issue policy: one month]

42.5.3. All train timings should be captured through data loggers into the Control Office

Application. This may require integrating the Control Office Application withSIMS or any SIMS-like platform created for this purpose. [Signal and C&ISDirectorates: six months]

42.5.4. Loss of punctuality should cease to be a Key Performance Metric for annual evaluation of a Branch Officer. Number of failures should, instead, be thePerformance Metric. [Efficiency and Research directorate: three months]

42.5.5. An IT based system to compile and analyse the equipment failures thus capturedneeds to be built to generate an MIS and action plans for corrective action.[Safety Directorate: six months]

42.5.6. Standard proforma for measurements of track and rolling stock has been

finalised by RDSO and is awaiting issue. This should be included in theAccident Manual. [Safety Directorate: three months]

42.5.7. Accident Enquiries should go beyond the immediate cause and establishwhether there has been a systemic neglect of maintenance, lack of materialinputs, poor quality material, lack of training, lapses in supervisory and officer-level monitoring etc. There needs to create a standard performa for accident enquiries to ensure this. [Safety directorate: three months]

42.5.8. Emphasis in every enquiry should be on “what went wrong” rather than “who went wrong”. A policy directive needs to be issued in this matter. [Safety directorate: three months]

42.5.9. A system for “Error Counting” rather than counting of actual incidents or

accidents should be established as per the Heinrich Ratio Principle. This is a scientific principle that can prevent actual accidents. [Safety directorate: three months]

44. Safety Cadre Vacancies, Yardsticks and Staff Surrender:

44.1. Safety Category Cadres have a vacancy of 16.44% on a sanctioned strength of 7.47lakhs, i.e. a shortfall of 1.23 lakhs. The worst affected cadres are those of Guards(27.45%), SSE/SE/JE Pway (20.08%), Keyman (40.01%), Trackmen (21%),SSE/SE/JE C&W (20.72%) and Drivers (24.24%) [Annexure – 15]

44.2. Yardsticks for various jobs must continuously be tightened in view of emergingtechnologies and their adoption. [Various Directorates: six months]

44.3. Sanction of Staff Essential for Safety, such as C&W Maintenance, Loco Sheds, Signal,TRD, Track and Station Staff, should be done on the lines of that prescribed for LocoCrew, i.e. without matching surrender and purely on the basis of additional workload.

44.4. Surrender of staff is a contentious matter even though it is a desired objective of IR is tolean out its work force. Surrenders are done under coercion and often complied as a matter of “quota”. There is an immediate drop in level of maintenance due to depletion of manpower levels unless there is a matching induction of technology or labour saving devices. It is expected that executive will be more willing to surrender staff if this scheme is implemented, at the same time bringing in technology to improve safety and performance.

44.5. Recommendations:

44.5.1. In order to incentivize Staff Surrender the Department or the Officer surrendering such staff should be given two years’ saving on the surrendered staff’s salaries and allowances to acquire labour saving devices, bring inautomation, material handling implements, inspection tools, IT equipment etc.to compensate for the loss of manpower. This money will, of course, not bespent in one year and will most likely be spread out over 2-4 years.

44.5.2. RRBs must speed up their process if tightening of yardsticks is to be acceptable. Vacancies yardsticks need to be quickly filled up. The time cycle for recruitment through RRBs and RRCs should be cut down to six months, i.e.from the date the indent reaches an RRB the panel should be ready within six months. (K 2.11.4 and 5.1)

44.5.3. RRBs should make a standby panel of 100% of indented numbers in each selection so that coverage for non-joining and attrition can be made withoutwaiting for the next selection cycle.

44.5.4. A comprehensive Outsourcing Policy for non-core activities need to be issued so that surrender of staff does not result in degradation of performance in safety and non-safety areas. This should be done within next six months. (K 2.11.5 and5.5)

44.5.5. The stipulation of matching surrender for new assets, new services and new

facilities should be withdrawn. New assets, services and facilities requireadditional manpower. [Finance Directorate: three months]

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