New tech is fundamentally altering how we should run trains

It was around 7 pm on June 2 that the Coromandel Express collided at full speed with a stabled goods train at the Bahanaga Bazar railway station in Balasore, Odisha. The coaches derailed and hit the Yesvantpur-Howrah Express travelling in the opposite direction, leading to the death of 288 people and leaving over 1,100 injured.

It has been widely reported that the accident occurred because someone made a blunder while connecting the newly installed level crossing’s electrical lifting barrier to the relays in the nearby junction box. This connection was required for linking the barrier to the electronic interlocking system (EIS). This blunder caused the point that sets the direction for the train to malfunction. It failed to reset the track to the main up-line after the passage of the goods train when signals were set for the run-through of the Coromandel Express, which resulted in the train entering the loop line and colliding with the parked goods train.

According to the standard operating procedure (SOP), this should not have happened. Simply because after making the connection, the circuits have to be tested and only after that is the station returned to normal working. We will have to wait for the report of the Commissioner of Railway Safety’s statutory inquiry to understand what led to the accident and if the SOP was violated.

On the face of it, the accident will most likely be taken as a case of human failure and those responsible, as already stated by the Railway Minister, will not be spared. The assumption behind this statement is that it is the bad apples the unreliable people who don’t do what they are expected to do and undermine a basically safe system.

The only way to make the system safer is to restrict human contribution, bring in automation, enhance supervision and get rid of those responsible for the lapses. However, this approach has failed to decrease the number of accidents attributed to human failure in the Indian Railways (IR). This number continues to hover around 50 per cent. Clearly, we need to look at human failure through a new prism.

The new view of human error is that identifying those responsible is not the conclusion of an investigation but its starting point. Simply because human error is not the basic cause of a failure but a symptom of a deeper trouble within the system. That is the reason why getting rid of those held responsible doesn’t get rid of the problem because it is systemic and there will always be others to step into their shoes.

Hence, efforts to understand error should begin with seeing how people try to reconcile multiple goals in the complex dynamic setting of the environment in which they are working. And how people’s assessments and actions made sense to them at that time, given the circumstances that surrounded them then.

Modern microprocessor-based technologies that are being introduced in the IR, especially signalling, have added new vulnerabilities that did not exist before and have opened new and unprecedented doors to a system breakdown.

The new technologies do not remove the scope for human error, they alter it. The technologies may give new capabilities for train operation and monitoring, but they invariably bring in new complexities, too. And, more importantly, new technology shows that the existing ways of working are ill-adapted to the way people do or did their work. The whole organisational decision-making structure needs to be re-thought through if system safety is to improve.

It needs to be understood that in today’s world, information has become the key and a basic resource as important as capital, land and labour were in the past. The new technology is fundamentally altering how we should run trains. Furthermore, if information is a key resource and processing it a key technology, then utilising it effectively becomes an area of prime concern.

Today, the IR is floating on a sea of data obtained from data loggers fitted on station interlocking panels, control offices, locomotives, etc, and it is unable to effectively mine the data for enhancing safety. The IR’s inability to convert data into useful safety information and inject it into decision-taking information flows results from a lack of summarising protocols. Effectively, then, the data, though available, plays little part in improving the decision taken by individuals within the available attention span.

It is important that we resolve this issue and design proper information interfaces which will select the relevant facts and bring them to impinge on the safety decision-making processes adequately, especially at the top management level. As things stand today, the top management normally becomes aware of the ground situation after an accident; it is an infirmity that a proper interface can address.

More than ever before, for safe and efficient working, the evolving technical system requires increasing social interaction across departments and individuals. The current organisation structure makes it difficult to cope with these requirements. The management, finding the organisation dysfunctional and itself under pressure for containing accidents, turns judgemental in punishing and rewarding. The result has been increasing distrust and lowering of ethics in reporting accidents and compliance with instructions.

It is not rules and codes which eventually ensure safety. It is trust by the employees in the rules and codes that runs the system. In turn, this trust is dependent upon the ethical implementation of the rules. Owing to the perceived erosion of ethics in those charged with implementing the rules the employees and junior officers the system seems to have been undermined, notwithstanding the honest intentions of the management to ensure safety.

A composite organisation is needed, where the responsibility for reporting the status truthfully and ownership for safety are of inter-departmental groups. The social system components of the socio-technical system seem to be determining the effectiveness of the massive investments into the technical component for improving safety. For effective functioning, the demands of the technical system on social relationships at the workplace have been either disregarded or considered relatively unimportant.

Investments are needed to bring about the required change in the social component of the socio-technical system to make the new technologies work effectively. Money from the Rashtriya Rail Sanraksha Kosh should not be spent entirely on the technical component of the socio-technical system. A portion of it should be set aside for strengthening the social component to study the demands of the new technologies on workplace behaviour and for evolving a composite organisational structure.