This a heartfelt appeal to the Indian Railway’s top management to wake up and prevent the complete commercialization of a public engineering organization that is the lifeline of the nation.

The latest railway accident of Utkal express (19^th August 2017), resulting in death of 23 and removal of ME, GM, DRM, CTE,  Sr.DEN etc. is a glaring example of what has gone wrong with the Indian Railways over time. Such accidents, which are primarily designed by humans by commission or omission, hurt deeply. Ironically, once again, there are no signs of addressing the core issues, but rather at dousing the fire, and killing the symptoms, rather than the disease.

One just need to talk to one of the 13,00,000 + railway employees and arrive at a list of ills in the organization. Thse range for erosion of dedication and sincerity, poor recruitment policies, over staffing, over-emphasis on passenger amenities at the cost of safety items, etc. The list is endless and everyone has his own unique understanding of the problem. But, is this not common in the case of any organization? What gets consistently missed in this long list is the recognition that a primarily engineering organization is getting progressively commercialized! The people at site have been punished, and accountability fixed to the highest levels in the organization. This is like any commercially run professional organization, and the mission seems to have been accomplished in making railway staff responsible for their actions. But this leaves one wondering — will these actions prevent the second accident of Utkal Express at the same place?

Some facts. Trains run on steel rails, and the steel rails have to be continuous. One of these rails developed a crack which was detected at noon (12:00 hrs). Till 17:46 (more than 5 hours later) when UTKAL express ran off the rails at this point, the tracks had not been closed down for repairs. It was being debated upon between operating managers and their engineering counterparts—should we close the track or not! No one realized that if there is no track, there are no trains to be run.

The response! On well recognizes that accidents of this magnitude do not happen by the fault of one! Firstly, those who faltered in fixing the track have been taken up. They should be. Everyone in the hierarchy – ranging from all those at site to the one in the Board should be sacked summarily, as they failed to recognize the importance of their work. They had completely missed the fact they are playing with the lives of public, and their jobs are a small part of it. I fully stand by the sacking of PWI to the Sr.DEN! Knowing the guts of system, I can draft their list offences in exact detail identifying how they contributed directly to the accident. Each of them were aware of the incident in realtime, but played it safe personally – to make railways unsafe for the public. Why was the rail cut without the block, and why was the banner flag not put up, are some of the failures for which they are directly responsible. This makes the people responsible for maintaining the track responsible.

Secondly, and more important—- who made them do that! For this, the removal of the DRM, CTE, GM to the ME becomes justifiable. They did not know of the incident in real time, but by their repeated actions and inactions they were responsible for the actions of their men!

However, we have all been silent about one part! What about the traffic department (operations the holy cow) who have refused to allow time for maintenance, or the engineering departments heads who could not put enough courage in their men to stop a train from running on a broken track! A key and important part here has been played by traffic department, which has cleverly become a hero here (while being the key instigator behind the crime). The full brass of operating people needs to be taken up similar to engineering and fixed. That is, those involved with the incident in realtime (section controller, Chief controller, DOM) and those behind the scene who had given the courage to behave the way that they did (which includes the CFTM/CPTM/COM the Operating equivalent of CTE, and the Operating equivalent of ME at the board level i.e., MT).

To make the role of operating more obvious one needs to know that the allotment of time for maintenance is an age-old problem in railway working. It is a tussle between the engineering and the operations since the railways started operating. One of the primary agendas for cross functional incharges (the DRMs and GMs) has traditionally been to maintain this delicate balance. Time had to be allowed for maintenance, at the cost of punctuality and moving higher traffic! And, there were times when this was fought tooth and nail, when people believed in the importance of their work. In the Indian Railways, the key problem has always been that while railways is a complex engineering institution, ironically in our case it is run by social science professionals. With time, the engineering has become secondary to operating/commercial interests, and result is obvious in this accident.

My prior experience with railways makes me fear that engineering will once be punished, while the operating will once again go scott free, making the organizations transition from the engineering to commercialization complete. This is not the last Utkal express accidents, but only one of the many which keep happening increasingly in the railway system, while it looses its engineering sheen!

Now,I travel far less by train compared to what I have done during most of my railway life. These are some observation during one such train journey in August 2017, and written while on the train. Railways is a huge system, with a very capable set of people, but it has been delivering far less than what it is capable of. In this piece, I identify two reasons which could lie behind this.
 The railway system fails to systematically learn from failures.
o The system is too busy hiding, defending, and negotiating failures, that there is little energy left for systematically learning from failures.
 There are far too many ears and eyes inspecting, compared to the minds and hands at work.
Below I attempt to qualify each of these conjectures with some examples.
LEARNING FROM FAILURES
As I look outside the train window, I see multiple rakes of covered goods wagons roll by. These were the BCNA wagons that had given me many restless nights during my railway days. The conventional covered wagon had been redesigned in 1990’s to increase its loading capacity. This also led to its doors getting modified for easy loading and unloading. Launched and celebrated as a great innovation it soon emerged that during train running the doors would open out, and break signals and other fixed structures. This became an operational nightmare, with trains behaving as torpedos. After numerous attempts of hiding, defending, and negotiating, the failure was recognized and it was decided that the doors would be redesigned for new wagons, and also modified in existing wagons. Wagons were called back and refitted with modified doors. A huge failure, which would have cost railways crores of rupees.
Firstly, is there an estimate of what the mistake costed railways! While we do have guess estimates of what the challenger crash costed, or what the titanic sinking costed, but we have never cared to estimate the cost of this failure. If you don’t measure it, you are unlikely to address it. Secondly, mistakes happen, and when one attempts new ideas they happen more often. But, these mistakes are supposed to pave the steps to success. I wonder, what the railway management’s take away was from this failure, other than ensure that changes to proven design not be made. Thirdly, was this a one-off failure? We would never know! We never got it studied and never got it documented.
Sitting in one of the most modern coaches over the railway system, every ten minutes I am subjected to a longitudinal jerk. This jerk, a decade after the introduction of LHB coaches, is enough evidence that little learning has happened from failures! This problem is known to railway managers from the first time that they ran trials on LHB rakes, and it still exists a decade later! There are many more such failures – rail fractures, OHE snapping, etc. which I can name. And, many more of those which go unnamed in the railways failure investigation, getting attributed to law order or cow runover! For instance, buckling of track in extreme winter, to which we never even attempted to find solutions to!
It would not be out of place to argue that the significant improvements in railways overtime are largely technology driven, and not because of learnings from failures. Most of the things within the direct sphere of influence of railway managers have remained the same, with little visible improvements on their own (for instance poor quality in purchase). Even office cleanliness and efficiency in procurement had to be externally driven by the prime minister and technology respectively.
INSPECTING AND WORKING
I remember a time during one of my early postings. I got so hassled inspecting the same problems again and again, that I resolved not to visit a depot unless I had addressed all the previous observations that had been made, or had made some progress worth reporting. However, the inspection quotas ensured that I was back inspecting the same depot again, noting down the same action points once again. The system so routinely inspects, that it forgets what it is inspecting! Please see the photograph of electrical panels below! The covers of electrical panels have been opening and hanging for over 3 decades now, and it is the same problem (may be varying in degree) whether it be general second, or Rajdhani/ Shatabdi! Railways is a very democratic organization. This problem is the attributed cause of serious fires in general second coaches, and a regular eye sore in higher class coaches. Only today I saw a video of an air plane crash being attributed to a knob being left in the wrong position after maintenance, losing over a 100 lives.

Have no inspecting officers noticed it in all their train journeys? If we can’t lock the covers and keep them in their place, let us not have them! They are already missing in 50% of the places, let them not be fitted in the first place.
Another classic example is the innocuous notice below.

I have been training my pre-teens to keep themselves occupied in restaurants (while waiting for food) by looking for spelling mistakes in the menu card! It is an entertaining exercise, but with word having inherent spell check fewer and fewer mistakes are found. The notice above would have provided them with a gala time. It is a public notice that no one cared to proof read before printing! Further, while railways would have spent a significant amount of money printing them and pasting them, no one cared to ensure that they be pasted straight. Also noticed the half peeled seat numbering stickers—the once that were recently pasted with brail lettering! Is there one thing that we can do properly! May be yes! 5 years later I saw most door closures working, and having date of fitment over two years back. But someone would have to verify this if it is true.
However, these are tell-tale signs to the bigger problem. They have been addressed in the inspecting culture by having more inspections! But would that solve the issue! Would the door closure issue be fixed by the inspections? It got resolved (if it did) when the Railway Board changed specifications and ensured their quality! A job that according to me was not its responsibility.
Again, these are not isolated cases. How have the ills of collie overcharging, broken platform floors, broken lights, dirty linen, broken road surfaces at railway crossing escaped the attention of the regularly inspecting officials! Actually, they have not missed the attention of these officials, they have simply been ignored! We need more of the hands at work, rather than the eyes and ears inspecting finding faults and ignoring them.
And above all, it will definitely help if we can have some minds at work too!
Epilogue:
Opening the newspaper today and reading about a railway accident reconfirms the second point about inspections that I made above. Utkal Express derails near Khatauli, killing 30, when the site of accident is being inspected by a senior officer. Do not jump to conclusions, as circumstantial evidence and piecing together evidence is not enough. How can a senior civil engineer inspecting at a site under maintenance cause an accident? Pun intended! In my 23 years of railway experience, this was an ideal setup for one to find broken brake blocks, wagon parts, or even any other rolling stock component on track. And, suddenly there is an alternate story of how the train suddenly jumped because of a previous train’s component on track. I await one!

I have spent the last 5 days reading about the life experiences of Jagdish Khattar (An ex IAS, MD of Maruti Udyog 2000-2007), visited two government offices (NHAI and Railway Board) and a Visa processing center. Four very different government run organizations — with key differences lying in full/partial governmnet ownership, Indian/UK, policy/operational, service/manufacturing — but also similar. All of them existing to do essential public servcie jobs, and with their tasks being of regular and routine nature. What struck me was the deep entrenchment into routine working and it being THE JOB (NHAI and RB) as against outsourcing it or breaking it up (Maruti or UK VISA). People in NHAI and RB were busy with routines, and this has become their life and job.

This also reminds me of a remark in Mr. Ashwani Lohani’s ten year old book — “ Remaining busy is considered synonymous to deliverance. How busy an individual is has become an established norm for judging the operational efficiency of the person” Pg 6 Ch 1 and later what follows is a “A perpetual frown on the face that conveys the impression of carrying the trouble’s of the world on one’s head” Pg 7, ch 1. The Sarkari way of working!

I am uncomfortable with this, and the perpetuality of this routine working! The troubling questions — first and foremost– Is there anything wrong with this sarkari way of working! If not, we are fine and let us carryy on as is. If it worries us, the existing options lie in outsourcing (UK Visa) or in change in ownership (Maruti)! The second question – are these THE options or we can think of alternatives beyond them. The third question — How long will the bureaucracy take to think of the alternatives! Will the other stakeholders hold their patience for all this time? How long before they start exploring the existing available options.

The looming threat! Maruti negotiated when it found that the only option for it lay in replacing the routine manual material movements with conveyors and robots, quite in contrast with they had thought of 2 decades back. UK Visa office cut the work out from their embassy and handed it over to low paid Indians. We continue to tell our students — recognize that the nature of work is changing and is changing fast! When will the sarkar recognize the need to shed the routine working and hand it over to their own or external systems. Devote the highly intelligent resources that they possess to more value adding roles!

Have managed to get published in one of the top journals in the management field — Journal of Business Ethics (list maintained by Financial Times https://www.ft.com/content/3405a512-5cbb-11e1-8f1f-00144feabdc0).

Neither is business ethics my core focus, nor is development of pedagogical tools my expertise area. However, both the areas are closely intertwined with what a business management educator does. Hence, I am proud (and extremely proud) of the publication ” Integrated Live Case: A Contemporary approach of Business Ethics Pedagogy.”
Can be accessed online form the link here, or write to me to get a copy.
( https://link.springer.com/article/10.1007/s10551-017-3514-6?wt_mc=Internal.Event.1.SEM.ArticleAuthorOnlineFirst )

What we do here is quite comprehensive and interesting! We survey business ethics pedagogy literature to identify what they have to say about teaching business ethics (408 papers reviewed). With this we develop a framework that we call the “ACD framework” (Approach, Content, and Delivery). This comprehensively identifies the different aspects of business ethics pedagogy, in the form of six binaries — two in each of the ACD elements — Approach (Theory or Realworld Connectedness), Content (Depth or Breadth), and Delivery (Traditional or Innovative). Moving further, we provide and propose a new business ethics pedagogy — Integrative Live Case(ILC) — as a generic way to address the different needs of the ethics pedagogy. To make our case stronger, we provide a instantiation of our proposal, providing a detailed template of how to use ILC to address the needs of a good business ethics pedagogy.

Writing this paper has been a great and highly fulfilling learning exercise in team working, idea generation, and academic writing. Our team (3 of us) may have easily spent more than 150 hours each on this project in team meetings, and a similar amount in individually doing our work. With the mission accomplished, the whole time spent in worthwhile both as a result, and also in what it has left behind with us. We can think a little more clearer, and also a write a little better, without a doubt.

I write this giving myself a pat on the back, and moving forward! Amen.