A detailed inquiry conducted by the railways has blamed “lapses at multiple levels in managing train operations under automatic signal failures” for the June 17 accident involving the Kanchenjunga Express and a goods train.

Ten people were killed when the goods train rammed into the rear of the stationary Agartala-Sealdah Kanchenjunga Express near Rangapani station, on the outskirts of Siliguri.

The report, prepared by Janak Kumar Garg, chief commissioner of railway safety (CCRS), also underscored the top priority of installing an anti-collision device, Kavach, in the region to prevent such accidents.

In his 29-page inquiry report submitted to the Railway Board on July 12, Garg detailed five major provisional findings. The loco-pilot of the goods train and two other railway employees had also lost their lives in the crash.

The Northeast Frontier Railway (NFR) has already suspended four employees for dereliction of duty in connection with the accident.

“Having carefully considered all evidence, records submitted, observations made during the site inspection, and other circumstantial evidence produced by Northeast Frontier Railway, I have come to the conclusion that the rear-end collision... occurred due to lapses at multiple levels in managing train operations under automatic signal failures,” the report, a copy of which was accessed by this newspaper, said.

Among the major findings, the first one refers to the issuance of the wrong paper to the loco pilot to pass the red signals between Rangapani and Chatter Hat railway stations, where the automatic signal was not working.

“The authority T/A 912 was given to Loco Pilot to pass all mentioned defective signals without any Caution Order. This created an impression in the mind of Loco Pilot that all defective signals can be passed at the maximum permissible speed of the section,” the report said.

“Issue of T/A 912 instead of T/D 912 in case of all signal failure violating the provision of SR (sub-rule) 9.12/1,” it added.

The report said different station masters had been following different procedures for issuing T/A 912. “There is no uniform system, indicating misinterpretation and misunderstanding of rules at field level.”

As the Railway Board had initially blamed the deceased loco pilot of the goods train for the accident, multiple railway employees’ organisations raised protests. The organisations claimed that the accusation was unfair before a full-fledged probe. They argued that the T/A 912 form issued to loco pilots did not have any speed limit, and the station manager should have issued the form T/D 912, which carries speed limit instructions.

Garg’s report mentioned that “inadequate counseling” of loco pilots and station masters about train operations in automatic signalling territory created “misinterpretation and misunderstanding of rules”. The CCRS gave top priority to installing anti-collision devices, recommending to the railway authorities the prioritisation of the system’s intsallation to prevent such accidents.

“The occurrence of as many as 208 cases of Signal Passing at Danger from 1.4.2019, to 31.03.2024, out of which 12 cases resulted in collision, highlights the limitations of preventive measures taken by the Zonal Railways (counseling of loco pilot/assistant loco pilot, safety devices, etc.). This underscores the need for the implementation of the Automatic Train Protection system (KAVACH) on top priority,” the report reads.

“Use of non-signaling-based systems such as Artificial Intelligence-based detection of the RED aspect of the signal and providing an early warning to the loco pilot/GPS-based anti-collision systems shall be explored for provision in locomotive cabs across Indian Railways in non-ATP (automatic train protection) territory,” it added.

After the preliminary probe report was submitted, several associations of loco pilots and railway employees raised questions about why the loco pilot of the goods train, who lost his life in the accident, was blamed by the authorities.

“From the day of the accident, we have been saying blaming the loco pilot cannot be fair. The report of the CCRS proved that we were right. The railway authorities should now focus on increasing the required infrastructure, including the installation of Kavach, to avoid such rail mishaps,” said V.B. Singh, general secretary of the Eastern Railway Trinamool Men’s Congress.

“Report of Commissioner of Railway Safety on Kanjanjunga accident reveals the adverse effects of downsizing in safety categories. None of the staff, both supervisory and supervised, were aware of the correct procedure to be followed in case of a signal failure. This situation was created by deputing staff to work in the automatic signalling system without proper training due to an acute shortage of staff,” said K.C. James, secretary-general of the All India Loco Running Staff Association.