An investigation into the 2019 Botswana Railways passenger train fatal accident has revealed a toxic culture of bullying, manipulation and outright lying by management in a bid to cover up fatal flaws and safety failures.
The investigation report compiled by an inquiry board chaired by Olebile Moakofi concluded that., If it was not for failure in the critical decision-making process at the helm of BR’s top management, despite direct advice to stop trains, this accident could have been averted.”
Botswana Railways was woefully unprepared for the accident that killed two crew members and lied to the Board of Inquiry about the extent to which Botswana’s rail transport system was unsafe.
Worse still, the report revealed that the actions of management before, during and after the accident betrayed a culture of stonewalling, manipulation and outright lying.
The investigation uncovered that at some stage the water provided on the passenger train was contaminated with E. coli.
In an apparent attempt to cover up the incident, the Botswana railways Safety, Health, Environment and Quality (SHEQ) manager lied to the Board of Inquiry (BOI) during the investigation.
States the report: “It is evident that whilst the Acting SHEQ Manager vehemently denied any knowledge of water contamination as attested to by the Health and Safety Inspector, the BOI noted with dismay that the Acting SHEQ Manager’s version was devoid of the truth…. The most reliable information was that of the Health and Safety Inspector, who provided the BOI with supporting evidentiary material
The Acting SHEQ Manager “continued to deny knowledge of non-availability of safety equipment such as first aid kits and fire extinguishers in the passenger train whereas the train crew had testified to the lack thereof. The BOI observed further that he did not seem to appreciate the importance of membership bodies such as National Occupational safety association (NOSA). The general safety culture at BR has deteriorated and the current Acting SHEQ Manager seems to be overwhelmed by the responsibilities of the position.”
Released last week, the accident report on the derailment of BR train around Pallaroad 10th December 2019 also states that the Acting Civil engineer lied to the BOI about circumstances surrounding the accident.
“The Acting Civil Engineer gave inconsistent statements on material issues and hence the conclusion that he lacked credibility when he appeared before the inquiry. Apart from manipulating other employees (his subordinates, his rather evasive and indecisive behavior left too much room for unreliability in the crucial section like Civil Engineering at BR.”
Even the company former Chief Executive Officer, Leonard Makwinja was not spared the criticism. The report stops short of casting aspersions on Makwinja’s credibility and competence:” “With so much happening (given the prevailing weather conditions) on the eve of this accident, it would be unthinkable to imagine or believe that the CEO was unaware of the sequence of events. In fact, if that was the case, then it raises a lot of questions because as the saying goes, the buck stops with him. During the interview the CEO indicated that he first learns about the derailment from a colleague at MTCHQ (Ministry of Transport and Communications Headquarters) The Board of Inquiry found this very strange and interesting. Ideally as the CEO of an institution such as BR, inherently susceptible to adverse weather conditions as was the case he should have been more proactive and inquisitive on the particular day. The CEO should have taken the initiative to establish with certainty the safety of passenger train operations, to the extent of personally stopping trains and later discipline those having failed to do so.”
The report states that the fact that the BR Chief Executive Officer (CEO) heard about the derailment from a colleague at parent Ministry of Transport and Communications instead of direct information from his Directors and Acting Safety Manger, indicates a total system collapse.”
It emerged that the passenger train was running without a voice recording (the equivalent of an aero plane’s black box). States the report: “BOI summoned for the voice recordings of the occurrence train for the period between 9th December 2019 until the derailment and the Board was informed that the system crashed in September 2019. Hence the recordings which would have shed light into communications between the OCC and the occurrence train crews could not be availed upon due demand.
“The availability of the voice recording system could have provided crucial missing communications between the occurrence train crews and the OCC, however its unavailability had no direct cause on the accident.”
All in all, everything that could go wrong did go wrong: According the report, the derailment was caused by failure of the unsupported track as a result of wash-away, when the heavy locomotive moving at a relatively high speed of 64 km/h came into contact with it at or around 464 km peg.
The BR leaner driver failed to sound the whistle as they approached the windowmaker. States the report: “Failure by the learner driver to sound the whistle suggested that all cab occupants were deep in conversation that impacted on their concentration hence nobody saw the excess water towards 464 km peg.”
It emerged during the inquiry the track between Gaborone and Ramatlabama needed urgent mechanized maintenance.
“A study carried out in 2005 on improving the drainage system along the main line, was never implemented. Though the study had not covered other critical areas like this occurrence site, it was estimated to cost about P23 million then,” reads the report.
It further emerged that “the Acting Track Master gave inaccurate reports about the track inspection around 464 km peg. He further altered an important document partly under the instruction of the Acting Civil Engineer,” stated in the report.
According to the report, the Acting Director of Operations failed to convert a memo into an operational notice for circulation. Added is that on the day of the occurrence, he singled out one message best known to him and forwarded it to the executive management WhatsApp group. The message was used as the basis for the refusal to stop trains that night. This according to the report was deemed as malicious and reckless behavior or action taken with conscious disregard for safety.