He said the train driver, or hostler, of train 40 (TR40) without passengers, encountered communication difficulties with the operation control centre (OCC) that inadvertently led to the crash.
The hostler was employed to drive the train manually after it malfunctioned on May 24 while it was in the tunnel between the Kampung Baru and KLCC stations.
“The hostler did not report the track section number to the OCC. This should be reported periodically to the OCC,” Wee told a press conference today on the findings of the investigation committee into the crash.
Elaborating further, Wee said both of TR40’s vehicle on-board communication (VOBC) had gone offline forcing the time-out.
“During the process of resetting both VOBCs and driving the TR40 manually to the re-enter point (at Dang Wangi) both the hostler and OCC’s train controller had overlooked and missed critical procedures that are part of the process.”
Meanwhile, the other train carrying 213 passengers, TR81, received inaccurate information that TR40 had departed.
Wee added that TR81 was initially held back at the KLCC LRT station while a manual route reservation (MRR) was implemented as TR40’s malfunction was being resolved.
“However, the MRR was lifted and TR81 was prematurely made to depart KLCC station towards Kampung Baru station without the proper verification that TR40 had been safely reset and re-entered into automatic train operation (ATO) mode.”
The investigation committee chairman Isham Ishak said checks found Prasarana’s maintenance of its trains to be in order.
“All of their trains are well-kept and well-maintained,” he said, adding that it was seldom that both of a train’s VOBC’s would malfunction.
Wee also said the ministry will see to it that the company’s top management takes immediate action on the investigation committee report’s 23 recommendations, which he had tabled to the Cabinet yesterday.
The committee’s recommendations include five short-term changes, 11 medium-term changes, and seven long-term changes that would take more than six months to implement.
Short-term improvements (within three months) include posting two hostlers during manual operations, with one acting as a safety and compliance officer.
Wee said work tools for hostlers carrying out their duties in low visibility environments such as LRT tunnels should also be upgraded.
The committee also proposed setting up a Sighting Committee to perform audits on the track markers.
Some of the committee’s medium-term recommendations were for a technical evaluation on SOPs for manual operations in tunnels and to undertake periodic audits.
SOPs used in the OCC must also be improved and be subjected to periodic audits.
The committee also recommended improvements to the accountability of the train management towards all SOPs, emergency response plans and safety procedures.
They also suggested a job safety analysis on all existing and future personnel in critical positions to improve competency and knowledge.
The committee also called for a risk evaluation on communications equipment between hostlers and the OCC.
Among their long-term proposals include a reliability, availability, maintainability and safety (RAMS) study on all Prasarana Malaysia Bhd and Rapid Rail Sdn Bhd assets and systems.
Electronic train detection systems to ensure “time-out” trains are detectable remotely should also be improved.
The LRT collision resulted in 47 passengers being seriously injured. The rest suffered minor injuries.
He said preliminary investigations found that the train driver, or hostler, of TR40 failed to follow the correct orientation.
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