Human, Environment, System, & Technology: Learning from the KA 65 and 350 accident
Tauhid Nur Azhar
A transportation accident can occur due to the involvement of several factors that contribute with various configurations and weights. Not only transportation accidents or disasters, cases such as the Chernobyl nuclear reactor leak, the explosion of the Union Carbide Bhopal reactor, to the case of Ethylene Glycol contamination in cough syrup that has just shocked the country, are conditions of disasters caused by multi-factors, or the accumulation of a series of processes that lead to the emergence of an undesired condition.
What elements are involved and contribute to the occurrence of an accident or disaster? At least theoretically, there are 4 domains that need to be considered: humans, environment, systems, and technology.
Humans are the mastermind, actor and operator, as well as the subject affected by an accident or disaster. Humans who design a system, and humans who develop its supporting technology. On the other hand, humans are also those who carry out or operate the system, as well as users, and also the subjects affected by system failures that lead to accidents.
Environmental factors are factors consisting of many natural elements that affect the performance of a system developed by humans. Within it can be factors of climate and weather, geomorphological conditions, geological conditions, to the diversity of life that exists in the diversification of biomes etc.
Systems are a structured pattern, designed, developed, and operated to achieve a specific goal effectively and efficiently. For example transportation systems, banking transaction systems, health service systems etc.
While technology is part of the utilization of science products in the form of applicable and implementable applications that can support or become enablers in a system. In the transportation system, for example, aviation technology with aircraft, propulsion systems, navigation systems, to flight management is developed.
Likewise in the railway-based transportation system, there is traction technology, power (diesel electric, OCS, third rail, Maglev, etc.), interlocking system (signal, switch, block, etc.), technology for controlling and communicating trains (communication based train control), to technology for railroads, ticketing, stations etc.
Therefore, when an accident occurs in one of the transportation sectors such as the event on January 5, 2024 at Km 181+700 of the Haurpugur-Cicalengka track in the form of a collision between KA 65 Turangga which runs from Surabaya Gubeng to Bandung and KA 350 Commuter Line which runs from Padalarang to Cicalengka, we need to conduct a comprehensive investigation stage that can accommodate aspects of human, environment, system, & technology, as we have discussed briefly above.
The authority to investigate according to current regulations is in the hands of the National Transportation Safety Committee. This is in accordance with the rules and legal principles that are written in Government Regulation №62 of 2013 regarding Railway Accident Investigation, and Presidential Regulation №2 of 2012 regarding the National Transportation Safety Committee.
Thus, to obtain a valid conclusion regarding the factors causing and various conditions contributing to the occurrence of the extraordinary event on KA 65 and 350 can be seen in the final investigation report that will be released by KNKT when the entire investigation and data processing and conclusion making process based on data and evidence that is available has been processed and analyzed.
Therefore, allow me in this opportunity to try to present some supporting concepts for the investigation in an effort to elaborate on the HEST factors above in the context of understanding the chain of processes that can cause accidents in the transportation sector.
In transportation safety studies in general, the role of the human factor associated with human error is often discussed. Even based on statistics, this human error factor is the largest contributor in accidents, reaching around 2/3 of the chain of causes of aircraft accidents (Wiegman & Shappel, 2000).
If human error is part of the human factor, then the human factor is influenced by human performance (Eurocontrol, 2010), which can be in the form of anatomical physiological aspects such as anthropometric data, age, health, visual-auditory ability, motor response, reflex mechanisms etc. It also involves pathological factors such as health status and certain medical conditions. Then there is the psychological factor, where there is a mental and emotional dynamic that is influenced by the psychosocial situation and condition.
Based on various safety transportation studies, especially aviation, and related to the human factor, various conditions are found to be suspected of being able to distort performance in the human factor field. In the AMT Handbook no. 12, these disturbances in human factors are called The Dirty Dozen.
As for the dirty dozen itself, it consists of:
1. Lack of Communication: Inadequate professional communication processes that have the potential to create conditions of misperception and misinterpretation, relying more on assumptions and personal opinions that have physiological limitations.
2. Complacency: Excessive self-satisfaction and pride that can lead to overconfidence, potentially resulting in negligence and disregard for specific regulations due to feeling highly competent in the tasks being performed.
3. Distraction: Engaging in parallel activities while performing tasks, such as using mobile devices for non-work communication, browsing, chatting, or even conducting business activities. These distractions can divert attention and concentration from the main task at hand. Personal issues, the work environment, and various aspects of social interaction can also cause distractions.
4. Lack of Knowledge: Insufficient knowledge, experience, education, and training processes, marked by a lack of knowledge about work regulations, rules, and a low understanding of the situation and conditions within the scope of work.
5. Lack of Teamwork: Low capacity for professional communication can lead to silos and barriers in building team cooperation, involving professional relationships across personal and work unit boundaries. A mindset focused only on personal tasks and unit goals can hinder the flow of processes and functions in achieving the main objectives due to a lack of understanding among strategic units.
6. Fatigue: Physical and mental exhaustion that can result in a decline in an individual’s physiological capacity. Attention, concentration, analytical ability, situational awareness, perception formation, and response actions may not align with regulations or the actual conditions being faced. Fatigue is closely related to ergonomic aspects and the biological profile of personnel on duty. This is influenced by working hours and duration, fitness level, work environment conditions, work pressure, etc.
7. Norms: Conditions that develop during the implementation of professional tasks. They are not documented as formal values in the form of standard operating procedures (SOPs) that can be evaluated for compliance. However, they are sometimes present in the communal spirit within the work environment and can be a major disruption to compliance with rules. Norms or conditions considered normal, for example, may occur in the way problems are managed and resolved in a manner not specified in SOPs or work regulations. They may seem practical and innovative at first glance but can be dangerous because the risks and systemic impacts are not measured and controlled. Based on norms, practical steps are usually taken, which then become habits in the work environment, even if they do not align with task guidelines in the context of official duties.
8. Lack of Awareness: Lack of awareness of the dynamics of change in the work environment due to established routines. This is especially true in repetitive or mechanistic tasks. This lack of awareness can make personnel insensitive to various symptoms and anomalies that may occur, which have the potential to cause significant problems that disrupt the operational system or other functions.
9. Stress: Stress management, including coping processes and minimizing stressors, is an important capacity in optimizing an individual’s professional role. Acute and chronic stress can affect brain function and the human mental system through the psychoneuroimmunology pathway, as proposed by Hans Selye’s theory. Increased levels of stress hormones such as ACTH, cortisol, and epinephrine can impact the performance of the nervous system, including the decision-making system, which becomes more impulsive and defensive in survival mode. Decisions that are usually rushed, lack consideration, and involve only one subjective perspective.
10. Pressure: Pressure is an integral part of stress and stressors (stress-causing factors). Pressure can be systemic, originating from job demands, or organic, caused by various personal problems affecting the individuals involved. In the current digital era, pressure can arise from online loans or various other social conditions that indirectly affect a person’s performance.
11. Lack of Resources: Insufficient resources, including human resources and support resources, including work facilities and infrastructure. A shortage of personnel can lead to fatigue and excessive workloads. Insufficient resources, such as work infrastructure, can hinder professional activities and potentially reduce the capacity and performance of the personnel involved.
12. Lack of Assertiveness: In the context of human factors, lack of assertiveness is usually closely related to the work environment, leadership models, and related professional communication concepts. Communication deadlock and leadership styles that do not accommodate suggestions, opinions, or grievances from the team can negatively affect the development of assertiveness, causing reluctance to discuss or address professional issues. As a result, this condition can accumulate chronic problems and trigger systemic issues with unforeseen dimensions.
Concrete examples of the human factor study mentioned above can be found in a real case that has been investigated and analyzed in-depth, recorded in an official report titled “Laporan Akhir Investigasi Laratan Lokomotif CC 2031698 Dipo Induk Semarang Poncol Semarang Jawa Tengah Daop IV Semarang 28 April 2013” (Final Report of the Investigation of the Runaway Incident of Locomotive CC 2031698I apologize for any confusion, but I couldn’t find specific details about a specific incident involving a runaway locomotive CC 2031698 at Dipo Induk Semarang Poncol in Semarang, Central Java, Daop IV Semarang on April 28, 2013. It’s possible that the incident you mentioned may be a localized case or not widely covered in publicly available information.
Locomotive CC 2039816 is a locomotive planned to serve train KA 11 Argo Sindoro, departing from Semarang Tawang station to Gambir station at 05:30 AM local time.
On Sunday, April 28, at 12:17 AM, locomotive CC 2039816 entered track 1 of Dipo Lokomotif Semarang Poncol after completing its service for train KA 12 Argo Sindoro. The locomotive’s engine was then turned off for volume checking and refueling.
At 12:37 AM, the engine of locomotive CC 2039816 was restarted and moved from track 1 to track 2. At 12:42 AM, the engine was turned off, and the locomotive was cleaned by the cleaning service personnel. Afterward, the daily check (DC) was conducted.
At 03:54 AM, the locomotive’s engine was restarted for engine warming. During the engine warming, the reverser lever was in the neutral position, the throttle lever was set at position 8, and the independent brake was set to full service braking.
The next step was the inspection of the locomotive’s operational fitness, including the following No Go Items: air pressure for the independent brake (50 psi), automatic brake (70 psi or 4.8–5.1 kg/cm²), and the functioning of the deadman pedal.
The inspection also covered other No Go Items equipment in the engineer’s cabin, such as the locomotive whistle, spotlight, fire extinguisher, cabin lights, window wiper, signal lights, stop block, and operational speedometer. The locomotive radio was checked by communicating with the PK/OC personnel.
After completing the inspection of No Go Items equipment in the locomotive’s cabin, the Daily Check supervisor descended from the cabin and proceeded to inspect the equipment in the bogie, including brake blocks, wheels, and gearbox bolts. Then, the equipment at the locomotive’s short end, such as the cowcatcher, air brake hose, and safety chains, were inspected and found to be in good condition. While heading towards the locomotive’s long end, the DC supervisor checked the fuel volume in the tank, which should be 1,750 liters.
At 04:05 AM, while inspecting the cowcatcher, air brake hose, and safety chains at the locomotive’s long end, the DC supervisor heard the diesel engine’s sound become louder, and the locomotive started moving slowly from track 2 towards the boundary of Dipo Lokomotif Semarang Poncol and passed through turnout 43, which was positioned straight into the Semarang Poncol station yard.
Before locomotive CC 2039816 started moving, on track 1 at the Semarang Poncol locomotive depot, locomotive CC 201 from series KA 92 Senja Utama arrived, accompanied by a locomotive guide officer (PL) and assistant drivers assigned by the engine inspector to pick up locomotive CC 2039816. The daily check inspector assumed that locomotive CC 2039816 was moving because it was being pulled by the PL officer to be connected to the Argo Sindoro train’s series at Tawang station.
The route taken by locomotive CC 2039816 when it went out of control was the same route as locomotive CC 201140 (old nomenclature) from KA 92 Senja Utama, which entered the Semarang Poncol locomotive depot, so the switches at the Semarang Poncol station were still oriented towards track 2.
At 04.06 WIB, one minute after the locomotive started moving on its own, the GPS data logger in the Locotrack system showed that the locomotive’s speed at the Semarang Poncol station was 45 km/h.
At 04.10 WIB, CC 2019816 passed Jerakah station directly at a speed of 126 km/h. Then at 04.12 WIB, it passed Mangkang station directly at a speed of 117 km/h.
At 04.20 WIB, at Km 17+300 between Mangkang and Kaliwungu stations, the locomotive’s speed increased to 145 km/h and it went off the rails on a curve with a radius of 400 m, where the allowed speed according to Gapeka is 70 km/h.
The independent brake was in the bound position, so the locomotive could not move or had weak power because the diesel engine’s temperature was still below its operating temperature, below 71ºC (160ºF). The Over Reading Selenoid (ORS) was receiving current, so the Load Control Potensiometer (LCP) moved to the minimum field. The locomotive would move with weak power because the current going to the main generator was still weak.
According to the daily check inspector, when preparing the locomotive, he positioned the independent brake handle in the full service position, the engine control switch (ECS) in the running position, the control circuit breaker (CCB) switch in the on position, the throttle handle in position 8 or full power, and the reverse handle in the neutral position.
The engine’s RPM was increased to position 8 to quickly reach the operating temperature of 71ºC, which was indicated by the High Idle Relay (HIR) working.
After the HIR worked, the daily check inspector checked the No Go Items and lowered the throttle handle to position 0 after the engine temperature reached 70 ºC.
From the KNKT’s analysis and also in terms of recommendations, it is known that there is a high probability that human factors, systems (regulations), and technology (switching and safety systems) significantly contributed to this case.
Locomotive CC 2039816 is a locomotive planned to serve train KA 11 Argo Sindoro, departing from Semarang Tawang station to Gambir station at 05:30 AM local time.
On Sunday, April 28, at 12:17 AM, locomotive CC 2039816 entered track 1 of Dipo Lokomotif Semarang Poncol after completing its service for train KA 12 Argo Sindoro. The locomotive’s engine was then turned off for volume checking and refueling.
At 12:37 AM, the engine of locomotive CC 2039816 was restarted and moved from track 1 to track 2. At 12:42 AM, the engine was turned off, and the locomotive was cleaned by the cleaning service personnel. Afterward, the daily check (DC) was conducted.
At 03:54 AM, the locomotive’s engine was restarted for engine warming. During the engine warming, the reverser lever was in the neutral position, the throttle lever was set at position 8, and the independent brake was set to full service braking.
The next step was the inspection of the locomotive’s operational fitness, including the following No Go Items: air pressure for the independent brake (50 psi), automatic brake (70 psi or 4.8–5.1 kg/cm²), and the functioning of the deadman pedal.
The inspection also covered other No Go Items equipment in the engineer’s cabin, such as the locomotive whistle, spotlight, fire extinguisher, cabin lights, window wiper, signal lights, stop block, and operational speedometer. The locomotive radio was checked by communicating with the PK/OC personnel.
After completing the inspection of No Go Items equipment in the locomotive’s cabin, the Daily Check supervisor descended from the cabin and proceeded to inspect the equipment in the bogie, including brake blocks, wheels, and gearbox bolts. Then, the equipment at the locomotive’s short end, such as the cowcatcher, air brake hose, and safety chains, were inspected and found to be in good condition. While heading towards the locomotive’s long end, the DC supervisor checked the fuel volume in the tank, which should be 1,750 liters.
At 04:05 AM, while inspecting the cowcatcher, air brake hose, and safety chains at the locomotive’s long end, the DC supervisor heard the diesel engine’s sound become louder, and the locomotive started moving slowly from track 2 towards the boundary of Dipo Lokomotif Semarang Poncol and passed through turnout 43, which was positioned straight into the Semarang Poncol station yard.
According to Setiawan (2015), the routes of each train journey can experience conflicts on single or double tracks. The routes of train journeys include:
1. Routes that can be formed according to the configuration of tracks and turnouts at the stations.
2. Routes used by train journeys out of the total possible routes.
3. The Conflict Rate, which represents the degree of conflict between each used route.
Referring to Setiawan (2015) again, the complexity of factors influencing the calculation method of station capacity cannot be separated from the calculation of Conflict Rate to obtain the value of interlocking system capacity.
The capacity of the interlocking system can be investigated using a simple simulation method using the Conflict Degree Matrix Table (Tabel Matriks Derajat Konflik or TMDK).
The above process is also an important part of the concept of studying the operational patterns of the railway network, in addition to the type of train transportation, the number of trains per day, the length of passenger and freight train sets, the maximum speeds of passenger and freight trains, the station locations, the functions and classes of stations, the types of activities in the stations, the block sections and block intervals, the line capacity, and the track layout at the stations (Setiawan, 2016).
The types of conflicting routes that can occur are as follows: self-correlation, which is when two train routes move on the same route. Then there is convergence, which occurs when two trains move from different directions to the same destination. Next is divergence, when two train routes move from the same origin to different destinations. Lastly, there is the conflict of routes in the form of crossing when two train routes move from different origins and destinations.
Based on the configuration of tracks and turnout systems at each station, routes (formed routes) can be established. For example, there may be tracks dedicated as mainlines or tracks to be traversed by non-stop passenger trains, etc.
To secure the tracks and train routes by prioritizing the approach of managing route conflicts, an interlocking system is used, which integrates turnouts, signals, and the control desk as the control area at the station.
The first relay interlocking system built in Indonesia was made by Siemens (Germany) and is known as the DRS-60 type relay interlocking system, where the basic interlocking elements are relays. The control is done from the control desk, and the signals used are color light signals, while the turnouts are operated by electric motors. The tracks within the station area are equipped with track circuit-based train detection systems.
The block connections between stations use interface blocks from the relay system to the electromagnetic block system. The cable installation starts from the relay room and is connected to all external equipment.
The second interlocking system is also a relay interlocking system made by Siemens, called the Modular Interlocking System-801, first generation, produced in 1980. The relays used are of the K50 type (UIC-Codex 736 standard, type C) arranged in module form. The control desk, color light signals, turnout motors, track detectors, cable installation, and block connections between stations are the same as the DRS-60 type. The MIS-801 signaling system can be used in large station areas and developed to serve 2–3 stations with fast service times and efficient use of operators.
There is the Ansaldo relay interlocking system made in Italy. The basic element for its interlocking is the P-150 relay combined with the Genisys electronic control equipment made by Union Switch & Signal Inc (United States). The cable installation itself starts from the relay room and is connected to the farthest external equipment such as entrance signals, and the farthest track circuits up to the entrance signals. The track circuits used have high impulse voltage. Axle counters are used in block sections to detect trains. (DJKA website) The most advanced interlocking system currently being used in Indonesia is the LEN/SIL-Safe 400 Interlocking System produced by LEN Railways System, equipped with a moving block system and ATP (automatic train protection) system.
In the operation of the Jabodebek LRT based on ATO (Automatic Train Operation) with level of automation GoA-3, the ATP system is integrated with OBCU and TCMS equipped with various sensors such as smoke sensors, derailment, and obstacles that can trigger emergency braking and stop the train.
Now, what about environmental factors or natural conditions? Direct obstacles to the operating system can be encountered in conditions such as landslides or floods. In the current rainy season, especially on mountainous lines or routes, there are many cases of trains experiencing slipping. This condition not only puts pressure on train crews and train controllers but also affects the schedule of train journeys, resulting in delays and unusual situations.
The existence of abnormal conditions due to weather disturbances such as slipping, track switching due to road obstacles (such as landslides, etc.), and heavy traffic during certain seasons requires a comprehensive situational awareness approach.
The combination or accumulation of dynamics and pressures from human, environmental, system, and technological aspects (as technological performance can be affected by changes in natural conditions) can have an impact on the decline in performance quality associated with safety.
The conditions underlying an event like the recent accident need to be thoroughly examined and studied.
A situational awareness study of the event, with unverified assumption data through a series of valid investigative processes, opens up several possibilities related to the conditions that occurred at that time. For example, delays in the schedule can trigger interpretations and assumptions that lead to a disorientation of the journey control process.
It is also possible that there were conditions where decision-making hierarchy with autonomous authority that allowed execution in the field, even if it did not comply with central journey control orders, may have contributed to this incident.
Other contributing factors may include lack of precision in operating journey control, including providing signals/messages for a safe route even if the route is not safe. Similarly, departures without confirmation and a seeming focus on assuming there are delays, etc., also need to be further investigated.
If the data and facts from the official investigation are relevant to the above information, and the human factors as well as the conditions of the system, environment, and technology are successfully mapped in terms of their roles and contributions to the accident, then it is likely that the directives and recommendations in the final investigation results presented as safety directions will focus on improving journey control regulations, evaluating SOPs, and improving compliance levels among personnel at all operational levels. Departmental regulations need to be re-examined, and journey control personnel need additional training.
From a technological aspect, it can be suggested to implement journey control technology with a safer interlocking system, such as an integrated moving block concept with ATP (automatic train protection), that can control journey safety and take safety measures such as implementing automatic stops or emergency braking if the system indicates any operational conditions that could potentially jeopardize the journey.
That would be the ideal option to minimize the risk of operational system failures due to various factors, including those related to human factors.
In conclusion, this is a brief study today regarding the aspects of human, environment, system, and technology and their relevance to efforts to minimize accidents or incidents in the transportation sector, which we both hope to avoid. It is our sincere hope that we can learn lessons from past events and use them to continuously improve in the future.
Finally, our best prayers go out to all the train personnel who were victims in the tragic incident yesterday. May their good deeds and kindness receive the best reward from Allah SWT.
