Int. J. Critical Infrastructures, Vol. 16, No.

1, 2020 77

A case study of Elphinstone Road foot-over-bridge

stampede in Mumbai

Sanjeev Kadam*
Symbiosis Centre for Research and Innovation,
Symbiosis International (Deemed University),
Pune, 412115, India
and
Amity Business School,
Amity University Mumbai,
Panvel, 410206, India
Email: sckadam69@yahoo.co.in
Email: sckadam@mum.amity.edu
*Corresponding author

Prabir Kumar Bandyopadhyay

Symbiosis Institute of Business Management,
Symbiosis International (Deemed University),
Pune, 412115, India
Email: prabirbandyopadhyay@sibmpune.edu.in

Abstract: Planning or implementation delays of critical infrastructure (CI)

projects resulted in misfortunes such as accidents, stampedes or deaths. In this
descriptive case study, an incidence of the stampede at the suburban train
station in Mumbai has discussed. An endeavour has been made to examine
underlying causes which instigate direct causes reinforced by contributing
causes. Indian Army was being roped in for constructing additional
foot-over-bridge (FOB) after the stampede. This case features the earnestness
of appropriate and timely development of associated infrastructure in and
around suburban stations in Mumbai proportionate to abundant passengers
commuting. Post stampede reports from newspapers, televisions channels and
the internet have largely used to build this case. Pre and post cause analysis
discussion on Elphinstone Road FOB stampede case is an eye-opener to justify
sustainable emergency management and associated infrastructure development
in Mumbai.

Keywords: associated infrastructure; critical infrastructure; Elphinstone Road;

emergency; evacuation; foot-over-bridge; FOB; Mumbai; railway; stampede;
suburban train.

Reference to this paper should be made as follows: Kadam, S. and

Bandyopadhyay, P.K. (2020) ‘A case study of Elphinstone Road
foot-over-bridge stampede in Mumbai’, Int. J. Critical Infrastructures, Vol. 16,
No. 1, pp.77–90.

Biographical notes: Sanjeev Kadam is an academician in the field of

Operations Management with a mechanical engineering background. Presently
he is associated with Amity University Mumbai as an Assistant Professor.

Copyright © 2020 Inderscience Enterprises Ltd.

78 S. Kadam and P.K. Bandyopadhyay

He carries versatile military experience in mechanical engineering operations

and maintenance field. Also, he had experience in manpower consultancy for
oil, gas, petrochemical, power and manufacturing sectors. His scholarly areas
of interest include – operations management and operations research, logistics
and supply chain management, business research methods, quality management
and project management. He is currently pursuing his PhD research work from
the Symbiosis International (Deemed University), Pune, India.

Prabir Kumar Bandyopadhyay is a Professor at the Symbiosis Institute of

Business Management, Symbiosis International (Deemed University), Pune,
India. He has a PhD in Engineering and had a long stint in Management
Consultancy and Training with National Productivity Council, India.
He worked with ISPAT Group and Hindustan National Glass looking after
various initiatives like TPM, Six Sigma, enterprise risk management and
business excellence. He is a Six Sigma black belt and qualified business
excellence assessor.

1 Introduction

Mumbai had gotten a remarkable downpour on Friday, 29th September 2017 morning.
It was a usual rush hour at every suburban station in Mumbai. At Prabhadevi (formerly
known as Elphinstone Road) suburban station at around 10:30 IST, a stampede erupted
on a foot-over-bridge (FOB) connecting Elphinstone Road on Western Railway (WR)
and Parel on Central Railway (CR), causing 23 deaths and many seriously injured. It was
a consequence of intense crowd pressure exacerbated by anxiety and suffocation.

1.1 Purpose and method of the study

This contextual investigation is intended to highlight the significance of timeliness of
planning and implementation of critical infrastructure (CI) projects. For this reason, the
descriptive case of incidence of a stampede at a suburban train station in Mumbai has
been developed and discussed in detail.
An endeavour has been made to visit and observe the spot of stampede occurrence to
learn probable causes of incidence. Post stampede the incidence had been covered
virtually by all newspapers and television (TV) correspondents in India through different
angles. It is indispensable to examine and use related discussions, remarks of authorities
published in newspapers and aired on TV news channels to support this contextual case
study. Related accessible literature has likewise been bolstered to endorse the case.
This case study has structured into six sections. Section 1 begins with introduction,
purpose and method of the study. In Section 2 relevant literature has reviewed. Section 3
presents a backdrop of the case entailing Mumbai suburban train operations with
Elphinstone Road station and FOB stampede. Section 4 deliberate about pre and post
stampede analysis with passenger flow during the stampede, emergency management and
preventive actions exercised. Section 5 describes the role of the Indian Army in FOB
construction. Finally, in Section 6 the learning outcome have been pronounced before
concluding remarks.
 A case study of Elphinstone Road foot-over-bridge stampede in Mumbai 79

2 Related review of literature

Fruin (1993) assumed 2–3 persons per square metre would be a safe crowd and at
4–5 persons per square metre congestion starts building. However, at around seven
individuals per square metre swarm turns out to be a fluid mass and shock waves could
be propagated through the mass enough to lift and propel individuals off their feet.
In this section, literature with reference to human/crowd behaviour in crisis, staircase,
infrastructure vulnerability and design being necessarily reviewed to support this case
study.

2.1 Human/crowd behaviour in crisis related

Shiwakoti et al. (2018) investigated the conduct of travellers during an occurrence of a
crisis in an underground train station. It observed that a few travellers would probably
exit promptly, some would hang tight for directions, some would hold up at common
areas, a few would help people with challenges, some would pick the least swarmed exit
to pass securely. A few travellers are probably going to do nothing or potentially push
others and feel that they are less inclined to pass securely. Marsden (1998) concluded
that crowd management needs an understanding of crowd behavioural dynamics.
It recommended training in passenger and crowd behaviour safety. It has observed that
training boost confidence of managers to manage passengers in all situations. Richardson
(1994) explained that the crowd needs an understanding of sequences of disaster,
triggering events and their coupling causes.
Some more literature reviewed includes swarm behaviour in emergency situations
(Beltaief et al., 2017); herding behaviour of a crowd (Zafar et al., 2017); human
movement in crowds (Mohamaddan and Case, 2016).

2.2 Staircase related

Xing et al. (2017) observed that female passengers probably involved in escalator-related
injuries than male. Stringent design code needed to avoid such accidents. Jiten et al.
(2016) investigated walking speed on stairways depends on space available to the
passenger and it reduces gradually with increase in density and reduction in space.
Li et al. (2011) viewed crowd congestion appears easily on staircases connecting
platform and ticket hall, during the evacuation. Total evacuation time decreases with the
increase in width. Jiang et al. (2010) specified staircases in suburban stations were
bottlenecks during the evacuation. It would be possible to predict evacuation performance
by varying upstairs speed and width of the staircase. Xing et al. (2017) and Chi et al.
(2006) understood escalator riding accidents usually caused by passengers carrying out
other tasks such as carrying luggage, failing to stand firm, looking after accompanying
the person, loss of balance, not holding handrail, unhealthy passengers and people struck
by another passenger.

2.3 Infrastructure vulnerability and design related

Johansson et al. (2011) conducted a vulnerability analysis of the railway system with
seven interdependent supporting systems. Disruptions at any infrastructure affect others
80 S. Kadam and P.K. Bandyopadhyay

due to their interdependencies and hence identifying vulnerability would be essential to

avoid future crisis. Robert and Morabito (2009) advised that commuter should keep
knowledge of geographic inter-dependencies among CIs using minimum information of
the specific location. Cheng and Yang (2012) pointed exit, stairways, passages and
turnstile are key target areas considered for emergency evacuation. Still (2007) used
simulations to examine fundamental principles of pedestrian and evacuation to guide on
crowd dynamics and evacuation analysis. Sime (1999) suggested the necessity of warning
system evaluation by considering design, technology, management and occupancy.
Sime (1991) viewed an increase in vulnerability results due to poor safety management,
inappropriate communications and design of the settings. Necessarily we should
understand the influence of people, actions and environment along with an
interdisciplinary focus on psychological and social perceptions, the political and
economic impact of safety initiatives, medical policy and environmental design.
Some more infrastructure related literature includes vulnerable environments in
transport infrastructure (Coconea et al., 2014), human-induced vibrations in lively
footbridges (Venuti, 2012), disruption of a networked CI system (Tu et al., 2008),
disaster potential by identifying vulnerable neighbourhoods (Jones and Andrey, 2007).

3 Background of the case

The number of inhabitants in the island city of Mumbai in 1971 was 40.1% of total
Mumbai metropolitan region (MMR) which dropped drastically to 12.7% in 2011;
nonetheless, the total populace of suburbs expanded from 59.9% to 87.3% (Acharya and
Nangia, 2004). With demographic changes from 5.9 million in 1971 to 22 million plus in
2018, residential topography of Mumbai and it is MMR has changed considerably.
The map of central Mumbai has been significantly changed from mill land into high
risen business buildings. The encompassing zone of Elphinstone Road station such as
Parel, Lower Parel, Prabhadevi, Kalachowkie, Jacob Circle, Mahalaxmi, Dadar and
Byculla was land of mills. Typically, mills had a ground floor only and approximately
150 workers used to work in 15,000 square feet space. Most of the mill workers used to
live nearby in one or two-storey ‘chawls’.
Now the scenario is completely changed. This area is now becoming hub of finance,
media and tertiary services. Under the smart cities project more than Rs. 2 Trillion have
been invested in the adjacent regions such as Lower Parel, Parel, Elphinstone Road,
Currey Road and Chinchpokli which is likely to bring 14% of cities GDP. The territory is
developing as central business district which offers employment to approximately
0.98 million people (Iyer, 2017).
The vertical growth of Mumbai due to the additional floor space index (FSI) of 0.5 in
island city will again upsurge the opportunity of employment in the region. Due to lack of
affordable residential space in this region, the greater part of these employees migrated to
outskirts of Mumbai and hence need to travel daily by suburban local trains. Because of
such reasons, these regions have seen exponential growth of the passengers boarding and
alighting at Parel and Elphinstone Road. From the station to the offices or homes,
movement of passengers is dependent on road transports especially; bus or autos
available close-by station.
 A case study of Elphinstone Road foot-over-bridge stampede in Mumbai 81

Alongside almost all areas, nearby railway stations and FOB’s faces encroachments
from so called ‘feriwala’ (hawker) who used to sell products at lucrative rates than the
market. Though time being these feriwala’s were off the area’s due to immediate action
taken by the authorities.

3.1 Mumbai suburban train operations

Mumbai’s suburban train service is a lifeline of passengers for commuting throughout

Mumbai. Mumbai suburban railway spreads over 390 kilometres with 115 stations and
operates with 2,877 train services with around 7.5 million daily ridership. It has observed
that traffic demand reaches or exceeds the capacity at 61 stations on suburban train
network during morning peak hour. Peak hour in the morning observed 18% more traffic
than peak evening hour. Mumbai’s suburban railway system is the highest passenger
carrying suburban rail system in the world. In a right to information (RTI) query reply
received from government railway police (GRP) in 2015, revealed that 25,722 passengers
fell from Mumbai suburban trains in the past ten years, of whom 6,989 died (PTI, 2015).
Since its inception, passenger traffic in the suburban train has increased manifold;
whereas the capacity and its associated infrastructure with suburban train stations
augmented inadequately.

3.2 Elphinstone Road station

Elphinstone Road station (officially renamed as ‘Prabhadevi’ in 2016) falls on WR and

Parel station on CR. Elphinstone Road FOB constructed in 1972 to link up CR and WR
lines which became a transferring point for passengers. This cause exponential growth of
passengers boarding and alighting on these stations in central Mumbai. In a survey
conducted by Wilbur Smith Associates (2013), the highest section load observed on
Dadar-Elphinstone Road with 143,690 passengers for up direction.
In 1971–1972, Mumbai’s suburban train carried 915 million passengers using
1,161 services; however, in 2016 it looked to cater around 2.7 billion passengers with
2,800 trains per day. Nowadays, Parel and Elphinstone Road stations together witness
sales of more than 7.5 million tickets annually. Over one hundred thousand passengers
use this FOB daily which is approximately 8–10 times more than in 1971–1972.

3.3 FOB stampede

At the time of tragedy, the FOB overcrowded due to unprecedented downpour. Many
passengers assembled on FOB to take cover for a minute. In the meantime, four trains
arrived at the station spark snowballing the crowd close by FOB. According to an official
report submitted by the WR chief security officer after recording statements of 30 victims
and examining video footage of the incident, heavy rain forced people outside the ticket
counters to rush towards the already jammed staircase for cover. Likewise, the constant
flow of passengers arriving at the station from all sides and some passengers with
substantial baggage who lost their balance on the staircase triggered the stampede.
82 S. Kadam and P.K. Bandyopadhyay

Before the rescue team arrived, 2–3 on duty railway protection force (RPF) personals
and other commuters helped victims. However, 7–8 people died on the spot; some
declared dead when rushed to nearest King Edward Memorial (KEM) Hospital.
Immediately after the stampede, railway authorities and police began investigating
the case.
Figure 1 shows the stampede site location on Google map and Figure 2 was an
actual stampede spot with ticket booking office room on FOB adjacent to the staircase
(PTI, 2017). Figure 3 is an actual image captured from the video uploaded by NDTV on
the internet (NDTV India, 2017).

Figure 1 Stampede spot on Google map (see online version for colours)

Figure 2 Staircase on which stampede took place with ticket booking office (see online version
for colours)

Source: Photo from http://www.financialexpress.com

 A case study of Elphinstone Road foot-over-bridge stampede in Mumbai 83

Figure 3 Crowd on staircase at the time of stampede (captured from a video on NDTV)
(see online version for colours)

4 Stampede analysis

In this section, we discussed pre and post stampede analysis along with passenger flow
during the stampede, emergency management and preventive actions exercised.

4.1 Pre-stampede analysis

The accident-prone circumstances befall every day on every suburban station in Mumbai,
especially during peak hours. In this section pre-stampede analysis conducted to
understand the situations which might have led to this stampede considering various news
reports.
In 2015, two members of parliament, in separate letters had cautioned railway
minister with the concerns over problems faced by commuters, incapability of FOB for
handling passenger traffic and the need for widening the existing FOB.
In 2016, then railway minister Mr. Suresh Prabhu approved and allocated
Rs. 11.86 crore for the construction of 12 metre wide new FOB to connect WR and CR at
Elphinstone Road. Nonetheless, the bridge could not be built early because the proposal
got stuck up in bureaucratic alleys (Political Bureau, 2017).
In an RTI inquiry by city-based activist, Anil Galgali revealed that the commissioner
of railway security had delayed clearance of FOB construction file related to constructing
a bridge connecting Parel and Elphinstone Road station. Railways, however, has clarified
that the project sanctioned in 2016 and the tendering work was underway.

4.2 Passenger flow analysis during stampede

Just before stampede occurrence, numerous passenger flows happened from all the
possible directions and concentrated towards the FOB. As discussed earlier, due to
unprecedented downpour, the number of passengers from the Elphinstone Road station
approach took a haven under FOB roof. Around the same time, four trains which arrived
at the Elphinstone Road station added the number of passengers for exiting by using the
same narrow FOB during the same period. Whereas from the other side, some passengers
tried moving upstairs and some endeavoured to propel downstairs. This bidirectional flow
84 S. Kadam and P.K. Bandyopadhyay

on the narrow FOB staircase caused the obstacle for exit and flow of the passengers from
the FOB at both the ends.
Figure 4 is a schematic portrayal of the flows which demonstrates the distinctive sets
of passengers/commuters amassed on the FOB and staircase which caused a stampede.

Figure 4 Schematic representation of passenger flow during the stampede time (see online
version for colours)

4.3 Post stampede cause analysis

Post-tragedy many versions of reasons had reported in the news which caused a
stampede. In this section, an attempt has been made to compile all possible causes.
The stampede erupted due to the flow of passenger’s movement on the staircase from
both directions. Nonetheless, it necessitates comprehending the reasons for the encounter
of passengers towards FOB and staircase.
One of them was due to slipping off the passenger on the FOB staircase. Another one
was a rumour floated that the FOB had collapsed or was collapsing. It raised panic among
the commuters which resulted in a rush towards the FOB’s exit. One more version was a
misinterpretation of spilling of flowers (in Hindi ‘Phool gir gaya’) as bridge collapse
(in Hindi ‘Pool gir gaya’).
Railway officials invalidated a case of structural or mechanical failure or electrical
short circuit.
The different reasons which led the stampede are classified as direct, contributing and
underlying causes. Direct causes were real-time causes which led the situation at that
instant. Contributing causes did not contribute undesired outcome directly but rather
indirectly strengthen direct causes. Underlying causes could be actions or inaction which
 A case study of Elphinstone Road foot-over-bridge stampede in Mumbai 85

may fortify direct causes. The different reasons have grouped under these three categories
as follows:
 Direct causes
a Rushing of commuters towards FOB and staircase from both directions.
b Width of FOB and staircase.
 Contributing causes
a Unprecedented heavy rain.
b Arrival of four trains at the time of the accident.
c Carriage of heavy luggage during peak hours.
d Rumour of FOB collapsing.
 Underlying causes
a Bidirectional flow of passengers on the staircase.
b Undisciplined passenger flow.
c Delays on scheduled projects.
d Under or no development of station structures in proportionate to the growing
passenger traffic.
e Lack of associated infrastructure with suburban train stations such as pedestrian
road.
f Increasing number of working personnel’s in the vicinity of the station.
g Lack of affordable housing.
Cause and effect diagram used herewith for further detailed cause analysis in five
categories planning, human, policy, infrastructure and nature as shown in Figure 5.
Figure 5 Cause and effect diagram (see online version for colours)

PLANNING HUMAN

Unplanned  Increased passenger 
bidirectional  population 
Unplanned arrival of  Passenger flow  
four trains at a time 
Undisciplined movement 
behaviour of passengers   Rushing of passengers 
No Planning of associated  to cover from rain 
infrastructure to meet 
increased passenger demands 
Elphinstone FOB 
Lack of affordable Housing  Non‐availability of 
Stampede 
policy for employees  Escalators  No separate 
working in the area  passageway      
for carriage of 
Delay in project  heavy luggage   Unprecedented 
No proportionate  approval    Rain 
infrastructure 
Redevelopment policy  Underdeveloped  Width of FOB and 
Infrastructure  Staircase 

POLICY INFRASTRUCTURE NATURE

86 S. Kadam and P.K. Bandyopadhyay

4.4 Post stampede emergency management and preventive actions

Immediately after the stampede, authorities ordered a probe to investigate the incidence.
The probe panel recommended confinement for carrying heavy luggage during peak
hours. The movement of commuters, mainly vendors, carrying baskets stuffed with goods
during peak hours needs restriction. Other recommendations by the panel include
relocating the booking office on FOB, provision of an additional staircase and use a quick
mode of communication to ensure timely reaction.
The audit of stations on both the central and western line revealed several
discrepancies and necessary work initiated. Provision of barricades at the bridges for
crowd control and platform expansion at several stations has been initiated, informed by
railway minister. Also, more than 3,000 escalators installations approved on railway
stations in India, out of which 372 would be in Mumbai. It had recommended the
installation of more closed-circuit television cameras (CCTV) at the railway station to
monitor passenger movements from the station master’s office, RPF and city police
stations.

5 Construction operations by Indian Army

Despite many early requests to build new wider FOB, the project could not take off.
Railways would require a year to construct the same FOB due to procedural formalities.
Immediately government, initiated decision to build new FOB by the Indian Army with a
project deadline as 31 January 2018 at an estimated cost of Rs. 10 crores to bring relief to
commuters at the earliest.
The Border Roads Organisation (BRO) and General Reserve Engineer Force (GREF)
corps of the Indian Army are known to have strong operational expertise in road and
bridge construction. The Indian Army’s Bombay Engineering Group from Pune took over
the responsibility of this construction project. Other defence institutions such as the
College of Military Engineering were also roped in to expedite the work.
The army planned to construct the Bailey bridge which has an average life of
50 years. After the approval of Commissioner of Railway Safety, the railway
administration approved the design prepared by the army for the construction of a
70 metre FOB to connect Parel and Elphinstone Road. The bridge was an extension of the
current north-end FOB at Parel and land at the west side of the Elphinstone Road outside
station premises. The railway and the army signed a memorandum of understanding
(MoU).
As Mumbai suburban train is a lifeline of Mumbaikar, it cannot hold down its
operations on a routine working day. Due to the intense pressure of commuters, only four
hours per day would be available for work. The construction of this FOB would have
completed within a week by the Indian Army. However, due to rail traffic, high-voltage
overhead wires and constant movements of trains, the deadline extended to 31 January
2018.
It was a challenging and risky job for army men as required to cross railway lines
many a time. Railway Minister Piyush Goyal appreciated the Indian Army and said that
the work by the army would serve as an example for all 17 zones of the Indian Railways.
Railway officials from these zones would visit the station and inculcate such speedy work
 A case study of Elphinstone Road foot-over-bridge stampede in Mumbai 87

practices in their respective divisions, added Goyal (Staff Reporter, 2017). However, the
involvement of the Indian Army in civilian construction work during peacetime criticised
by many people (Business Line Bureau, 2017).

5.1 Current status on Elphinstone Road station FOB

Railway has constructed new wider staircase on Elphinstone Road station parallel to the
old staircase and currently in use by the commuters. The new FOB construction by the
Army at the Elphinstone Road missed 31 January deadline due to the revision of bridge
design. The army sought a railway block to launch girder on the bridge. The deadline to
complete work then extended to 15 February. Due to more intricacy in new design, the
army took another fortnight to complete the FOB construction work (PTI, 2017).

Figure 6 Indian Army’s Bombay Sappers at Elphinstone Road FOB (see online version
for colours)

Source: Hindustan Times (2018)

Figure 7 Elphinstone Road FOB constructed by Indian Army with metal sheets rooftop with a
gap between sheets (see online version for colours)

Source: Hindustan Times (2018)

88 S. Kadam and P.K. Bandyopadhyay

Finally, on 26th February 2018, central and WR took over the FOB. Figure 6 shows army
personnel working at the construction site. However, according to expert’s observation
gaps between metal sheets will lead to a water leak and hence commuters
can not use it in case of heavy rain as shown in Figure 7 (Ahmed, 2018; HT
Correspondents, 2018).

6 Conclusions with learning outcomes

The following could be significant learning outcomes from this case study:
 Post-stampede as an immediate action, ticket booking office relocated and new
additional staircase erected as per recommendations of the inquiry panel. However,
passenger flow and dispersal from the platform and station premises need regulation
for boarding and alighting.
 This case study encourages the necessity of up-gradation of stations and associated
infrastructure in proximity to malls, supermarkets, commercial complexes and high
risen buildings.
 In the case of Mumbai suburban railway, length of the platform, the number of entry
and exit points, a width of FOB’s and staircases are few requirements need
augmentation on priority.
 Civilian authorities need to learn a lesson from the Indian Army, especially quick
decision making and implementation of projects at the earliest.
 Authorities need to develop the sustainable rehabilitation policy for and against
feriwala’s before they occupy their spaces once again. Properly marked hawking
zones would manage the movement of commuters and vehicles.
Elphinstone Road stampede would be an exemplary case to understand the significance
of timely planning and implementation of CI projects. Associated project delays are
frequent, especially in the public domain. Nonetheless, overlooking timeliness of critical
project could be fatal. Governments require to understand the futuristic risk of not taking
up decisions when expected. In many situation’s authorities needs learnings from the past
or otherwise major or minor accidents will befall.
The case study enlightens that not only direct causes but also underlying and
contributing causes instigated this stampede. It acknowledges mismatch between
demographic changes and associated infrastructure developments in central Mumbai as a
major cause of this unfortunate stampede.
Due to anticipated procedural delays, the Indian Army roped in to build new FOB.
Despite many operational constraints, the Army played a praiseworthy role in
constructing new FOB.
Authorities should think about the urgency for immediate research and apply a model
for integrated, reliable and sustainable transportation system proportionate to suburban
city development which would be an obligation to achieve a smart city tag.
 A case study of Elphinstone Road foot-over-bridge stampede in Mumbai 89

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