No. SAC/1/2011-12/WCR/ Dated: 25.05.

2011

To,
The Chief Commissioner of Railway Safety,
Ashok Marg,
Lucknow-226001.

Sub: Derailment of Train No. 12173 Dn (Udyognagari Express)

between SORAI- SUMER Stations on 09.05.2011 at about 06.18 hrs.
on Bhopal-Bina Broad Gauge Section of Bhopal Division.
*******
Sir,

In accordance with Rule 3 of Statutory Investigations into Railway Accidents

Rules issued by Ministry of Civil Aviation, I forward herewith the Preliminary
Report of my Statutory Inquiry into the derailment of 12173 Dn Udyognagari
Express train between Sorai and Sumer stations of Bhopal-Bina, double line,
Broad Gauge, Electrified section of Bhopal Division of West Central Railway at
about 06.18 hrs. on 09.05.11.

I. INTRODUCTION:

1.1. Preamble:
On 09.05.11 at about 06.18 hrs 12173 Dn Udyognagari Express train with a load
of 22 = 44 coaches hauled by AC Loco No. 21334 WAM4/CR running between
SORAI-SUMER stations derailed at Km.900/16-24 on SORAI-SUMER Broad
gauge double line section of Bhopal Division of West Central Railway in Vidisha
Distt. of Madhya Pradesh.

1.2. Inspection and Enquiry:

1.2.1. On 09.05.2011 at about 9.00 hrs. I received a call from CCRS/LKO on my mobile
phone informing me that train No.12173 Dn Udyognagari Express train had
derailed between Sorai and Sumer Stations on Bhopal-Bina Broad gauge section
of West Central Railway and injury to passengers were expected. He asked me to
conduct statutory enquiry into the accident as CRS, Central Circle in whose
jurisdiction the accident had occurred was preoccupied. I immediately got in
touch with CSO/WCR and advised him that I will be holding statutory enquiry
into the accident on 11th & 12th May, 2011 at Bhopal. He was asked to preserve
all the clues and evidences. He was also asked to carry out detailed photography
and videography of the accident site. West Central Railway was asked to publish
the notice for holding of enquiry by the undersigned on 11th & 12th May 2011 at
Bhopal. Accordingly notification was published in News Papers by CPRO/WCR.
Divisional Authorities were advised to inform Civil & Police Authorities of the
enquiry schedule.

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I left Lucknow on 09.05.11 by 12194 Dn Pratapgarh-_Bhopal Express and
reached Bhopal at about 11.00 hrs. on 10.05.11.

I then proceeded to the accident site by CRS/Spl accompanied by DRM and other
West Central Railway Officials. I inspected the accident site along with
CSO/WCR, CTE/WCR, CRSE/CR and DRM/Bhopal. The accident had taken
place on a straight track. The location of derailed coaches were explained to me
with the help of photographs and sketch prepared by joint team of supervisors. In
all six coaches had derailed from the rear end. There were four coaches
numbering CR 03706 GSLRD, CR 99435 GS, CR 89217 WGSCN & CR 92227
WGSCN lying off the track near the accident site. The track had been restored.
The last coach which was an RA had been taken to Sanchi station after re-
railment while sixth and seventh coaches from the rear had been kept at Sumer
station. The sixth coach from the rear had derailed by its rear trolley while the
front trolley was on rail. The seventh coach from rear had not derailed but was
kept at the Sumer station because it could not be dispatched with the front 15
coaches of the train after the accident as the rear coupling hook of the 15th coach
had broken in the accident and the train had parted after 15th coach. These two
coaches were later on brought to sick line in Bhopal for detailed inspection, where
these were inspected after running out the trolleys.

I also visited BMHRC & Railway Hospital at Bhopal where injured passengers
were admitted for treatment. I enquired about their treatment/ care from the
attending doctors and family members of the patients. Proper medical care was
being given to the patients. I was accompanied by CSO, DRM, Bhopal and CMS
during hospital visit.

Notification for holding the enquiry was published by issuing advertisement in the
news papers. Bhopal Division officials also informed Civil & Police Authorities
of the enquiry. Following officers were present during the enquiry:

1. Mr. B.Deva Singh CSO/WCR/JBP

2. Mr. R.K. Meena, CTE/WCR/JBP
3. Mr. Jagdish Prasad, CCM(PS)/WCR/JBP
4. Mr. E.S.Marcus, CRSE/WCR/JBP
5. Mr. A.K. Tiwari, CRSE/CR/CSTM
6. Mr. Ghanshyam Singh, DRM/BPL.
7. Mr.M.P. Mehta,CTPM/WCR,JBP

Divisional officers were called in as and when required. Evidences of 58

witnesses were taken.

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1.2.2. Preservation of Clues at the site of Accide nt:

The joint note regarding the accident was prepared by senior supervisors of
Bhopal Division after reaching the accident site.

Railway Administration had taken still photographs of the site, damaged track and
affected coaches involved in the accident. Videography of the site was also done.

A sketch of the accident site was prepared and signed by Divisional Authorities
showing the details of the site of accident.

The recording of the speedometer of electric locomotive No. 21334 WAM4

(BSL) was preserved by the Division and a print out with a technical note by Sr.
DEE made available during enquiry.

The broken left and right rail in the rear of derailed coaches was also kept in the
custody of Sr.DSO and shown to me during enquiry. The broken rails were sent to
RDSO for chemical and metallurgical testing along with broken draw bar hook of
15th coach No.CR 03247 WGSCN.

1.3. The Accident:

1.3.1. Train No.12173Dn Udyognagari Express, (LTT-PBH) an air braked broad gauge
train started from BPL Station at 05.25 hrs. and passed through Sorai Station at
06.13 hrs.The train had derailed at Km. 900/16-24 on Dn Main line at about 06.18
hrs. 6 coaches having number CR 03275WGSCN, CR 92227 WGSCN, CR 89217
WGSCN, CR 99435 GS, CR 03706 GSLRD & NR RA-1 RDSO had derailed.
Due to high bank at site four coaches had capsized. The train had parted between
15th & 16th coach as the rear draw bar hook of coach No. CR 03247 – 15th from
engine-BPL end had broken (this coach had not derailed).

1.3.2. ‘Right’ and ‘Left’, ‘Ahead’ ‘Before’ ‘After’ and ‘Rear’ referred in this report are
with reference to the direction of the train movement.

1.4. The Nature of weather:

The weather at the time of the accident was clear and visibility was good.

1.5. Casualties:
I regret to report that as a result of the accident, 02 passengers lost their life, 10
were grievously injured and 32 passengers sustained simple injury.

1.6. Passenger occupancy:

The 12173 Dn Udyognagari Express (LTT-PBH) express train was running with a
load of 22=44 coaches. The occupancy of the train was 1380 against the capacity
of 1452.

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 II. RELIEF MEASURES

2.1. Intimation:

After the accident, Loco Pilot of Train No. 12173 informed about the accident at
06.22 hours to TLC. Guard of the 12173 Dn Udyognagari Express, informed all
concerned on mobile phone and also the adjacent SMs on walkie talkie, about the
accident at 06.25 hrs.

2.2. Medical attention and relief:

2.2.1. ARME/ARMV Scale-1 is available at ET & BIN and ARMV Scale -2 at BPL
stations of Bhopal Division. They all left to the accident site as under:

ET-ARMV - Left ET at 07.07 hrs. – Sorai Arrl. 09-10 hrs. and stabled.
BPL-ARMV- Left BPL at 06.50 hrs.- Reached site 08-40 hrs.
BIN-ARMV- Left BIN at 06.50 hrs. – Arrl. at site 07.50 hrs.

CMS/BPL along with Doctors and paramedical team left BPL by road and
reached site at 8.20 hrs.

MS/BIN along with Doctors and paramedical team reached site at 7.45 hrs.

A Team of non-Railway Doctors from Civil Hospital, Vidisha reached site at 7.15
hrs. Local people, police and civil authorities organized road vehicles and
ambulance at the site and transported injured passengers to the District Hospital,
Vidisha & Bhopal.

2.2.2 Movement particulars of various ARTs are as under: -

S.N. Event ART – ET ART – BPL ART- BINA

1. Time of Ordering 06.25 06.25 06.25
2. Time of Departure 07.08 07.15 07.17
3. Time of arrival at Sorai 11.35 08.15 -
4. Time of departure from Sorai 12.31 09.55 -
5. Time of arrival at Sumer - - 08.43
6. Time of departure from Sumer - - 15.33
7. Time of arrival at Site 12.55 10.15 15.55
8. Time of work started 16.10 11.00 17.20
9. Time of work closed 23.15 12.00 23.15
10. Time of departure from Site 01.15 15.00 01.20
(10.5.11) (9.5.11) (10.5.11)

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2.2.3. Relatives of the injured passengers were informed through local police station as
well as by passengers themselves who arrived at hospital.Help line service was
also opened and telephone numbers were displayed on local news channels.

2.2.4. Disaster management cell of BPL division and Station Master of Sorai and Sumer
station, informed the civil authorities Vidisha immediately.

2.2.5. Tea, water and biscuits were arranged and served free of cost to the injured
passengers at site and hospital.

2.2.6. Details of the accident and the list of injured passengers was given to the media.

2.2.7. Ex-Gratia Payment:

Following Ex-gratia was announced:
(a) Death case : Rs.5 lakh
(b) Grievous injury : Rs. 1 lakh
(c) Simple injury : Rs. 25,000/-

A total amount of Rs.18, 00, 000 had been paid as ex-gratia by the division.
Remaining amount should also be paid expeditiously.

2.3. Restoration:

2.3.1. The front portion of the train No. 12173 Dn left the accident site with 15 coaches
at 8.18 hours and reached Sumer station at 8.25 hours. The train left Sumer at
11.05 hours with the passengers and arrived Bina at 14.15 hours. The 15th coach
was detached at Bina station and 5 more coaches of coaching special were
attached to this train. The train left Bina at 17.25 hours for Pratapgarh. Coaching
Special was run from Bhopal at 9.05 hours which collected stranded passengers
from Vidisha and Sorai stations and arrived BIN at 15.20 hours. Up line was
given fit at 7.30 hours. ARME Bina was the first train which was sent on the Up
line from Sumer Station at 7.45 hours. Dn track was given fit at 3.40 hours on
10.05.2011 after removing derailed coaches and repairing the track. Dn OHE was
given fit at 3.40 hours and the first train No.12615 passed through accident site at
04.15 hours.

2.3.2. Interruption of passenger traffic:

No. of trains cancelled: 01

No. of trains short terminated: 03

No. of trains diverted: 16

Detention to trains:

Up Direction 33= 52 hrs. Dn Direction 28 = 41 hrs.

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 III. THE TRAIN

3.1. Composition and Marshalling Order of the train:

(i) Locomotive of 12173 Dn Udyognagari Express.

The train No. 12173 Dn Udyognagari Express (LTT-PBH) was hauled by Loco
No. 21334 WAM4 (BSL) weighing 112.8 tonnes. The loco was manufactured at
CLW and was commissioned on 14.05.1982. The locomotive was provided with
head light, speedometer, speed recorder, flasher light and all were in working
condition. After the last IOH on 20.11.2010, its last trip inspection was done on
05.05.11 at Igatpuri. It had earned 90000 Kms up to 22.04.11 since IOH.

(ii) Coaches:The train No. 12173 Dn Udyognagari Express (LTT-PBH) was running
with the load 22=44 coaches, the marshalling order and other details are given
below:

S.No. From the Coach No. Built by Year built Date of last POH Date of
Engine Return

1. 1st CR 95709GSLR BEML 1995 MTNS/15.12.10 7/2011

MTNS/09.01.10
2. 2nd CR02416GS ICF 2002 8/2011
MTNS/07.01.11
3. 3rd CR07439GS ICF 2007 8/2012
MTNS/31.03.10
4. 4th CR03054WGACCW ICF 2003 11/2011
MTNS/02.03.11.
5. 5th CR08148 RCF 2008 10/2012
WGACCN
MTNS/19.12.09
6. 6th CR04102 RCF 2004 07/2011
WGACCN
MTNS/04.11.10
7. 7th CR96105 RCF 1996 06/2012
WGACCN

8. 8th CR09251WGSCN BEML 2009 BEML/08.09.09 09/2011

ICF MTNS/11.12.09
9. 9th CR97808 WGSCN 1997 07/2011
ICF MTNS/01.04.10
10. 10th CR87242 WGSCN 1987 11/2011
ICF MTNS/01.06.10
11. 11th CR04201 WGSCN 2004 01/2012

12. 12th CR10234 WGSCN BEML 2010 BEML/01.01.11 01/2013

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 MTNS/01.06.10
13. 13th CR06220 WGSCN BEML 2006 01/2012
MTNS/16.11.09
14. 14th CR07254 WGSCN BEML 2007 06/2011
MTNS/27.07.10
15. 15th CR03247 WGSCN ICF 2003 03/2012
MTNS/24.03.10
16. 16th CR06229 WGSCN ICF 2006 10/2011
MTNS/18.02.10
17. 17th CR03275 WGSCN RCF 2003 09/2011
CR92227 WGSCN MTNS/20.02.10
18. 18th RCF 1992 09/2011
CR89217 WGSCN MTNS/23.10.10
19. 19th ICF 1989 05/2012
CR99435 GS MTNS/09.01.10
20. 20th ICF 1999 08/2011
CR03706 GSLRD MTNS/23.10.10
21. 21st ICF 2003 05/2012

22. 22nd NRRA-1 RA/RDSO RCF 2004 AMVM/30.11.10 01/2013

(a) Total length of coaches/train excluding engine – 22.297 x 22 = 490.53 mtr

(b) Whether fully braked or not: Fully air braked.

The brake power of the train was 100% as per BPC and also the joint note
prepared after the accident.

3.3. Damage and disposition:

Four coaches were totally damaged and were put off the track. The cost of the
damage worked out by Railways is as under :-

3.3.1. Coaches (C&W) - 60.10 lakhs

3.3.2. Signaling & telecommunication – 00.50 lakhs

3.3.3. Engineering - 10.00 lakhs

3.3.4. Traction distribution (TRD) – 00.20 lakhs

Total cost of damage - Rs.70.80 lakhs.

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 IV-LOCAL FEATURES:

4.1. The Section and Site:

4.1.1. The accident took place at Km 900/16-24 on BPL-BIN double line electrified
broad gauge section between Sorai and Sumer stations in BPL division of West
Central Railway falling in the civil district of Vidisha in the state of M.P. The
track runs through open cultivated plain land. The accident took place on the level
straight track.

4.1.2. The track at the site of accident runs in the south to north direction. The track
standard details are as under:

• Rail 60 Kg/M, year of rolling 1998,

• Year of laying – 2000 with MBC sleepers

• Density 1660 sleeper per KM.

• LWR Track.

4.2. Signaling & System of working:

The signals are MACL and stations have standard II(R) interlocking Trains are
worked under absolute block system.

4.3 Important Kilometerage of stations/locations :

The Kilometerage of various points are mentioned in this report as reckoned from
BPL Railway Station are as under:

Bhopal 836.78

Sorai 895.57

Accident Site 900/16-24

Sumer 903.90

Bina 975.15

4.4. Permissible speed and speed restrictions :

Maximum permissible speed on Bhopal-Bina section is 120 Kmph for Rajdhani

Express. There are 06 permanent speed restrictions in the section with no
permanent speed restriction between Sorai and Sumer and on the day of accident

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 there were no temporary speed restrictions in force between Sorai and Sumer
stations.

4.5. Head quarters:

Track : Sr. DEN (N)/BPL

ADEN/BIN & SSE/P-Way/BHS

S&T : Sr.DSTE/BPL, DSTE (Sig)/BPL

TI : TI/BPL

Control Office : BPL

V-SALIENT FEATURES

5.1. Time of Accident:

The train had passed through Sorai station at 06.13 hours. As per Guard of the
train he felt a jerk at 06.18 hours. As per the speed recorder chart of the Loco, the
train speed started dropping at 06.18 hours. Thus the time of the accident can be
taken as 06.18 hours.

5.2. Speed of the Train:

As per the speed recorder chart the train was coasting at a speed of 100 KMPH
when the speed started dropping. Thus the speed of the train at the time of
derailment can be taken as 100 KMPH. The possibility of over speeding can be
ruled out from the speed recorder chart.

5.3 Hanging part in train:

A team of supervisors had inspected the track behind the point of drop of the
wheel for a distance of 90 Mtrs. but there was no hit mark on the track before the
point of drop of wheel. This fact has been recorded in the joint note also.

5.4. Condition of track:

5.4.1 The first point of drop was noticed at a distance of 48.03 Mtrs. after KM Post
900/16 inside the left rail on the sleeper next to the multiple weld failure on the
left rail. No point of mount was noticed on rail in the vicinity of point of
derailment by the joint team of supervisors.

5.4.2 As per the joint note, multiple fractures were seen in the left rail in the weld zone
(No.18/1 left AT weld) and the rail had broken into four pieces in multiple plains.
A gap of 920 mm had been created in the left rail. A piece of rail head 240 mm

9
 long had completely detached from the rail in the weld zone. The bottom piece of
the rail had fractured from the bolt hole in the leading rail. Two fish plate bolts
were also found nearby, one of which was bent and other was broken. This weld
joint was under observation and had been provided with joggled fish plates.

5.4.2 Examination of failed weld joint revealed that the inner joggled fish plate was not
supported on the fishing plane as the riser surface was protruding and there were
shiny marks on the spot indicating that the fish plate was not properly assembled
due to the protrusion. There were marks on the four corners under the broken rail
head indicating that the rail head was supported on four spots only by the fish
plates instead of the whole fishing plane.

5.4.3 Right side rail had also broken through AT weld joint (No.18/1 right AT weld) at
a distance of 6.1 meter after the failed weld joint on the left rail. A gap of 620
mm was seen between the broken parts of right rail after fracture. An old flaw was
visible on the rail top table which was 25 mm deep and 70 mm wide. The head of
the right leading rail had marks of hammering on the fractured face.

5.4.4 The PSC sleeper next to the welded joint (No.18/1 left AT weld) was badly
crushed at the first point of drop where the left wheels had dropped inside the rail
and only reinforcement wires were visible. The sleepers had got shifted to the left
side and ERCs on the right rail had come out.

5.4.5 There was extensive damage to the track for a length of 109 meters in which 5
rear most coaches had derailed completely while the 6th coach from the rear had
derailed by rear trolley only.

5.4.6 During inspection of track on 10.05.2011 along with railway officials it was seen
that fitment of joggled fish plates on defective welds/rail was not being done in
the prescribed manner. Following discrepancies were common: -

a) Fastening with two bolts on the same side of the weld

b) Not fastening with two far end bolts

c) Use of ordinary fish plate with gas cut instead of rolled joggled fish plate

d) Nuts not fully tightened on bolts but tightened on a few threads only due
to damaged threads of bolts.

5.5 Condition of Rolling Stock:

5.5.1 No damage was seen on the locomotive.

5.5.2 The first 16 coaches and the locomotive were on track even after derailment
without any damage. Train parting had taken place between 15th and 16th coaches
due to breakage of rear draw bar hook of the 15th coach.

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5.5.3 No hanging part was noticed in the 15th and 16th coach. The derailment had started
from the 17th Coach No. CR-03275. Only rear trolley of this coach was in
derailed condition. On the front trolley rear left wheel of this coach there were 7
dent marks on the flange periphery. The curvature of some of the dent marks was
similar to the damage caused by hitting on pendrol clip or a round bolt. Fresh
rubbing marks were seen on the outer face of this wheel rim. One mark had
bluish appearance as if it had rubbed against hard steel possibly rail face. The
axle box loop safety strap and safety lug of the rear trolley of 17th coach which
had derailed were found freshly broken and had detached from the trolley.

5.5.4 During wheel measurement of 16th & 17th coach it was observed that some wheels
were under size as per 13mm root radius gauge.

VI- PROVISIONAL FINDINGS

6.1 Findings:

Having carefully considered the details of joint observations, inspection of site,

discussion with various sources, factual, material and circumstantial evidence, at
my disposal so far, I have come to the conclusion that most probably the
derailment of 12173 Dn Udyognagari Express at KM 900/16-24 between Sorai-
Sumer stations on Bhopal-Bina Section of W.C. Railway on 09.05.2011 was
caused due to failure of AT weld.

The accident is classified under the category “Failure of Equipment –

Permanent Way”.

VII – IMMEDIATE RECOMMENDATIONS

7.1 Railway should use only standard fittings for joggling of rails and welds. Field
staff should be properly equipped to ensure this.

7.2 It should also be ensured that the joggled fishplates are supported on the fishing
plane only and not on the metal protrusion of weld riser.

( P.K. Bajpai )
Commissioner of Railway Safety,
North Eastern Circle,
Lucknow

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No. SAC/01/2011-12/WCR/ Dated: 25.05.2011

Copy to:

The General Manager, West Central Railway, Jabalpur.

The Secretary (Safety), Ministry of Railways, Railway Board, Rail Bhawan,

New Delhi.

( P.K. Bajpai )
Commissioner of Railway Safety,
North Eastern Circle,
Lucknow

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 LIST OF ABBREVIATIONS USED

ADEN Assistant Divisional Engineer

ARME Auxiliary Relief Medical Equipment

ART Accident Relief Train

BG Broad Gauge

BSNL Bharat Sanchar Nigam Limited

BPC Brake Power Certificate

CCRS Chief Commissioner of Railway Safety

CSO Chief Safety Officer

CMPE Chief Motive Power Engineer

CCM (PS) Chief Commercial Manager (Passenger Service)

CMS Chief Medical Superintendent

CRSE Chief Rolling Stock Engineer

CTE Chief Track Engineer

CUG Closed User Group

DRM Divisional Railway Manager

DMO Divisional Medical Officer

Dn Down

Dy Deputy

ERC Elastic Rail Clip

GM General Manager

HQ Head Quarter

Loco Locomotive

MBC Mono block concrete

M.P. Madhya Pradesh

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POH Periodical Overhauling

Sr.DEN Sr. Divisional Engineer

Sr. DSTE Senior Divisional Signaling & Telecom Engineer

Sr.DMO Senior Divisional Medical Officer

SSE Senior Section Engineer

SLR Coach with compartments for second class

S&T Signaling & Telecommunication

TI Traffic Inspector

VHF Very High Frequency

WAM-4 Type of Loco

Station code :

BSL Bhusawal

BIN Bina

BPL Bhopal

LTT Lokmanya Tilak Terminus

PBH Pratapgarh

SORI Sorai

SUMR Sumer

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