KUALA LUMPUR, June 10 — Certain critical rail operating standards of procedure (SOP) were not adhered to which led to the eventual Light Rail Transit (LRT) train collision on May 24, Transport Minister Datuk Seri Wee Ka Siong said of the findings of the nine-member investigation committee today.
Wee said the aforementioned findings by the committee headed by Transport Ministry secretary-general Datuk Isham Ishak included 23 recommendations on existing system improvements presented to the weekly Cabinet meeting held yesterday.
“Investigations found that during the transfer process of the malfunctioning train (TR40) to reset both its Vehicle On-Board Communications (VOBC) and resume Automatic Train Operations (ATO) mode, the hostler and Operations Control Centre officers have disregarded critical SOP, indirectly causing TR40 to manually move northbound towards Gombak and not southbound towards the Lembah Subang depot as intended.
“At the same time, another train (TR81) is being held at KLCC station for about 10 minutes but was given clearance to depart the station towards Kampung Baru station without obtaining accurate confirmation which states TR40 has been reset to ATO. This led to their collision.
“The findings of the investigation are not aimed at proving the guilt or liabilities of any parties,” he told a virtual press briefing here.
In the 8.33pm incident on May 24, a train without passengers collided with another train carrying 213 passengers in the tunnel between the Kampung Baru and KLCC LRT stations.
The incident, which an internal investigation initially found to have been caused by human error, seriously injured over sixty of the 213 passengers on board, with six of them admitted to an intensive care unit.
The 23 recommendations accepted by the Cabinet were divided into five short-term, 11 medium-term (three to six months) and seven long-term (six months and beyond) changes.
Among the immediate recommendations are that two hostlers be posted for manual train operations and safety compliance. Another is to upgrade work tools to ease working duties under low-visibility situations within the tunnels.
The committee also called for an improved checklist for both the hostler and Operations Control Centre during manual operations and the setting up of sighting committees to audit existing train signs.
Wee said Prasarana Malaysia Bhd’s top management must implement the recommendations “by hook or by crook” as it involved the safety of the general public, adding that the ministry viewed the matter seriously.
“The Cabinet meeting on June 9 has accepted the investigation committee’s 23 recommendations to achieve these systemic improvements expeditiously and the ministry will audit the progress of these improvements periodically.
“The government views this incident seriously and has directed the ministry to strictly ensure that every effort is taken to review and revamp safety procedures and operating guidelines in Prasarana and Rapid Rail Sdn Bhd’s rail services and asset maintenance,” he said in a news conference aired on Facebook.
Recounting the chronology of events
Wee said the four-coach TR40 had initially suffered technical malfunctions to one of its VOBC around 6.26pm when it lost communication with the OCC, which led to the train being vacated of passengers and taken out of service for maintenance purpose at the Lembah Subang depot in Ara Damansara, Selangor.
En route to the depot, Wee said the train’s second VOBC malfunctioned as well around 8.13pm, which led to a hostler being dispatched to manually operate the train — now stranded near the Kampung Baru station in Kuala Lumpur after its failsafe kicked in — towards the southbound Dang Wangi station for it to be reset and resume ATO mode towards the depot.
At this point in time, another passenger-laden train — TR81 — heading in the same southbound direction was awaiting clearance at the KLCC station and a Manual Route Reservation (MRR) was implemented to prevent the train from departing.
Despite inadequate information exchange between the hostler and OCC, Wee said critical rail operating SOP were not strictly followed when the MRR was lifted prematurely without proper verification that TR40 had been safely reset.
He said the hostler was supposed to precisely inform the OCC on the respective track numbers to determine whether the malfunctioned train was indeed heading towards the right direction and not on the direct path of any oncoming trains.
Based on voice recordings obtained during the course of investigation, Wee said communications between both parties did take place but was not done in a proper manner.
Under normal circumstances, Wee said a waiting train will only be released from a station after it has gotten clearance from the OCC which would have confirmed no obstruction was present in the tunnel after a hostler has notified of any developments in the tunnel.
Later, Isham also said the committee found that maintenance undertaken by Prasarana was in accordance with the manufacturer’s manual that had been established.
“In terms of maintenance, we do not see any discrepancies or anomalies in the maintenance of trains. The trains are all kept in order and well maintained.
“It’s just that the SOP was not followed thoroughly,” he said, adding that VOBC malfunctions were uncommon and the May 24 incident had been coincidental.