A multiplicity of inquiries
There are, however, a few unique features about this accident.
For the first time ever a Railway Minister not only visited the site of the accident but also chose to remain at the site to oversee relief and restoration work till the lines were restored for traffic.
Even more exceptional was the visit of the Prime Minister himself to the site of the accident, perhaps a historical first for the Indian Railways.
However, his statement that “instructions have been given to ensure proper and speedy investigation of tragedy and to take prompt and stringent action against those found guilty”,
जांच
1 even as a statutory inquiry by the Commissioner of Railway Safety was to begin, gave the impression that it had already been determined that the accident was caused by human agency.
2 The subsequent handing over of the inquiry to the Central Bureau of Investigation is also unprecedented, the reason for which is not readily apparent unless criminal intent is suspected.
3 A “preliminary enquiry” by a committee of senior supervisors even as a statutory inquiry by the Commissioner of Railway Safety was yet to begin is also rather unusual.
Number of derailments
Statistics show that over the last two decades, the number of derailments which constitute the majority of accidents has drastically declined from around 350 per year around the turn of the millennium, to 22 in 2021-22.
The fact that this has been achieved in the context of a nearly threefold increase in freight loading and more than a doubling of passenger traffic lends credence विश्वास to the conclusion that the overall safety performance of the Railways has improved significantly over the years.
The problem with an index
such as safety is that all that is required to sully the record is a single major accident. That, unfortunately, is the nature of the beast. Everything about railway safety has been discussed threadbare घिसे-पिटे in a number of committees in the past.
There is no need to reinvent the wheel. In all the reports of the various committees, there is perhaps one aspect that has not received sufficient attention. It does not cost much but is perhaps one of the most difficult things to implement.
Safety and the information flow
This concerns the flow of information regarding unsafe practices or situations on a real-time basis. Unlike many other organisations or industries, where the activities or operations are concentrated more or less in a limited area physically (for example, nuclear power plants, steel and chemical plants), the activities of the Railways are spread geographically over a wide area, involving a multiplicity of disciplines (departments) that need to work in close coordination on a real-time basis to ensure the smooth and safe running of trains. In order to ensure uniformity in the compliance of rules and regulations and safety in operations, a large number of codes and manuals have been evolved for different departments over the decades to standardise the procedures as far as possible.
Ever since the inception of the railways in this country, periodic field inspections by authorities at various levels have been one of the main tools for the management to ensure compliance with laid-down procedures and standards of workmanship. Accordingly, every department has evolved a set of schedules for the inspection of various work centres and operational procedures — for every level of the management, from the lowest to the highest. While this system has, by and large, stood the test of time over the decades, it suffers from a few drawbacks, particularly in the context of railway safety.
By its very nature, the “top-down” approach places the onus of detecting deviations from the norm on the higher authorities. It becomes a veritable “cops and robbers” scenario, in which the higher authority looks down on the staff at the cutting-edge level with suspicion and distrust; and, conversely, the staff at the lower levels adopt an attitude of “catch me if you can”. It encourages window dressing and sweeping of problems under the carpet. Transparency and frankness are usually the casualties in such a situation.
This can be counterproductive, particularly in matters that concern railway safety. As is well known, many accidents are the culmination of “near miss” situations, unsafe practices or deviations from the norm over a period of time. Detection and rectification of such deviations at the earliest opportunity can prevent many unsafe situations from developing into serious accidents. While in every case a remedy may not be available, even becoming aware of the shortcomings on a real-time basis can often help the management in avoiding a major disaster.
Real empowerment
This is not some idealistic concept. A system called Confidential Incident Reporting and Analysis System (CIRAS) was developed by one of the British universities nearly three decades ago for application on the British Railways in the mid-1990s. The underlying philosophy is to encourage the lower staff to point out deviations on a real-time basis, maintaining the confidentiality of the reporter, and encouraging the expression of frank views. The system, in effect, turns the conventional top down inspection on its head. This is in fact an example of real empowerment of staff.
With the rapid advances in communications and information technology since CIRAS was developed nearly three decades ago, the introduction of a similar reporting system on the Indian Railways should not be difficult.
However, there is a need to sound a note of caution. The success and effectiveness of a CIRAS-like reporting system depends not only on putting in place the physical infrastructure (which is the easier part), but also a total change in the mindset of the management, from the highest to the lower levels, vis-à-vis the staff at the field level. There has to be an attitudinal change from the conventional approach of fault-finding and punishment to a more enlightened ethos of a shared commitment to ensure safety at all levels. The aim should be to correct, not punish. Listen to the voices from below and act. Effecting this change is not easy.
Improving safety and sustaining that improvement involves unremitting drudgery and hard work 24X7, 365 days, year after year — an unglamorous endeavour, all for achieving a non event. It is not spectacular or attention grabbing like the introduction of shiny trains or the commissioning of impressive station buildings. Therein lays the real challenge of sustaining safety on the Railways.
A couple of thoughts in conclusion. Perhaps it is time to have a serious rethink on the recently introduced Indian Railways Management Service (IRMS) scheme, which is bound to destroy whatever loyalty and sense of “ownership” that exists towards a particular discipline (department) amongst the management cadre. That bodes ill for safety management on the Railways. It is perhaps also time to revert to the earlier system of having a full-time Cabinet Minister for the Railways. Unprecedented levels of investments at a time when the organisation is going through a challenging phase of transformation amidst many external challenges requires undivided attention at the highest policy-making level.
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