Cause of Accident:
Crew Error: Locomotive pilot overshot a danger signal and assistant failed to use emergency brakes.
Signalling System Failure: Three automatic signals malfunctioned, but proper actions weren't communicated by staff.
Lax Procedures: Stationmasters bypassed safety protocols and issued unauthorized permissions to proceed.
Safety Lapses:
Faulty Coach Design: Anti-telescopic features in coaches malfunctioned, not absorbing impact energy.
Modified Coach Structures: Design changes by Integral Coach Factory (ICF) might have reduced energy absorption.
Recommendations:
Improved Coach Design: At least the last two coaches in passenger trains should have stronger crash-worthy features.
Modified SLR Coaches: Luggage compartments should be placed at coach ends to create a collapsible buffer zone.
Review of Loco Placement: Avoid attaching dead locomotives next to main engines in passenger trains.
COMMENTS