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Saturday, April 30, 2011
Learning from train tragedy
Six years have passed since the April 25, 2005, train crash on West Japan Railway (JR West) Co.'s Fukuchiyama Line in Amagasaki, Hyogo Prefecture, in which 106 passengers and the driver were killed, and 562 others were injured. In the ensuing years, people have been asking why the accident occurred and how a recurrence of such a tragedy can be prevented.
On April 15, a Japan Transport Safety Board team, consisting of five experts and seven accident survivors and bereaved family members, made a proposal to establish an investigation system that would contribute to improving the safety of public transportation. Wide public discussions should be held on the proposal, which contains very reasonable points.
In a related move, on April 25, JR West and 4.25 Network, a group of family members of the victims, issued a report on their investigation of the accident, which unearthed problems with JR West. The company should make the best use of the findings to enhance the safety of its train operations.
The most important point in the JTSB team's proposal is a call to sever the board's own accident investigation from the investigation of criminal negligence. At present, the entire content of a report on an accident written by the JTSB is submitted to the police and is used as evidence in a criminal trial. Under this system, there is a strong possibility that employees and officials of a company that has become the target of the JTSB's investigation will refrain from telling the whole truth about an accident, fearing that what they say may be used as evidence against them in a trial. This would make it difficult to recommend and take proper measures to prevent a similar accident from occurring in the future.
The JTSB's team proposed that the board should only submit reports on concrete facts related to an accident to the police and should not submit such things as the boards' analysis and assessment of an accident and testimonies by individuals.
The proposal follows the prevalent thinking in the international community that an independent commission or board's investigation into an accident should be aimed at preventing the recurrence of a similar mishap, not at punishing people involved in an accident. The proposal includes compelling a company involved in an accident to take part in the JTSB's investigation with the goal to use its knowledge and expertise to look into not only the direct cause of an accident but also any organizational problems in the company that may have led to an accident. The proposal also calls on the JTSB to reflect what accident victims have "noticed" in the board's investigation.
The team also proposed that not only employees directly involved in an accident but also the company that employs them should face criminal punishment. Behind the team's proposal is the idea that such factors as a company's safety equipment, inadequate training, and its culture and pressure on employees could lead to an accident.
This proposal is reasonable and is a correct response to criticism that the June 2007 report by the then Aircraft and Railway Accidents Investigation Commission only focused on physical factors that caused the accident. In the scene of the Amagasaki accident, JR West reduced the radius of the curve from 600 meters to 304 meters in December 1996. The train entered the curve, which has a speed limit of 70 kph, at more than 110 kph.
Immediately after the accident, it was suspected that the driver increased the train's speed to make up for a delay that he had caused. It was also pointed out that JR West's "education" of employees who commit errors that lead to delays was so harsh that it led the driver to speed in an attempt to make up time.
In their investigation, JR West and 4.25 Network group delved into the psychology of the driver and factors behind his mental state, and whether JR West's education of an employee who makes a mistake is appropriate. In the report by JR West and the group, JR West did not rule out the possibility that its tight train schedule caused the driver to feel pressured to keep to the strict timetable. JR West president Takayuki Sasaki has said that his company will study the relationship between the train schedule and the driver's mistakes.
This is a step in the right direction by JR West. A survey of JR West drivers by the JTSB team found that about 90 percent felt that the train schedule in question was too tight. In the report, JR West admitted that it had lacked a system to predict potential risks, and that it also lacked the environment in which mistakes could be properly reported to management and the operation control section. It also admitted that it did not have a system to study and understand the importance of human factors in train operations.
To improve safety, JR West must take concrete actions to correct the problematic points disclosed by the report.