NZ NOTE No, ECR/Safety/Accident/DHN/01/22 Hajipur, dt. 10.11.2022. Sub : Derailment of Train No. UP Goods NTCD in GAP station yard ‘of DHN division on 26.10.2022 at about 06.24 hrs. Vide“ N/1 JAG level committee consisting of Dy.CSO/Electrical, Dy.CSO/Mech, Dy.CSO/Traffic and Dy.CE/TSP was nominated to’ inquire into this incident, The complete Inquiry report is placed at P/l to 255 along with the supporting documents. ‘The Conclusion and Responsibility as drawn by the Committee may please be seen at P/215 to 218, Recommendations by the Committee is placed at Pr2i4, May kindly peruse and accept the report and findings, if agree to. Mrobdies Toya 1 Me dbo acciderd pit, bon rt hewn wha and don et go 21h hud bawe tan moomrmcl: Techoaonle mete” Rejpode DRM] D0 em amnion well Trend whith be pe te Glee Gaecl ory Chapanctin bina activ wf maetelent bende wha be pdretal om ite « 3, Merve, st aon Bol perme RDSO nceburclemne we tA ve ted baalea vielrtted , Peo herd Armerto’ the Bohne ang Bedwell, jet te ansibmn Tae sommepet BH Eevee. - aces utes. an Seat 23fifr— PeSo-NB In view of GM's remarks at N/2, para-wise compliance/reply is Indicated as below: 1. Report of DRM/DHN is enclosed herewith in the file at P/256 to 278. fe 2. IPO dtd 15.11.2022 issued by CELE, COM/G & CWE for Running of loaded Goods train with more than 50% BMBS from Gajhand! to Gurpa station in Up: direction \s placed at P/279 to 280. 3. Violation of following RDSO & Railway Bd. letters (P/281 to 288/A) have been cited in the report- a. RDSO L.No. EL/3.2.19/3-Phase dated 10.05.2022 b, RDSO L.No. MW/APB/BMB dated 23.07.2022 cc, RDSO L.No. MW/APB/BMB dated 25.01.2022 d. Rly.Bd. L.No. 2017/M(N)/60/3 dated 18/19.04.2022 In view of the above letters communicated to this Railway, CRSE/Freight had ss accordingly re-iterated the contents/issued guidelines to DRMS of all divisions Es which may be seen at P/289, for necessary counseling and compliance by all Se concerned staff. SrDEE/Op/DHN & DDU and SrDME/C&W/DDU have accordingly issued guidelines... which may be seen at P/290-294. ere Put up for kind perusal. 20 9N/a 1, The remarks in the conclusion of enquiry report regarding primary and secondary responsibility (at P/216 and P/215) are accepted subject to deletion of the words “and become unconscious” at (i) and (i) in Responsibility part at P/216. 2. The recommendations made by committee members (at P/214) are accepted. These must be duly followed. The JPO issued by HODs for GJD-GAP section working dated 15.11.22 must be implemented in right earnest, without fail. 3. Following recommendations are further appended, based on evidences from site after removal of debris and further deliberations with RDSO: ‘a. Matter should be taken up with RDSO for a thorough Design Review of complete 8MBS system particularly in view of brake block clasping force vis- avis vertical load on wheel for BMBS being only 16% as against 36% in conventional wagons of BOXN (at P/295 & 296). b. Suitable modifications for enhancing brake rigging efficiency and enhancing clasping force at wheel tread should be incorporated by RDSO to the extent feasible. c. Higher coefficient of friction of K-type brake blocks used in BMBS is a major aspect of its working in order to overcome lower clasping force impact and regular checks of same in RDSO test lab should be ensured. As per recent ‘communication from RDSO (at P/298), the test lab for brake block friction coefficient itself is under repair for long and RDSO needs to urgently repair it fot Zonal Railways to be able to send the brake blocks for testing as and when necessary. d. Proper attention in all schedules of brake-gear maintenance in BMBS rakes must be ensured: Regular training and technical seminars should be arranged for guidance of train examination staff. e. Event Recorder Data showed that Loco Pilot applied emergency brake with Regenerative brakes in working at 06.04.50 (at P/299) which led to a surge in speed and thereafter due to emergency application, the regenerative brakes remained unavailable to Loco Pilot. As such, suitable instructions regarding enginemanship with loaded BMBS rakes are to be mandated as regards to ensuring optimum use of regenerative braking along with train brakes when BMBS loads are being hauled by WAG9 Locos, particularly since these do not have in-built brake blending feature as available in WAG 12. Guidelines also need to be issued on how to handle train braking in neutral sections that are adjacent to continuous down gradient as was the case in Gurpa Home Signal approach. g. RDSO should publish Technical Investigation Report on BMBS failure for guidance of Zonal Railways. This was taken up with RDSO after previous incident on 07.08.22 of Loco Pilot loosing control of train brakes at Bakhri in SEE division and same needs to be followed up. rc 2yfrf 6M’ — Pe Ree a: Aho Be AALS Thema doy » bh vo Lo pike Aa WeC - Phae EAST CENTRAL RAILWAY JOINT INQUIRY REPORT INTO ACCIDENT OF DERAILMENT OF TRAIN NO. UP NTCD ON UP LOOP LINE BETWEEN KM 425/5-425/21,GURPA (GAP) STATION IN KODERMA (KQR) — MANPUR(MPO) SECTION OF DHN DIVISION AT ABOUT 06.24HRS ON 26.10.2022 BY A COMMITTEE OF HQ JAG OFFICERS CONSISTING OF DY. CHIEF SAFETY OFFICER/ELECT. DY. CHIEF SAFETY OFFICER/MECH. DY. CHIEF SAFETY OFFICER/TRAFFIC & x DY. CHIEF ENGINEER/TSP ECR/HJPari 1 [eae B02 2 a o200F 3. ear va ta eras Feet a [arr cd ts [sar ae aR aA, IT ae A aes eae 6 [=r er em a fea a Feeatforr ea 11 fore 7 | en We SaRA 3 | wee ast ‘8 Goods NTCD/32633 9 | S/ar ‘EOF H0-32633/WAG-9/CNB ‘tis-57 BOXN HL Coal Loaded + 01 BOXN HL Empty +02 Brake Van. 10 [sae Sara we | [tia TakeomonoT 11 | wrth > [ae aie vate 12 (| sar | 1:80 13 [Ra = | 3.75° Curve 14 | ae = | ae 15 | Fea ArT 16 | aia a C&W = Rs. 9,72,00,000 /- = P. Way — Rs. 19,06,000 /- peng ehbanes TRD = Rs, 56,97,500/- + S&T__— Rs. 156,806 /- Total Rs. 15,62,37,806/- 17 | eee ee ae : 1g | Seat ee Description c/e_[ our AT SITE ‘ART /DHN 06.30 | 07.45 09.47 Controlled at GID Crane/GMO 06.30 | 07.25 08.40 Controlled at HREE ‘ART /GAVA | 06.40 | 07.08 08.40 Controlled at PRPE Crane/DHN | 06.40 | 07.45 12.20 Grane/aRwD | 06.40 | 07.25 16.15 Crane/ONR | 07.00 | 08.08 12.26 Crane/ASN | 07.00 | 09.35 23.25 | Controlled at GID. Bulldozer/DHN_| 08.10 | 10.15 04.25 79 | eer 7 [aa Red & argue 20 | Sarai aia RASS aga Kaw o We passphe2 SUMMARY 1, | Date =| 26.10.2022 2. | Time = [06.24 Hrs. 3._| Railway/Division -_| East Central Railway/Dhanbad (DHN) 4.__| Gauge -_| Broad Gauge 5. | Location ~_| At km 425/5-425/21 in UP Loop Line, Gurpa (GAP) _ 6. | Station - | Gurpa (GAP) Class - |*B' (CPI) Signaling - | acts: Interlocking -_| STD. II'R’ 7. __| Nature of Accident |- | Derailment (D-4 Class) 8.__| Train Involved = _| UP Goods NTCD/32633 9, | Engine No./ Load |- | 32633/WAG-9/CNB Load- 57 BOXN HL Coal Loaded +01 BOXN HL Empty_+ 01 Brake Van. 10._| Speed = | About _112 KMPH 11. | System of Working | - | Absolute Block System 12. | Gradient ~_| 1:80 13._| Alignment ~_|3.75° Curve 14. | Weather -_| Normal 15._| Visibility ~_| Clear 16, | Cost of Damage - [C&W — Rs, 9,72,00,000 /- P, Way — Rs, 19,06,000 /- TRD = - Rs. 56,97,500 /- S&T__— _Rs._1,56,806 /- _ Total - Rs. 15,62,37,806/- 17._| Causality ~_ {NIL 18. | Relief arrangement | - Description C/F_| OUT AT SITE ART /DHN 06.30 | 07.45 | 09.47 Controle dat GID Crane/GMO 06.30 | 07.25 | 08.40 . Controlle dat HRE ART /GAYA 06.40 | 07.08 | 08.40 Controle : d at PRP Crane/DHN, 06.40 | 07.45 12.20 Crane/BRWD | 06.40 | 07.25 16.15 Crane/DNR_ 07.00 | 08.08 | 12.26 ‘Crane/ASN 07.00 | 09.35 | 23.25 Controle dat GID Bulldozer/OHN | 08.10 | 10.15 | _04.25 a Cause = _| As per Inquiry Report. Responsibility ~_| As per Inquiry Report. ye Vow Strpps: ae EAST CENTRAL RAILWAY HAJIPUR MAIN PAGE Train No. UP Goods NTCD (Dadri)CC Rake (Single Pipe)with load of 57 BOXNHL loaded (Coal) + 01 BOXNHL Empty + 01 Brake Van (BVCM) hauled by Electric loco no. 32633/WAG-9/CNB, on 26.10.2022. Train started from HZBN station (line no. 3) at 00.20 hrs, on 26.10.2022. Train stopped GID at 04.22 hrs, and departed at 05.55 hrs. After passing Lalbag BH (LBZ) at 06.05 hrs., LP applied break for controlling the train in falling gradient but did not control the train and he informed the Guard on walkie-talkie and also blown prescribed whistle code (03 shorts) for assistance of Guard. Guard also dropped the pressurebut no drop of pressure was noticed/ experienced by the Guard of the train and the train could not be controlled, After passing Dilwa (DLW) at 06.07 hrs., Guard informed to Dy. Chief Controller/DHN though mobile and also exchanged Red Hand Signal with on- duty SM/DLW. On-duty SM/DLW informed to on-duty SM/Nathganj (NGY) and Section Controller/DHN. Train passed NGY at 06.12 hrs. Baskatwa (BSCP) at 06.15 hrs. And Yadugram (YGM) at 06.18 hrs. Home Signal/GAP kept at ‘ON’ and set for run off line, In the mean while, due to loss of control the train entered in UP loop line/GAP with speed of 112 kmph, which was very much higher than the permissible speed of 30 kmph resulting 54 wagons of train got derailed and many wagons capsized between km 425/5 - 425/21 A in Koderia(KQR) - Manpur (MPO) section of Dhanbad (DHN) Division, Consequently, movement of trains from UP and DN line blocked, A Sketch of accident site at P-20 is enclosed for general appreciation. A Joint Inquiry Committee of JAG officers was nominated by General Manager/ECR for the purpose of fact finding the cause of accident vide Authority of Note No. ECR/Safety/Accident/DHN /O1dated 31.10.2022. we NO ge GerINQUIRY COMMITTEE Piss S. | Name of Members Designation / Hqr No. 1. | Shri P. K. Saxena Dy. CSO/Elect. 2._| Shri Ugrasen Dy. CSO/Mech. 3._| Shri Sunil Kumar Dy. CSO/Traffic 4._| Shri Alok Kumar Dy. CE/TSP. The Inquiry Committee started and conducted proceedings of inquiry after nomination of the Committee by GM/ECR on 31.10.2022 in the Station Director's Chamber, ECR, GAYA on 01.11.2022 and 02.11.2022 and GM (Safety) Office, ECR, Majipur on 3.11.2022, One of the Committee member ie. Dy. CSo/Mech./ECR had already proceeded the accident site after getting information about derailment of said train and reached the accident site on same day Le. on 26.10.2022. He had visited the accident site, observed the site evidences and involved in the restoration activities from 26.10.2022 28.10.2022, Other 03 members ie, Dy. CSO/Flect,, Dy. CSO/Trafic, Dy. CE/TSP/ECR had visited the accident site on 02.11.2022, The Committee members also inspected the point of drop zone, broken rail, condition of derailed & other wagons of affected train at the accident site, For indulry concerned witnesses were called along with relevant documents, their statements were taken and as per requirement, were cross examined too, Loco of affected train was brought to Gaya and further inspected jointly by Inquiry Committee members at Gaya. wee Sy1 Hl THE AC i pps? The affected train no. UP Goods NTCD (Dadri) CC rake (Single pipe)with load of 57 BOXNHL loaded (Coal) + 01 BOXNHL Empty + 01 Brake Van (BVCM) hauled by Electric loco No. Electric loco no. 32633/WAG-9/CNB, manned by LP — Shri Vijay Kumar/HZBN, ALP - Shri Satish Kumar Dangi/ HZBN& Guard - Shri Shashi Kant Kumar / HZBN with BPC No. 50000461629(CC Rake, Single Pipe) issued from DDU ‘on 10.10.2022.Train started from HZBN station (line no. 3) at 00.20 hrs. on 26.10.2022. Train stopped GID at 04.22 hrs. and departed at 05.55 hrs. After passing Lalbag 8H (LBZ) at 06.05 hrs., LP applied break for controlling the train in falling gradient but did not control the train and he informed the Guard on walkie- talkie and also blown prescribed whistle code (03 shorts) for assistance of Guard. Guard also dropped the pressurebut no drop of pressure was noticed/ experienced by the Guard of the train and the train could not be controlled. After passing Dilwa (DLW) at 06.07 hrs., Guard informed to Dy. Chief Controller/DHN though mobile and also exchanged Red Hand Signal with on-duty SM/DLW. On-duty SM/DLW informed to on-duty SM/Nathganj (NGY) and Section Controller/DHN. Train passed NGY at 06.12 hrs. Baskatwa (BSCP) at 06.15 hrs. And Yadugram (YGM) at 06.18 hrs. Home Signal/GAP kept at ‘ON’ and set for run off line, In the mean while, due to loss of control the train entered in UP loop line/GAP with speed of 112 kmph, which was very much higher than the permissible speed of 30 kmph resulting 54 wagons of train got derailed and many wagons capsized between km 425/5 — 425/21 A in Koderma(KQR) - Manpur (MPO) section of Dhanbad (DHN) Division. Consequently, movement of trains from UP and DN line blocked, UP line remained blocked from 06.24 hrs. of 26.10.2022 to 22.30 hrs. of 28.10.2022. Track fitness was given with speed-restriction of 10 kmph for the * train and onwards of 15 kmph at 18.20 hrs. of 28.10.2022 and OHE fitness was given at 22.30 hrs. of 28.10.2022, The 1* Commercial train no. DSL/Empty & HSYG passed from site via UP line at 22.44 hrs. & 22.58 hrs. respectively on 28.10.2022.DN Main line remained blocked from 06.24 hrs. of 26.10.2022 to 17.20 hrs. of 28.10.2022. Track fitness & OHE fitness were given at 17.20 hrs. with speed restriction of 10 kmph for the 1* train and onwards of 15 kmph of eo Nw oe99.10.2022. The 1* Commerciel train no, BOXN/E/60173 passed from site via‘ DN pe+} main line at 18.00 hrs. on 38.10.2022.DN 1* loop Tine remained blocked from 06.24 hrs, of 26.10.2022 to 12.18 hrs. of 28.10.2022, Track fitness was given at 42.10 hrs. with speed restriction of 10 kmph for the 1* wain and onwards of 15 anph of 28.10.2022 and OHE funess was given at 12.18 Fs: of 28.10.2022. The 4% Commercial train N0- poxn/e/7526 passed from site Via DN loop at 12.50 hrs. on 28.10.2022,1n view of this accident, ART/DHN, GMO , GAYA, 440 T BD Crane [DHN, BRWD, DDU, DNR & [AGN and Bulldozer/DHN were called, No injury / casualty were reported. After completion of restoration work Bp 140 T Crane JOHN, BRWD, DDU, DNR & ASN and Bulldozer/DHN left from site The prima-facie cause of derailment as mentioned 1 int note and relayed from site was “Loss of brake power during run.” 2, TIMEOF ACCIDENT: = As per the time recorded In the First Information Report, accident took place at about 06.24 hrs. 3. FFICERS V1 1 - FROM RB-Member/T! raction & Rolling Stock. FROM RDSO -DG/RDSO. FROM HQ- GM, ‘AGM, PCME, PCE, PCCM cum PCSO, PCEE, CELE, CRSE/Frt., CTE, CEDE, & Dy: cso/Mech./ECR. FROM DIVISION — DRM/OHN with others officers. 4. CASUALTY INJURY! NIL » wwe5, BRIEF DESCRIPTION OF ACCIDENT SITE:- pete Accident site is situated on UP Loop line between km 425/5-425/21, Gurpa (GAP) in Koderma (KQR)- Manpur (MPO)section under ECR, DHN Division. Accident took place in GAYA District of Bihar. This section is Broad Gauge, Double line, electrified and equipped with MACLS. This is ‘B’ route. This station is equipped with Std IIT ’R’, B class with Central Panel Interlocking. Gurpa (GAP) Station is situated at KM 425.54 from HWH. 6. Gradient:- 1:80 ( Falling gradient). In Up direction — Falling gradient of 1 in 200 from UP Inner Distant Signal (Gurpa) and thereafter Level upto station building, again falling gradient of 1 in 400 upto point no. 65/B (Gurpa) and then falling gradient of 1 in 200 in block section ahead. 7. Sectional Speed_(Ghat Sectoin — GJD — GAP):- 100 kmph (Coaching ) 55 kmph (Goods ) 8. Temporary Speed Restriction (Between GJD — GAP on 26.10.2022) :- SN] Station between |KmFrom] To ‘Speed (kmph) 1_|_Diwa _[_Nathganj | 410/27_| 410/29 45 2 [Nathganj |Baskatwa [414/41 | 414/43 45 8.1 Permissible Speed Restriction Between GID — GAP Via UP lint SN|_Location [PSR in kmph Reason 1 | 403/15-405/9 | 100 (Chg train) Ghat Section 2 | 405/19-406/19 80. "Due to 2.25° curve 3_| 406/19 = 407/15] 70 Due to 3.09° Curve Ghat section 4 | 407/15 = 408/15] 80 Due to 3.09° Curve Ghat section 5 | 408/15-418/1 65 Due to 3 nos, tunnels & 1 in 80 falling gradient 6 | _418/1-422/7 80 Due to continuous curve in falling gradeint 7 | A2aj7 = 425/13 100 Ghat Section w NU te OO9, TRAIN DETAILS:- Train No UP Goods NTCD (Dadri) Loco No. '32633/WAG-9/CNB. Name of Crew LP = Shri Vijay Kumar/HZBN ‘ALP — Shri Satish Kumar Dangi/HZBN Guard — Shri Shashi Kant Kumar/HZBN Load 57 BOXN HL Ld + 01 BOXN HLE + 01 BVCM BPC No. 50000461629/DDU (CC Rake, Single Pipe), issued on 10.10.2022 , validity upto 13.11.2022 or 10,000 km. Rake 1D DDU/260622194034 ["Type of Brake System, Conventional - 05, BMBS — 54, BMBS - 90% Brake Power as per BPC 100% (114 Brake Cyllinder) BPC Issued by SSE/JE Shri D. Singh/DDU. 10. PAR’ ED NS TRAIN:- Pear ED 54 (Fifty four)wagons of rear part (1° to 54"wagons from train engine) of train no. UP Goods NTCD/32633got derailed and capsized. Details are as under:~ S. |Rly/Wagon No./ _| Derailed by| Re-railed By/Thrown out No.| Type 1 | ECR/22101048880/ | Derailed 15.35 hrs. by DHN Crane on BOXNHL 26.10.2022. 2 | ECR/22101141505/ | Derailed 14.50 hrs. by DDU Crane on BOXNHL and 26.10.2022. capsized 3 | ECoR/22121116569/ | Derailed 15.48 hrs. by DDU Crane on BOXNHL © and 26.10.2022. capsized . 4 |SwR/22151176564/ | Derailed 16.48 hrs. by DDU Crane on BOXNHL and 26.10.2022. capsized 5 | SECR/22140936315/ | Derailed 17.47. hrs. by DDU Crane on BOXNHL and 26.10.2022. capsized 6 | ECR/ 22101145633/ | Derailed 18.48 hrs. by DDU Crane on BOXNHL and 26.10.2022. capsized 7 |WCR/ 22161123985/ | Derailed 19.17 hrs. by DDU Crane on BOXNHL and 26.10.2022. capsized 8 _[ ECoR/22121737948/ | Derailed 22.40 hrs. by DDU &BRWD Crane_on me NA , w SF “BOXNHL, and 26.10.2022. capsized 9 | SER/22071610087/ | Derailed 00.50 hrs. by DDU Crane on BOXNHL and 27.10.2022 capsized 10 | SCR/22091610210/ | Derailed 01.32 hrs. by DDU & BRWD Crane on BOXNHL and 27.10.2022. capsized 11 | ECoR/22121620547/ | Derailed 01.15 hrs. by DDU & BRWD Crane on BOXNHL and 27.10.2022. capsized 12 | ECoR/22121614881/ | Derailed 02.15 hrs. by DDU & BRWD Crane on BOXNHL and 27.10.2022. capsized 13 | SER/22072110678/ | Derailed BOXNHL and capsized 14 | ECoR/22121334772/ | Derailed 11.25 hrs. by DDU & DNR Crane on BOXNHL and 27.10.2022. capsized 15 | ER/22022110826/ Derailed 04.55 hrs, by DDU Crane Crane on BOXNHL and 27.10.2022. capsized 16 | SECR/22141610498/ | Derailed 11.28 hrs. by DNR Crane on BOXNHL and 27.10.2022 capsized 17 | SCR/22091616250/ | Derailed BOXNHL and capsized 18 | SCR/22091613198/ | Derailed 09.52 hrs. by DDU & DNR Crane on BOXNHL and 27.10.2022. capsized 19 | ECoR/22121621223/ | Derailed 18.12 hrs. by DDU & DNR Crane on BOXNHL and 27.10.2022. . capsized 20 | ECoR/22121614973/ | Derailed 14.18 hrs. by DNR Crane on BOXNHL and 27.10.2022. - capsized : 21 | ECR/22101170680/ | Derailed 07.20 hrs. by DNR Crane on BOXNHL and 28.10.2022. capsized 22 | SCR/22091611354/ | Derailed 09.38 hrs. by DDU Crane on BOXNHL and 28.10.2022. capsized 23 |NCR/22131612303 | Derailed 09.05 hrs. by DDU Crane on BOXNHL and 28.10.2022. capsized wo Nee oe phacy mioiserane) [SUIT [ALAS es by DOU Crane on BOXNHL oe a 25 | scryzzosiei099e, | Detaled — capsized 28 | econy22121620043/ | Deraled BOXNHL capsized 27 | secry22i4i237220/ | Devaled BOXNHL a 7B | SECR/20141143873/ | Deralied [13.10 rs. by DDU Crane on BOXNHL and 28.10.2022. capsized 35 | ECoR/20121615741/ | Derailed [09.55 hrs. by DHN Bulldozer on BOXNHL and 28.10.2022. capsized 30 | econy2zizz212360/ | Devaled BOXNHL capsid 31 | ecr e2ioisesz0z/ | Detaled BOxnel capsized 32 | wry 220aio17645/ | Devaled BOXNHL ond 33 | ser jazo7iozzeia | Derailed BOXNHL 2 ed 34 | ECoR/25120950461/ | Derailed [2310 Ws. by DAN Crane on BOXNHL and 27.10.2022. capsized 35 | ECoR/20121610350/ | Deralied [17.07 rs. by DHN Crane on BOXNHL and 27.10.2022. capsized 36 | EGoR/20121577308/ |Derelled [1838 ws. by OHN Crane on BOXNHL and 27.10.2022. capsized 37 | SECR/22141144045) | Derailed OLAS hrs. by DHN Crane on BOXNHL and 27.10.2022. capsized 38 |ECR/22101155153 | Derelled [1219 ts. by DNR Crane on BOXNHL and 27.10.2022. capsized 35 | ECoR/22121610302/ | Deralled | 21.30 hs. by DDU & BRWD Crane on BOXNHL and 26.10.2022. we NU ye or pl246piaas capsized 40 | ECoR/22121616052/ | Derailed [01.02 hrs. by DAN Crane on BOXNHL and 27.10.2022. capsized 1 | ECR/22101147767/ | Derailed [20.27 hrs. by DAN Crane on BOXNHL and 27.10.2022. capsized 42 | SECR/22141610368/ | Derailed | 2i.25 hrs. by DAN Crane on BOXNHL and 27.10.2022, 43 | SCR/22091574208/ | Derailed [01.30 hrs. by DHN Crane on BOXNHL and 28.10.2022, capsized ‘44 | ECoR/22121610876 | Derailed [06.07 hrs. by DHN Crane on 7BOXNHL and 27.10.2022, capsized 45 | SECR/22141586175] | Derailed |0254 hrs. by DHN Grane on BOXNHL and 27'10.2022. capsized 6 | ECR/221016163247 | Derailed | 12.41 hrs. by DAN Crane on BOXNHL and 27.10.2022. capsized 47 | scr aosieizeo1/ | Deialled BOXNHL oT ae 48 | wor s22t6s61040sy | Detailed BOXNHL capsized 49 [ECOR Derailed | 10.16 hrs. by DAN Crane on 722121613990/ | and 27/10.2022. BOXNHL capsized 50 bce paatoitessea) |Deled [0832 is. by DHN Crane on BOXNHL. and . 27.10.2022. 9s capsized 51 [cm aztersisees|eteled [ORCL Ws. by DEN Grane on roeed an 27:10.2022. capsized 5 | econpazizuiaerany [tale [0840 Ts. by DAN Crane on BOXNHL 10.2022, capsized 53 Tor aniaieizisey [Oeraled | 530 hrs. by DANN Crane on NR and 26.10.2022. capsized 54 Teca peatoreioesey |eied [142 hrs. by DH Grane on Benen and 26.10.2022. capsized wa owpieaz This train started from HZBN for NTCD (Dadri) with BPC No. 50000461629 (as CC rake) issued from DDU on 10.10.2022with validity upto 13.11.2022. Details are as under: W. Owner Wagon |BMBS | POHW/S Date | ROH Stn | Ret. No./W. Type Make Date _| Date T ECR/221010488807 ;OXNHL Ce Not bsw 21-08-21 03/26 2 (E0R/22101141505/ L oxNHL [nse. Not bupw 05/05/22 12/26 3 [ECoR/22121116569/ }OXNHL fe Not bMpw 02/05/22 11/26 4 BWR/22151176564/ BOXNHL nor MPW-07-05-22 11/26 5 SECR/22140936515/ , 7 IBOXNHL wentionalisw 10/08/20 | 20/01/22 | 03/25 @ OR) 22101145633 Fon. ese: Nt uw 29/04/22 1226 7 WOR) 22161123985 BOXNHL kknorr DW 29/04/22 12/26 8 [ECoR/20121737948) IBOXNHL |knorr /kBI. PUDW 06/05/22 12/26 9 beR/22071610087/ IBOXNHL Ease. Not bupw 06/05/22 12/26 To BoR/22091610210/ IBOXNHL Knorr Defaced 12/26 Ti [ECoR/221216205477 XNHL Knorr JUDW 04/05/22 12/26 12 CoR/22121614681) {Knorr jUDW 12/05/22 12/26 we er|BOXNHL 13 SER/22072110678/ | XNHL Knorr TEX 09-01-21 01/27 14 (ECOR/22121334772/ RDM [BOXNHL IMEDHAYKBI KNW 29/08/19 | 23/07/21 | 3/24 15 (ER/22020110826/ OXNHL Knorr |cesco-13-02-21 2/27 16 (SECR/22141610498/ q BOXNHL Knorr JUDW 04/05/22 12/26 17 5CR/22091616250/ Insp. Not [BOXNHL [ene UDW 05-05-22 12/26 18 (5CR/22091613198/ XNHL knorr/KBI_ PUDW-04-05-22 12/26, 19 (ECOR/22121621223/ XNHL Knorr JUDW-25-04-22 11/26 20 ECoR/22121614973/ bOXNHL Knorr JUDw 04-05-22 12/26 2 [ECR/22101170680/ IBOXNHL A |UDW-30-04-22 12/26 22 SCR/2209161 13547 [BOXNHL Knorr/KBI JUDW-05-05-22 12/26 23 INCR/22131612303 BOXNHL Knorr JUDW-04-05-22 12/26 2 eR! 221013876047 {Convention py.04-07-19 02/24 25 BCR/220916109997 nore —_ bUDW 28-04-22 12/26 26 FFCOR/22121620543/ nore buDw 04-05-22 12/26 gz BER 2211257220) knorr «RWS 06-12-18 a 07/23 28 (SECR/22141143873/60) NHL norr JUDW-06-05-22 12/26 wi Nn we oe pbse79 ECoR/22121615741/ XNHL IMeoHA —buDw 06-05-22 12/26 0, Foon 2212zah360/ frse. Not lasrw 01-04-22 03/27 31 FOR 221013852027 rag RWS 28-12-19 Ns 25-08 | ogi2e 32 INR/ 22031917645 nore ‘TEX 23-10-19 NEI 02-04 | rojas 33 BER/22071922814 enor WL 05-12-19 NO O10 | aps 34 JECOR/22120050461/ , OL XNHL fonventionalsorw-21-o7-20 MMOS! | r2ya5 35 [ECon/22121610933/ Lage prac} bupw-05-05-22 12/26 36 [ECoR/22121577308) BOXNHL Jknorr ——-buDW-29-04-22 12/26 — 37 WEOR 22141144245) OXNHL kknorr JUDW-05-05-22 12/26 38 feewanioissai35 xNHL pra — buDW-05-05-22 12/26 39 fecoR/22121610302/ | Some. rac —_bupw--04-05-22 12/26 0 [eCoR/22121616052) BOXNHL fenorr —-puDW-05-05-22 12/26 ai feoR/22101147767/ ait kknorr — PUDW-27-04-22 12/26 42 BECR/22141610368/ BOXNHL kknorr JUDW-06-05-22 12/26 8 feaatG 157207 DOU NHL not = PHSW 30/12/20 | 06-22 |. 8/25 44 ECoR/22121610876 BOXNHL MEDHA — PUDW-04-05-22 12/26 15 vue QZ @ Ne a tl 8 we PI: Ad45 BECR/ 22141586175) BOXNHL Knorr pwr 23-12-21 7126 46 [E0R/22101616324/ e IBOXNHL prac EUDW 605 12/26 7 BCR 722091613891) Knorr buDw 05-05-22 12/26 XNHL 4B WCR /22161610409/ RI? not = PUDW 06-05-22 12/26 4 |ECoR /22121613990/ DUDW.27-04- poe 24 nor Bap 12/26 50 [ECR /22101169304/ anaes BONAHL Ina UDW-30-06-22 12/26 ST WCR 22161115405) _|inap. Not m0. CR 72 fre: JUDW-30-06-22 12/26 52 ECoR/22121126421/ eae kknorr —-pupw 25/04/22 11/26 53 NCR 22151612198) knort JUDW 05/05/22 12/26 54 ECR /22101610896/ | brag puow 05/05/22 12/26 $B COR /22121613021 /BOXNHL [snore 56 WCR 22161611079 /BOXNHL peas BF FcR 22100050255 Hosp Wok BOXNHL lone 58 [ECR 22101151016 _[BMBS Insp /BOXNHL t done 59 [ECR 67102810073 (omvenore /BVCM, 12. DETAILS OF PREVIOUS RUNNING OF RAKE OF AFFECTED TRAIN: Loading at JGB-9/DHN on 20.10.2022. Unloading at PDTK (NR/UMB) on 23.10.2022, ‘Again loading at Banadag/DHN on 25.10.2022 for NTCD (Dadri) Total Km run from BPC issued = 5481 km (BSDC ~ NBCC, KNSP -TPSM, BNDG - BSPB, JNCP- PDTK & BNDG ~ NTCD : Derailed and Capsized at GAP. w We ee GO pha13. SPI RT of LOCO: - Speed in kmph [pistance Travel [Brake application| _ Remarks 00 00 = Start from GID 52 RG, AD 359 application 9 51. 4575 Emergency 5 65 6.09 Emergency 39. 38 7.60 Emergency 2 30. 7.75 Emergency, 9 113 20.72 Emergency Max. speed sf 113 21.33 Emergency Derailment 38 0 21.814 Emergency Stop Speed reduction started from 113 kmph at 06:19:39and train stopped within 59 seconds at 06:20:58hrs., travelling about 450 m distance. 14, INTERRUPTION: - UP line remained blocked from 06.24 hrs. of 26.10.2022 till 22.30 hrs, of 28.10.2022. Track fitness was given with speed restriction of 10 kmph of 1 train and onwards of 15 kmph at 18.20 hrs. of 28.10.2022 and OHE fitness was given at 22.30 hrs. of 28.10.2022, 1% Commercial train no. DSL/Empty & HSYG passed from site at 22.44 hrs. & 22.58 hrs. respectively on 28.10.2022. DN Main line remained blocked from 06.24 hrs. of 26.10.2022 to 17.20 hrs. of 28.10.2022, Track fitness & OHE fitness were given at 17.20 hrs. with speed restriction of 10 kmph of 1% train and onwards of 15 kmph of 28.10.2022. 1* Commercial train no. BOXN/E/60173 passed from site via DN main line at 18.00 hrs. on 28.10.2022. DN 1® loop line remained blocked from 06.24 hrs. of 26.10.2022 to 12.18 hrs. of 28.10.2022. Track fitness was given at 12.10 hrs. with speed restriction of 10 kmph of 1* train and onwards of 15 kmph of 27.10.2022 and OHE fitness was given at 12.18 hrs. of 27.10.2022. 1 Commercial train no. BOXN/E/7526 passed from site via DN 1% loop at 12,50 hrs. on 27.10.2022. no. BOXN/E/7526 passed from site via DN 1" loop at 12.50 hrs. on 27.10.2022. \e oe ow - ..9¢ \E pb3q15. RELIEF ARRANGEMENTS:- P28 Description |__ C/F OUT | Arrival AT SITE | Placement A. ART: ART /DHN | 06.30 07.45 | 09.47 (Controlled > at GID) ART /GMO | 06.30 06.56 | 08.40 (Controlled = at HRE) ART /GAYA | 06.40 07.08 | 07.45 (Controlled - at PRP, 22.20 at GAP) B, 140 T BD Crane: Crane/DHN | 06.30 07.45 12.20 12.40 with ART/DHN, Crane/BRWD | 06.30 06.56 15.45 17.10 Crane/DDU | 06.50 08.08 12.26 13.30 Crane/DNR | 07.30 08.22 21.07 06.35 (27.10.2022) | Grane/ASn | 07.00 09.35 23.25 = C, Bulldozer + Bulldozer/D | 08.10 10.15 | 15.10 (Controlled | 04.25 HN at GID) (28.10.2022) | D. Tower Wagon : GID 06.50 O71 08.05 - (26.10.22) PRP 07.00 07.58 08.20 - (26.10.22) BRHI 19.55 20.40 08.00 = (27.10.22) (28.10.22) DHN 08.12 08.29 11.33, - (28.10.22) GAYA 09.40 09.50 i251 = (28.10.22) GMO 12.00 14.05 22.35 (28.10.22) In general, Relief arrangements were satisfactory. vl “ga Wo ee 1816, RESTORATION:- Diesel Light Engine left GJD 08.53 hrs., arrived site/GAP at 09.17 hrs to clear 04 rear wagons and Brake Van. Started from site at 09.45 hrs. no, Details of restoration work are as under:- ‘S. | Wagon No. ‘Thrown out (Off Track) No. 7 | ECR/22101048880/ BOXNHL | 15.35 hrs. by DHN Crane on 26.10.2022. 2 | ER/22101141505/ BOXNHL | 14.50 hrs. by DDU Crane on 26.10.2022. 3 | ECoR/22121116569/ 15.48 hrs. by DDU Crane on BOXNHL 26.10.2022. 4 | SWR/22151176564/ 16.48 hrs. by DDU Crane on BOXNHL 26.10.2022. 5 | SECR/22140936315/ 17.47 hrs. by DDU Crane on BOXNHL 26.10.2022. 6 | ECR/ 22101145633/ | 18.48 hrs. by DDU Crane on BOXNHL 26.10.2022. 7 | WCR/ 22161123985/ | 19.17 hrs. by DDU Crane on BOXNHL 26.10.2022. 8 | ECOR/22121737948/ 22.40 hrs. by DDU & BRWD BOXNHL Crane_on 26.10.2022. 9 | SER/22071610087/ BOXNHL | 00.50 hrs. by DDU Crane on 27.10.2022 70 | SOR/22091610210/ BOXNHL | 01.32 hrs. by DDU & BRWD Crane_on 27.10.2022. 11 | ECoR/22121620547/ 01.15 hrs. by DOU & BRWD BOXNHL Crane_on 27.10.2022. 12 | ECoR/22121614881/ 02.15 hrs. by DDU & BRWD BOXNHL Crane_on 27.10.2022. 13 | SER/22072110678/ BOXNHL 14 | ECoR/22121334772/ 11.25 hrs. by DDU & DNR BOXNHL Crane_on 27.10.2022. 75 | ER/22022110826/ BOXNHL | 04.55 hrs. by DDU Crane Crane_on 27.10.2022. 16 | SECR/22141610498/ 11.28 hrs. by DNR Crane on BOXNHL 27.10.2022, 17 | SCR/22091616250/ BOXNHL 18 | SCR/22091613198/ BOXNHL | 09.52 hrs. by DDU & DNR Crane_on 27.10.2022. 19 | ECoR/22121621223/ 18.12 hrs. by DDU & DNR \ #e we pha?BOXNHL Crane_on 27.10.2022. 20 | ECoR/22121614973/ 14.18 hrs. by DNR Crane on BOXNHL 27.10.2022. 21 | ECR/22101170680/ BOXNHL | 07.20 hrs. by DNR Crane on 28.10.2022. 22 | SCR/22091611354/ BOXNHL | 09.38 hrs. by DDU Crane on 28.10.2022. 23 | NCR/22131612303 BOXNHL | 09.05 hrs. by DDU Crane on 28.10.2022. 24 | ECR/ 22101387804/ 11.45 hrs. by DDU Crane on BOXNHL_ 28.10.2022. 25 | SCR/22091610999/ BOXNHL 26 | ECoR/22121620943/ BOXNHL 27 | SECR/22141237220/ BOXNHL 28 | SECR/22141143873/BOXNH | 13.10 hrs. by DDU Crane on i 28.10.2022. 29 | ECoR/22121615741/ 09.55 hrs. by DHN Bulldozer BOXNHL on 28.10.2022. 30 | ECOR/22122212369/ BOXNHL 31 | ECR /22101383202/ BOXNHL 32_| NR/ 22031917645/ BOXNHL 33_| SER /22071922814 BOXNHL 34 | ECoR/22120950461/ 23.10 hrs. by DHN Crane on BOXNHL 27.10.2022. 35 | ECoR/22121610333/ 17.07 hrs, by DHN Crane on BOXNHL 27.10.2022. 36 | ECoR/22121577308/ 18.38 hrs. by DHN Crane on BOXNHL 27.10.2022, 37 | SECR/22141144245/ 01.48 hrs. by DHN Crane on BOXNHL 27.10.2022. : 36 | ECR/22101153133 BOXNHL | 12.19 hrs. by DNR Crane on 27.10.2022. 39 | ECoR/22121610302/ 21.30 hrs. by DDU & BRWD BOXNHL Crane_on 26.10.2022. 40 | ECoR/22121616052/ 01.02 hrs. by DHN Crane on BOXNHL 27.10.2022. 41 | ECR/22101147767/ 20,27 hrs. by DHN Crane on BOXNHL 27.10.2022. 42 | SECR/22141610368/ 21.25 hrs. by DHN Crane on BOXNHL 27.10.2022. 43 | SCR/22091574208/ BOXNHL | 01.30 hrs. by DHN Crane on 28.10.2022. 44 | ECoR/22121610876 06.07 hrs. by DHN Crane_on we ere ppsp23 so [BOXNHL 27.10.2022. 45 | SECR/22141586175/ 02.54 hrs. by DHN Crane on BOXNHL 27.10.2022. 46 | ECR/22101616324/ BOXNHL | 12.41 hrs. by DHN Crane on 27.10.2022. 47 | SCR /22091613891/ BOXNHL 48 | WCR /22161610409/ BOXNHL 49 | ECoR /22121613990/ 10.16 hrs. by DHN Crane on BOXNHL_ 27.10.2022. 50 | ECR /22101169394/ 08.22 hrs. by DHN Crane on BOXNHL 27.10.2022. 51 | WCR /22161115485/ 09.01 hrs. by DHN Crane on BOXNH 27.10.2022. 52 | ECoR/22121126421/ 08.40 hrs. by DHN Crane on BOXNHL 27.10.2022. 53 | NCR /22131612198/ 15.30 hrs. by DHN Crane on BOXNHL 26.10.2022. 54 | ECR /22101610896/ 14.21 hrs. by DHN Crane on BOXNHL 26.10.2022. 17, SELECTION OF WITNESSES & SUMMARY OF EVIDENCE:- Altogether, 26 Railway witnesses were called for examination and interrogation of 18 Railway staff was considered to be of relevance (because these employees were required to explain the reasons and fact finding). The statement sheets and cross-examination records are annexed with the Inquiry Report (Page-1 to AT) for ready reference. Those examined also included officials who were responsible for maintenance of the wagons and loco, Tethnical Notes of Sr.DEN(Cord,)/DHN(Page-188 to 191), Sr. OME/C&W/DHN(Page-192 to 196), Sr, DEE(TRD)/DHN (Page-62 to 64), Sr.DEE(OP)/DHN (Page-197 to 207), Sr. DSC/DHN(Page-57), Sr. DCM/DHN (Page-186 to 187), and Sr. DOM/DHN (Page-184 to 185) were also duly consulted. The evidences tendered by them are supposed to be the contributory factors to the cause of incident which is summarized as under:~ ee An(Sri Vijay Kumar /Loco Pilot(Goods) / HZBN (Page - 172 to 174): peat As per his statement, he took charge of the Train at 00.00 hrs and departed from HZBN at 00.20 hrs.After stopping at GJD station from 04.22 hrs to 05.55 hrs. the train departed at 05.55 hrs. As his train moved towards DLW from LBZ in down gradient, he tried to control speed of the train by dropping pressure but speed did rot controlled and speed of the train continuously increased. Again, he dropped more pressure but speed of the train could not be controlled. He again tried to control the speed of the train by applying A-9 and Emergency brake was also applied by the ALP, but the speed of the train did not controlled/ reduced. He shown red flag to SM/DLW and also attract attention of Guard by blowing prescribed Whistle code( 03 shorts). He again by maintaining pressure, dropped the same but speed again could not be controlled. He passed all Signals in OFF position. He saw Gurpa Home Signal red, and passed Gurpa Home signal in ON position. The Engine+ one wagon stopped in GAP Loop line During cross-examination, he replied that, he conducted Brake power test but the same was not conducted in proper Zone. Further he replied that after passing LBZ IBH, he dropped 1 Kg/cm2 pressure but speed did not reduced. Between DLW,Distant and Inner Distant signal, Emergency brake A-9 was applied by him and and his Assistant applied RS-1. He also tried to inform Guard through Walkie-talkie and by Whistle code but Guard did not reply.In reply to another question that how his train stopped, he told that Loco brake was-applied up to 2.5 Kg/CM2 and Engine+ one wagon( without rear trolley) not found and train stopped due to dragging of a wagon. He stated that Cause of derailment was failure of BMBS.The location where his train not controlled was in 4 degree curve and was in 1: 80 gradient. Further, he stated that less effective braking system was experienced in the past also with the train having BMBS. (ii) Sri Satish Kumar/ALP/HZBN (Page- 170 to 171) : ‘ss per his statement, he started from HZBN at 23.46. When he passed LBZ, for controlling the speed ,pressure was dropped by LP but he saw that roe Ns “ g gespeed did not reduce. LP applied A-9 and RS-1 by him but speed could p23? not be controlled, After LBZ, he shown red flag to all Station Master and reported to Guard of the train through Walkie talkie, He also switched ON Flasher light of the train. Speed increases during run. He lost his consciousness after seeing Gurpa Home Signal red. During the cross-examination, he conducted Brake power test between Hazaribagh Kansar Nawada and found OK, Further, he replied that any miscreant activity was not noticed at GID station. In reply to another question, he told that from Engine, in five Wagons Brake was active in 3 wagons. He also accepted that before starting from GID, he made conversation with Guard. In reply to another question he told thet Emergency Brake was applied between Distant and Inner Distant signal of DLW station, He further told that DJ was opened before GAP Neutral section. He also accepted that before entering in GAP Station speed was about 100 KMPH. He also he stated that less effective braking system was experienced in the past also with the train having BMBS. According to him cause of accident was poor brake power. (iii) Sri Arjun Chandra Hembram, SSE/TRD/GJD (Page- 168 to 169) : As per hs statement, he got information about accident at 06.33 hrs. by TPC/DHN. He offered GID Tower Wagon at 06.50 hrs. at reach site at 08.08 hrs. Power Block was granted from GAP/SP to PRP/SSP in both UP and DN. During the cross-examination, it was asked whether he agrees with the cause of accident mentioned in the Joint note and what was the base for the same. He replied Prima facie cause of accident as per Joint note is failure of brake system. He with joint signatory came to the conclusion for the same by observing each and every thing. (iv) Sri Mritunjay Kumar Akela, Asstt. Sub Inspector/GAP (Page-166 to 167): As per his statement, he told that about 06.14 hrs. SM/GAP announced that a train coming with loss of contro! and it was to be derailed in UP loop line. RPF should remove all public. Then he and A.K.Pandeycleared all public from PF No.1 & 2. As they were clearing Public, he p/232- saw at about 06.20 hrs. a engine with one wagon came and stopped near RPF’s barrack and smoke was coming from the wheel of the engine. He further moves towards accident place and cordonned the accident spot. During cross-examination, he replied that there was no miscreant activity at the station in his knowledge from 05.03.2022. Further it was asked regarding his observation in accident affected train, he replied engine was coming with loud sound towards his barrack and stopped there. Smoke was seen coming from the wheels of the engine which was extinguished by LP and ALP by fire extinguisher. Further he did not say anything regarding cause of derailment. (v) Sri Niraj Kumar Sinha, TI(M)/PRP(Page- 164 to 165) : As per his statement, he got the information through SS/GAP. Controller/ DHN had told on duty SM/ GAP to receive UP train in over run line. He immediately moves to GAP Station. During cross examination he stated that his beat is between DLW and BNF, In reply to another question regarding any miscreant activity, he told that that was not in his knowledge. He also told that having no any report regarding loss of brake power in the train. (VI) Sri Umesh Pratap Singh, SSE/TRS/CNB (Page- 162 to 163): ‘As per his statement, he got the information regarding accident on 26.10.2022 and reached GAP station on 27.10.2022 with RDSO team. Due to none availability of OHE at GAP station, he told that joint checks of Loco was not conducted at Gurpa station and the same was done at Gaya. Joint check was conducted on 28.10.2022 by 06 supervisors and all Pneumatic parameter of Loco was found OK. During cross examination, he ‘stated that Loco was commissioned on 30.11.2019 in the loco shed/CNB and having FTRTIL Make E-70 brake system. Last OH schedule conducted on 14.10.2022. In reply to another question he told that there is no report of loss of breke power cases with the Loco of CNB shed. He did not say anything regarding cause of accident.(VII) _ Sri Ram Akbal Kumar, SSE/P.Way/PRP (Page- 160 to 161): According to his statement, he got the information regarding accident through Engg. Control/DHN about 06.25 hrs. He rushed to accident site by motorcycle at 07.10 hrs. He saw that accident took place in UP Loop line between 425/5A- 425/9A in about 200 meters and wagons were in capsized condition. One wagon whose HWH end trolley was dragged with Engine also found in derailed condition. ‘According to him cause of accident was over speed and loss of control, During cross examination, he replied that he has been working on the present post from 15.07.2021 and his beat is in between 424/23 - 462/17. Location of derailment was ahead of Point no. 52A/E trap point (1 : 8.5). Speed of loop line track is 30kmph. In reply to another question regarding outside interference cases in the past, he told such type of activity is not in his knowledge.According to him cause of accident was loss of contro! and over speed. (VIII) Sri Manish Kumar Jaiswal, JE/Signal/PRP (Page- 158 to 159) : According to his statement, he got the information regarding accident of UP NTCD train at about 06.27 hrs, through signal control DHN. After arrival at GAP Station, he came to know regarding loss of control of train and route was set for UP Loop line but Home signal was not taken off. Derailment of train took place in UP Loop line damaging trap point no. 52AE, Location box 19 adjacent to Up loop line. As per Data logger, route for receiving the train was set at 06.13 hrs, train entered calling on track at 06.19 hrs, and passed Home signal at 06.19 hrs. The train cleared the Home signal and calling on track at 06.20 hrs. During cross examination, he replied that he has been working on the present post from 27.05.2022 and his beat is in between GAP-BNF. Further he told that there is no miscreant activity in affected section. Further he told in reply to a question that he is agree with the prima facie cause of accident. we , a o p23)(1X) Kumar Asutosh Sinha, $M/GJD (Page- 156 to 157): ‘According to his statement, he was SON’ duty in 00.00-08.00 shift as indoor SM on Panel. The said train arrived UP Loop line at 04.20 hrs. and after given precedence to parcel special, 12987, 12307, 12321 and 15021, the NTCD started at 05.55 hrs. from GJD. During cross examination, he replied that he has been working on the present post from 2015. Further it was asked regarding miscreant activity whether any information by any person or noticed by him. He replied that no miscreant activity was reported by any person or noticed by him. In reply to another question regarding any failure/defect reported by any one and crew, he told that nothing was reported to him by the crew. (x) Sri Rajesh Kumar Sinha, SS/GAP (Page —154 to 155): ‘As per his statement, he was ON duty in 00.00 to 08.00 hrs. shift with Manish Kumar, 15021 Exp. passed GAP at 06.09 hrs. and Line clear for UP NTCD was given at 06.10 hrs. As soon as, UP Exp. fully passed advanced starter, Line clear for NTCD was given. Immediately after granting Line clear to NTCD, Section Controller informed regarding loss of control of NTCD from DLW Station and he also asked to set the Runoff line. There is no provision of taking of home signal after setting of Runoff line. Announcement was regularly started to leave the PF by public and passenger and said information was also given to RPF. NTCD train left YGM block hut at 06.18 hrs. and with full speed entered in the UP Loop line and derailed. During cross examination, he told that he has been working on the present post from April 2009. He replied that no miscreant activity was noticed when he was asked regarding any miscreant activity in his duty hrs. In reply to another question regarding loss of control, he replied a case was happened at BSCP/BH and having no margin, the said train was made through and it was stopped before TKN station due to UP gradient. In reply to another question for setting of Main line to prevent accident he ae Nua “ew Gaon phx?told that as 15021 passed GAP at 06.09 hrs to prevent the rear, end p49 collision controller took the decision to set over run line which was right decision as per circumstances. ga st Shashi kant Kumar/Sr. Goods Guard(NTDC)/HZBN (Page- 152 to In his statement, he told that train departed from HZBN at 00.20 hrs. and arrived GID at 04.22 hrs. Again started from GID at 05.55 hrs. and passed LBZ at 06.05 hrs. When his Brake ~van was in between DLW Inner Distant signal and Home signal, he heard three small Engine Whistle and sound of Loss of control. He immediately dropped pressure but train did not stopped. Then he Applied the hand Brake of Brake-van but speed of the train continued rising. Ultimately train got derailed while entering in GAP UP Loop Line. During cross examination, he replied that he got the GDR from HZBN station and it was proper. Brakes feel test was also conducted after start from HZBN and it was found correct after dropping 1 KG/cm2 pressure. In reply to another question regarding action when he got information regarding loss of control, he replied that he saw his pressure gauge and BP needle was on Zero. He again dropped pressure but it could not be felt /acted. While passing DLW station, he show red flag and thereafter applied hand brake but train could not be controlied. He informed to Dy. Controller/DHN through his Mobile Phone regarding loss of control at about 06.10 hrs. Further it was asked, whether Brake test was conducted in Brake testing zone between KQR-GJD, he replied that it was done but train speed reduced very less. He further stated that During Emergency brake application Position of BP Gauge was zero and no any sound was heard. According to him cause of accident was Fallure of Brake power. (xii) Sri Vijay Kumar Verma /CTNL(Goods)/DHN (Page-150 to 151): In his statement, he told that re received information regarding loss of contro! at 06,09 hrs. by Guard Sri Shashikant Kumar while passing the train at DLW station. ‘According to him speed of the train in the Ghat section was not being controlled. we Ne TeHe immediately rushed to GC board and saw that the train which was running ples ahead of Goods train has passed already GAP station, Meanwhile, NGY station also heard saying regarding showing of red signal by driver. Immediately it was decided to receive the train at GAP runoff line and accordingly it was ‘informed to SM/GAP to set the run off line at 06.20 hrs. GAP/SM informed that the train is derailed while entering in Up loop line. Information was relayed to all concerned. During cross examination, he replied to a question that after receiving information regarding loss of control he did not took the decision to made OHE off because In the Up direction train_no. 15021 was running ahead of this goods train and in that case the train no. 15021 might have stopped and possibilty to collision with goods train was imminent which was out of control due to loss of brake power. Further, he also replied in reply to another question regarding loss of control of train no. TUN in 1996. which was also received in GAP Up line. (all) Sri Rajesh Kumar, Section Controller/DHN (Page -148 to 149) As per his statement, while he was taking charge on 26.10.2022 in 06-12 hrs shift. y.Goods came to board and informed regarding failure of brake in Train no. NTCD 32633, He also told for receiving the said train in GAP run offline, At the same time at 06.11 hrs., NGY/ SM informed regarding failure of brake of NTCD and speed of the train was also reported high and he also told that Loco Pilot was showing red hand signal. At 06.09 hrs., after receiving signal out of out section of 15021 from GAP, SM/ GAP was directed to receive the train NTCD in run over line, In is section, all train were controlled, At 06.19 hrs. train derailed while entering in Up loop line. During cross examination, he replied that he’ received information through Dy. Controller/Goods Sri B.K. Verma. when asked regarding how he got information regarding loss of control in the train, Further it was asked at the time of which train was running on the board and for its safe movement what action being taken by him, he replied at that time train no. 15021 Exp. was running ahead and he informed to GAP and PRP station for giving line clear.(xiv) Sri Dharam Singh, SSE/C&W/DDU (Page-146 to 147): As per his statement, on 10.10.2022 he was on duty in 16-24 hrs. shift. As per AYM/A Cabin TP/DDU-594 examined at 16.20 hrs DMY/A4 at 19.20 hrs, On 10.10.2022 DDU SP working as per Dy.CNL. During cross examination, he stated that he has been working in Dn. marshaling yard from 2018. Further, he stated that there were 6 conventional wagon and 54 BMBS wagon in accident affected rake. Further it was asked for preparing long haul with air brake’system, he gave fit to that rake. He replied that fitness was given in twin air brake system. In reply to another question he told that at the time of preparation of long haul train no. 5073 was in single pipe air brake system, Due to the one rake being fitted with single pipe, this rake was also to run with single pipe ait brake system. Further, he stated at the time of formation of long haul CC rake having 100% brake power and premium rake was with 98% brake power, He further told that in the twin pipe brake system, brake releases quickly. (xv) Sri Raj Kumar Verma, SSE/C&W/DDU(Page-144 to 145): As per his statement, he was working as shift in-charge in DRY on 10.10.2022. There were 5 batches of rake examiner and one batch for testing working under him, Accident affected rake.was after examination tested with twin pipe and brake power was found 100%. During cross examination, he stated that he has been working at DDU from May 2018 and as a batch in-charge of ‘p’ batch. In the accident affected rake examination was done in his presence and one wagon brake cylinder found defective, one wagon APM leakage and resultantly both wagons were made sick, In the 4 wagons APM lever was adjusted. According to him after operation of angle cock, train partially release automatically in 45 to 60 minutes. Had the Driver and Guard before starting from GID station would have checked the continuity, the accident would have been may be averted. w \e a pie?(xvi) Shri Tulsi Chaudhary, SSE/C&W/DDU (Page-142 to 143) + As per his statement, he was on duty in DRY/DDU in 16-24 hrs. shift on 10.10.2022. Train no. TP DDU 594, engine no. 23247 + 23294 load 58+1 came in ine no.7 at 16.20 hrs. Train 15 wagons were ‘examined from HWH end from both end from 16.30 hrs. to 17.45 hrs. and defects were noted on wagon as well as in diary. All defects were repaired up to 17.45 hrs. During cross examination, he stated that he has been working on the post from 36,09.2014 and after examination the premium and CC rake are being formed. He replied in affirmation when he was asked whether the accident affected train rake was examined in his presence. Train was examined in his presence. 2 wagons brake block, 4 wagons snubber spring, 4 wagons EM pad and ane wagon adopter was found defective. He told during reply of the question that after operation of angle cock, brake releases in 45 minutes partially. According to him, the cause of accident was not checking of BP gauge by Guard and Brake test was not done by driver, (xvii) Sri Pankaj Chaurashia/CLI/GJD(Page-139 to 141): In his statement, he stated that he got the information regarding accident through TLC. He reached at accident site by his two wheeler at 09.20 hrs. He conduct BA test of LP and ALP in presence of SS/GAP and PWI/PRP. He removed the speedometer memory card and there after inspect the loco and wagons. He found brake binding sign and also metal deposit on some wheels, Loco A-9 and SA-9 was found in applied position. RS was also In applied position and flasher light was In glowing condition. BPC was of 90% BMBS (Knor BREMS). One wagon was found attached with loco. After checking the brake van brake application found but in the near by wagon such mark was not found. During cross examination, after reaching the site he found A-9 in applied position. ‘As well as RS valve (Emergency brake) was also in applied position. Brake was found applied in all wheels and on some wheels metal deposit was also found. According to him, there were brake testing zone in between KQR-IBP-9 (GID) and we NV ge peebetween LBZ-DLW. When asked whether brake are being not functioning properly due to APM malfunctioning in ghat section and curve. When it was asked regarding counseling of brake testing zone, he replied that prescribed speed is 50 kmph and by dropping 1kg BP, in 20 second speed reduced to 35kmph. If it is not, then the same to be informed to GJD station and TKR is demanded, According to him, RDSO has fixed the speed 50 kmph in 1:100 grade and 65 kmph in level section. Further it was asked in the BMBS rake during GDR what is the instruction for checking of APM and brake cylinder. He replied in the available GDR proforma there is no column for APM test. He replied in affirmatively when he was asked whether driver Is being counsel for checking of APM and brake cylinder. (xviii) Sri Saroj Kumar, SSE/C&W/KQR (Page-137 to 138): In his statement, he stated that he got the information from C&W control/DHN at 06.10 hrs. regarding poor brake power in train no. NTCD 32633 and it was also asked to be ready for moving GAP station. He was ready for the same in the mean while at 06.40 hrs, he got the information regarding derailment of NTCD train at GAP . He moved. for GAP to check the train. He reached GAP at 09.17 hrs. and found brake van of NTCD train at KM 425/3 and in brake van no BP gauge was found. Guard was asked to show the BP gauge and he shown the same by taking Out from the Guard's box. 4 BOXNLHL wagons + 1 brake van by attaching loco No. 70157 made ready at 09.40 hrs and moved for GID station at 09.45 hrs, Rest 53 wagons were found being badly in capsized condition. Derailment was took Place between 425/5-425/21. Engine was on the track and on each wheel braking mark was found. During cross examination, he told that after reaching site, he found 4 wagons and brake van on the track, rest 53 wagons were derailed and capsized in very bad condition. At the barrack RPF/GAP engine was on the track and a loaded wagon was In derailed condition with it and its HWH end trolley was not available. Brake cylinder was found active. Further he was asked regarding brake system and brake cylinder of 4 wagons and brake van on the track, He replied that all ¢ wagons and » Vet oePia brake van brake cylinder was in active condition and brake block was-with wheel. He replied that engine was in shut down condition and Kalka end wheel north side brake block was in burnt condition, According to him the cause of the accident was due to not testing of brake in the brake testing zone between KQR-GJD and even after stopping GJD of loop for about 1.33 hrs. no continuity test was conducted, 18. SEQUENCE OF EVENTS: - After site visit, examination of documents &concerned employees, eye-witnesses and cross- examination, the circumstances and events leading to the derailment of train no. UP Goods NTCD/32633, the following are broad observations: - > After loading of rake, Said train started from Bandag siding to HZBN on 25.10.2022 for its destination NTCD (Dadri). GDR of this train was done at HZBN on 25.10.2022and no abnormalities was found. Train No. UP Goods NTCD (Dadri) CC Rake (Single Pipe) with load of 57 BOXNHL loaded (Coal) + 01 BOXNHL Empty + 01 Brake Van (BVCM) hauled by Electric loco no. 32633/WAG-9/CNB with load 5107.8 ton, Brake power and continuity of the rake was within validity. > Crew took charge of the Train at 00.00 hrs. Train started from Hazaribagh Town (HZBN) station (line no. 3) at 00.20 hrs. on 26.10.2022. Train stopped GID at 04.22 hrs. and departed at 05.55 hrs. After passing Lalbag BH (LBZ) at 06.05 hrs., LP applied break for controlling the train in falling gradient but did not control the train and he informed the Guard on walkie-talkie and also blown prescribed whistle code (03 shorts) for assistance of Guard. » Guard also dropped the pressure but no drop of pressure was noticed/ experienced by the Guard of the train and the train could not be controlled. After passing Dilwa (DLW) at 06.07 hrs., Guard informed to Dy. Chief Controller/DHN though mobile and also exchanged Red Hand Signal with on- duty SM/DLW. On-duty SM/DLW informed to on-duty SM/Nathganj (NGY) and ‘Section Controller/DHN. v vpla > Train passed NGY at 06.12 hrs. Baskatwa (BSCP) at 06.15 hrs. And Yadugram (YGM) at 06.18 hrs. Home Signal/GAP kept at ‘ON’ and set for run off line. In the mean while, due to loss of control the train entered in UP loop line/GAP with speed of 112 kmph, which was very much higher than the permissible speed of 30 kmph resulting train got derailed and many wagons capsized between km 425/5 - 425/21 A. Consequently, movement of trains from UP and DN line blocked, ‘The derailment occurred on UP loop line, GAP in Koderama (KQR) ~ Manpur (MPO) section of DHN Division. » At 06.24 hrs. Section Controller, DHN was informed by Panel SM/GAP, regarding derailment of train no. UP Good NTCD /on UP loop line, GAP. > 53 wagons were found derailed and capsized . Loco with 01 derailed front ‘wagon was travelled approx 450 meters in UP loop line of GAP station and rear 04 wagons with 01 B/Van were found on rail. 02 nos. wagons derailed in DN main line, 12nos. wagons derailed in UP main line, 38 wagons derailed in UP loop line and also 01 wagons derailed UP loop line near GAP station building. Distance between last derailed wagon and 1% derailed wagon (just behind engine) was about 450 meters. > Total 05 wagons, Including brake van in the rake were having conventional v v v brake system. Remaining 54 wagons were having BMBS air brake system. > All loco wheels were having signs of brake application. Skidding marks on some wheels was also observed. . One wheel set of one bogie of wagon no. 22140936315 having conventional brake system, 5" from loco having signs of heat generation due to braking. Details of Damaged S&T : Point machine with ground fitting of Point no. 52/A was found damaged. 1 no. point JB of point no. 52/A, 6 nos. TLIB damaged of track circuit no. 52T, OST, S1AT. 16 nos. track jumper cable damaged. Location no. L-19, Half L. Box (Bat. Box) one no. each. 04 nos, main cable (4X3 Core). 02 nos. main (2 X 12 core) & 1 X quad cable. 3 nos. 80 AH batteries damaged. 1 Track charger, 1 variable resistance. v v> Details of Damaged TRD : UP Main Line -02 nos. CA mast broken at location 425/789. 1 no, DCA mast damaged at km 425/3, 01 no. RE mast + dwarf mast broken & counter weight was grounded at km 425/9. Contact & centenary wire damaged between km 425/3 to 425/15. 01 no. un- insulated overlap damaged at km 425/3-5. 01 no. Turn out damaged between km 425/1-2. DN Main Line : 01 no. mast broken and centenary wire damaged at km 425/8. 01 no. un-insulated overlap damaged between km 425/10-16. 01 no. Turn-out damaged at km 425/6.0HE wire damaged from km 425/6-16. 01 no. cross-over affected at km 425/1-2. 01 no. RE grounded at km 425/16. UP Loop Line : RE was grounded of loop line & OHE damaged at km 425/1-2. 01 no. SCA mast broken and cantilever damaged at km 425/7A, OHW was damaged of loop line between km 425/3A-15/A. » It was confirmed after cross examination with crew of train before Starting the train from line no. 3, HZBN, that brake feel test was done but Brake power test but the same was not conducted in proper Zone. > Up loop line of GAP station was fit at the maximum speed of 30 kmph for train Movement but said train was entered with speed at 112 kmph as per Speedometer chart of loco, > Wagon no. ECR/22101048880, 1* from train engine, got derailed by 04 wheels of KLK end trolley and HWH end trolley was missing. » All wheels of Loco were on rail. Brake applied was observed at all wheels. Rear 04 wagons and 01 B/Van was on rail. > Dragging mark was found about 450 meter after deraliment of train. Tack, sleepers and fittings of track of UP Mainline were badly damaged about 200 meters. > As per log book of loco nothing abnormality/unusual was recorded except light and gauge light of ALP side was found out of order. v 19. ANALYSIS OF TECHNICAL APPRECIATION NOTES OF DIVISIONAL OFFICERS AND OTHER IMPORTANT FACTS: (i) There was sign of brake application (heat generation) on the wheels of loco, which indicated there was brake applied by crew. (li) Loco was jointly checked at Gaya and found all parameters within the limit. Hence there was no issue form the loco side. (ili) Loco Log Register was checked and found that no defect was recorded in the Register. Loco was also not due. ~ we New SF ao Praspio? (iv) GDR of. this rake was done at HZBN on 25.10.2022 and no abnormalities was found. (v) Track Structure at the derailment site: Rail-60 Kg, 90 UTS, Sleeper- 60 KgPSC, 1660 sleeper density, Fasting - Elastic Alignment : Straight Bank/Cutting — Cutting having varying height of 2-5m. All fittings in approach of derailment location were found intact and in sound condition and standard ballast profile was found in approach of derailment location, (vi) This patch is not a corrosion prone area. No corrosion is observed either in rail or in weld. (vil) Track parameter were jointly measured by Joint Signatories and all track parameters were found within permissible limit behind and ahead of the accident locations (POD) on affected and unaffected track. Track profile was also found proper in the vicinity of affected and unaffected track. (vill) As per Joint Note of the Sr. Supervisors prima facie cause of derailment was “Loss of Brake Power observed by LP during run’. (ix) ut of total 59 wagons, 05 wagons were fitted with conventional braking system and remaining 54 wagons were fitted with BMBS, (x) On the analysis of Speed Chart, the speed of train was approx. 112 kmph at the time of derailment and dropping of speed from 112 kmph to 0 kmph within 59seconds travelling a distance of about 450 meters. (xi) wagonswere allowed to run in CC rake which has safety implications. (xil) In Technical Noteof Sr. DEE/OP/DDU hasstatedthat: - “the possible cause of the derailment was due loss of control .” (xii) Sr. DOM/DHN opined in his Technical Note that “derailment occurred due to failure of breaking system.” we N\A we Qe/2>0 (xiv) Sr. DSTE/DDU has no comments about possible cause of derailment. FL (xv) _ In Technical Report, Sr, DEN/Cord/DDU opined that - The reason of loss of control which leads into higher speed of train ", (xvi) There was no evidence/clue of suspected miscreant activity/outside interference/sabotage which was observed or reported by anyone. It was also not established during cross examination with witnesses, local police, ‘Thus, sabotage angle is also ruled out”. (xvii) Probable cause of accident on account of OHE was also ruled out. In this regard, there was no any evidence or clue produced. In Joint Note also there was no mention. 20.DISCUSSION: |ENT- RS Factors relevant to cause of derailment:- |. Convulsion of nature, . Sabotage, ;. Obstruction on track. |. Defects in P.Way. . Defects in Rolling stock. Human failure panos These are discussed in the following paras. a. Convulsion of nature: There was no bad weather condition, Visibility was clear. Neither it was raining nor there was any storm. There is no evidence on record that the accident was caused by convulsion of nature, * b. Sabotage: The derailment occurred at 06.24 hrs. Visibility was clear. Loco Pilot could have noticed any suspicious movement or activity. However, he did not notice any such activity. The section carries heavy traffic and the section is very busy. No Railway witness during the Inquiry pointed out such possibility. ‘The officers also visited the site immediately after the accident did not have any reason to believe sabotage as the possibility. Hence it is concluded that the accident was not caused by sabotage. te Ne GTPiat | It was also established in Technical Report of Sr. DSC/ECR/ DHN that “The site was thoroughly investigated and there was no sign of any outside Interference. Thus, sabotage angle is also ruled out”. c Obstruction on track: Nelther loco pilot nor any body mentioned noticing any obstruction at track, During inspection by the officers and senior supervisors to reach the site, no evidence surfaced either then or later during the enquiry to the effect that an. obstruction was found on the track to the movement of the train. Hence it.is concluded that the derailment was not caused by obstruction on track. d, Defects in P.way- There is no defect noticed on part of P. way. e. Defects in Rolling stock- The instant accident involving freight train has the back ground of wagons fitted with BMBS. Taking into account the different study/trial reports by RDSO for BMBS and related instructions issued from Railway Board/RDSO to Zonal Railways, brake power vis-a-vis brake power of rakes fitted with under frame mounted brakes resulting into more braking distance varying from 18% to 24.2% with speed & gradient to the extent of 60 kmph & 1: 100. It has been also observed that the brake press drop In BP of BMBS rakes is also on a reduced scale to extent of 4:3 in comparison to under frame mounted brake system. In view of the above a number of stipulations/instructions have been issued by RDSO & Rly. Bd for safe operation of trains fitted with BMBS like - > Conduct of trial and specify the attacking speed at the approach of ghat as per the local conditions. > 50 kmps speed in 1:100 gradient. > Proper GDR check Brake application instructions for Crew, use of emergency & regenerative braking and other driving instructions like Brake feel & Brake power test at the specified locations, 100% BP Correct functioning of APM Twin pipe working of rakes with BMBS etc, Human failure- (i) It is noticed by the enquiry committee thatLP not conducted brake test between Koderma Gujhandi section at Mast no, 396/15 as prescribed special instructions in WTT DHN vide para SR 4.21 (ili)(b) & (iv) and become unconscious at the time of derailment while receiving train at v vv ”(ii) i) (iv) ) Gurpa loop line, In addition to that while taking over charge of loaded train LP has to check 5 wagons from Loco end with the application of A9 to full service position for checking no orange indicator on APM and no gap between sensor of APM and bogie frame and not conducting continuity test as per prescribed procedure. It is noticed by the enquiry committee thatALP become unconscious at the time of derailment while receiving train at Gurpa loop line. In addition to that while taking over charge of loaded train ALP has to check 5 wagons from Loco end with the application of A9 to full service Position for checking no orange indicator on APM and no gap between sensor of APM and bogie frame and bogie frame and not conducting continuity test as per prescribed procedure. Tt is noticed by the enquiry committee thatGuard has to check 5 wagons from Brake Van end with the application of A9 to full service position for checking no orange indicator on APM and no gap between sensor of APM and bogie frame and not conducting continuity test as per prescribed procedure, It is also noticed by the enquiry committee that as per the instructions issued by RB/RDSO, the BOXN/HL rake fitted with BMBS and with load greater than 3000 T the brake should be of twin pipe functionality. However in the instant case the culprit train was being run by single pipe, Tt was noticed by the enquiry committee at accident site that brake application found on loco wheel and bushes were rubbed on locomotive and first wagon attached. (vi) It was also noticed that damage marks found on sleepers due to 450 meter dragging, CONCLUSION AND CAUSE OF DERAILMENT (A) The instant accident involving freight train has: the back ground of wagons fitted with BMBS, Taking into account the different study/trial reports by RDSO for BMBS and related instructions issued from Railway Board/RDSO to Zonal Rallways, it Is now a settled proposition that the freight trains with BOXNHL stock (Loaded with more than 3000T) fitted with BMBS have poor/inadequate brake power vis-2-vis brake power of rakes fitted with under frame mounted brakes resulting into more braking distance varying from 18% to 24.2% with speed & gradient to the extent of 60 kmph & 1: 100. It has been also observed that the brake press drop in BP of BMBS rakes is also on a reduced scale to extent of 4:3 in comparison to under frame mounted brake system. Bo * a gem pptNe ly} In view of the above a number of stipulations/instructions have been issued by i RDSO & Rly. Bd for safe operation of trains fitted with BMBS like - > Conduct of trial and specify the attacking speed at the approach of ghat as per the local conditions, 50 kmps speed In 1:100 gradient. Proper GDR check > Brake application instructions for Crew, use of emergency & regenerative braking and other driving instructions like Brake feel & Brake power test at the specified locations, > 100% BP » Correct functioning of APM > Twin pipe working of rakes with BMBS etc, vv In the context above and with the background that the ill-fated freight train was fitted with BMBS, the enquiry committee fully acknowledging the inherent drawback associated with the BMBS, involved itself into exploring the aspects of failure/neglect of the associated instructions as stipulated by RDSO/Rly Bd. for safe train operation i.e. in particular BMBS BOXNL rake with >3000T load and accordingly fixed the responsibility as indicated below. However, the issue of BMBS needs a serious deliberation at the apex level for its running in ghat sections and accordingly, if so decided, to issue some necessary comprehensive stipulations and Its stricter compliance on part of Zonal railways. References: 1. RDSO letter no. EL/3.2.19/3-Phase dated 10.05.2022 2. RDSO letter no. MW/APB/BMB dated 23.07.2022 3. RDSO letter no. MW/APB/BMB dated 25.01.2022 (B). Having carefully considered all the relevant facts and evidences on record based on accident site visit, statements & cross-examination of witnesses, the circumstances and events leading to the derailment of the train, the committee has come to the conclusion that derailment of the train in all probability took place due to the reason as under:"Loss of brake power/effectiveness resulting into attacking/approaching On Gradient (in GID-GAP section) at higher speed leading to uncontrolled movement and speed exceeding 100 KMPH prior to approach of GAP station where the train was planned to be received in over runline, At this speed wagons could not negotiate the point (for constraint of 1 in 12 turnout) and thus got thrown we Be N-ye out due to centrifugal force resulting in derailment and piling up of re 53 wagons there.” RESPONSIBILITY PRIMARY- () Shri Vijay kumar,LP(G)/HZBN- for not conducting brake test between Kodarma Gazandi section at Mast no. 396/15 as prescribed special instructions in WIT DHN vide para SR 4.21 (iti)(b) & (iv) ° ; showing poor enginemanship, at the time of derailment while receiving train at Gurpa loop line. In addition to that while taking over charge of loaded train LP has to check 5 wagons from Loco end with the application of A9 to full service position for checking no orange indicator on APM and no gap between sensor of APM and bogie frame and not conducting continuity test as per prescribed procedure. (Violation of G&SR 2.11, 4.31, 4.32 & 4.41) (ii) Shri Satish kumar ALP/HZBN- for not conducting brake test between Koderma-Gazandi section at Mast no. 396/15 as prescribed special instructions in WTT DHN vide para SR 4.21(iii)(b) &(iv) “_ showing poor enginemanship, at the time of derailment while receiving train at Gurpa loop line. In addition to that while taking over charge of loaded train LP has to check 5 wagons from Loco end with the application of A9 to full service position for checking no orange indicator on APM and no gap between sensor of APM and bogie frame and bogie frame and not conducting continuity test as per prescribed procedure. (Violation of G&SR 2.11, 4.31, 4.32 & 4. 441) (iii) Shri R.K.Verma, SSE C&W/DDU- for poor maintenance of APM fitted with the BMBS rake of the culprit train as maintenance record \, ee oe