PUTRAJAYA: The May 24 Light Rail Transit (LRT) collision was caused by non-adherence to critical rail standard operating procedures (SOP), an investigation committee found.
The oversight had “inadvertently” resulted in one train moving in the opposite direction, while another had been released prematurely, said Transport Minister Datuk Seri Dr Wee Ka Siong.
At a virtual press conference yesterday, Dr Wee explained the sequence of events that eventually led to the collision that day.
A train, labelled as Train 40, had experienced technical difficulties when both of its vehicle onboard communication (VOBC) systems stopped.
Train 40 was then supposed to be brought to Lembah Subang depot for maintenance. However, it lost communication with the operations control centre and stopped between the KLCC and Kampung Baru LRT stations.
A hostler, or train driver, was called to manually drive Train 40 to the Dang Wangi station in order to reset the train’s two VOBCs.
“During the process of resetting both VOBCs and driving the Train 40 manually to the re-enter point, both the hostler and the train controller at the operation centre had overlooked and missed critical procedures during this process.
“This inadvertently resulted in Train 40 being manually moved north towards KLCC station instead of south-bound towards Dang Wangi station, ” said Dr Wee.
At the same time, another train referred to as Train 81 – was at the KLCC LRT station and had passengers on board.
As Train 40’s situation was being resolved, Train 81’s southbound journey towards Kampung Baru station was put on hold under the Manual Route Reservation (MRR) mode.
The MRR, however, was lifted prematurely before Train 40 completed its job, resulting in both trains colliding between KLCC and Kampung Baru.
“There has to be communication to ensure that the hostler on Train 40 had completed its job.
“Train 81 should not be released from KLCC while there was another train in the tunnel.
“Because there was no strict compliance with SOP, this resulted in the collision between Train 40 and Train 81, ” said Dr Wee.
Following the findings by the nine-member investigation committee headed by Transport Ministry secretary-general Datuk Isham Ishak, the Cabinet has approved 23 recommendations.
“The goals of the committee’s findings were to identify any gaps and to recommend systemic improvements to both Prasarana Malaysia Berhad and Rapid Rail Sdn Bhd’s rail services and asset maintenance.
“Public safety must be made a paramount concern in the rail service industry.
“This report is not for the purpose of apportioning blame nor liability on any party, ” said Dr Wee.
Among the short-term recommendations, which must be implemented within the next three months, is for two hostlers to be assigned during manual train operation within tunnels.
One hostler will drive the train while another will act as a safety and compliance officer.
The committee also called for the checklists used during manual operation and critical situations to be reviewed.
For the medium and long term, the recommendations include improving refresher courses and recertification for hostlers and operation centre personnel to maintain their competency.
Dr Wee said Prasarana and Rapid Rail must implement the 23 recommendations “by hook or by crook”.
“This is for the safety of the people and commuters.
“The ministry will make sure they deliver and comply with the SOP 100%, ” said Dr Wee.
The incident caused injuries to 213 passengers, with several in severe condition.
Dr Wee said three passengers had been discharged from Hospital Kuala Lumpur’s intensive care unit (ICU) and were now being monitored by neurosurgeons.