Building the safety culture of JR East Japan TOMOAKI KURIHARA

HIDEAKI KIMURATransport Safety Department

East Japan Railway Company

International Railway Safety Conference in VancouverOctober 8, 2013

1. Introduction of JR East Group.

2. Safety efforts in the JR East Group

3.“Soft” measures for Safety in the

JR East Group

4.Raising up a Culture of Safety

Contents Contents

2

1. Introduction of JR East Group.

2. Safety efforts in the JR East Group

3.“Soft” measures for Safety in the

JR East Group

4.Raising up a Culture of Safety

Contents Contents

3

JR Group Map JR Group Map

JR East

JR Central

JR West

JR Shikoku

Tokyo Osaka JR Kyushu

JR Freight

JR Hokkaido

4

5

Nagano

Niigata

Tokyo

AkitaHachinohe

Shinjo

Shinkansen 　　　　 1134.7 km 　　Conventional lines 6377.9 km 　　New direct lines (see above) 275.9 km 　　

*The figures are as of April 1, 2011 　

Number of employees 59,130 　Working kilometers 7,512.6 km 　Number of stations 1,689 　Number of in-service trains 12,757 　Number of trains 　　　　 13,157 　Income JPY 1,705.7 billion 　Number of station escalators 1,751 　Number of station elevators 1,109 　

　 Overview of JR East （ 1 ）　　 Overview of JR East （ 1 ）　

Extension work underway (Shinkansen) 　

Shin-Aomori

6

Passengers: 16.50 millionTrain-kilometers: 700,000 KM

Door openings: approximately 6 million times

Signal validations: approximately 1.2 million times

Crossing openings: approximately 700,000 times

Per day:

　 Overview of JR East （ 2 ）　　 Overview of JR East （ 2 ）　

1. Introduction of JR East Group.

2. Safety efforts in the JR East Group.

3.“Soft” measures for Safety in the

JR East Group.

4.Raising up a Culture of Safety.

Contents Contents

7

Safety Basic Plan 1994-1998Integrated plan covering both

tangible and intangible aspects

Safety Basic Plan 1994-1998Integrated plan covering both

tangible and intangible aspects

Safety Priority Investiment Plan 1989-1993Formulation of a safety-related

investment plan

Safety Priority Investiment Plan 1989-1993Formulation of a safety-related

investment plan

Safety Plan 21 1999-2003Prevention of major accidents and

improvement of transportation quality

Safety Plan 21 1999-2003Prevention of major accidents and

improvement of transportation quality

Safety Vision 2013 2009-2013Approach safety through

independent thinking and acting

Safety Plan 2008 2004-2008Going back to basics and

re-approaching safety

Safety Plan 2008 2004-2008Going back to basics and

re-approaching safety

Midterm Plans for SafetyMidterm Plans for Safety

8

Creating a culture of safety

Rebuilding a safety

management system

Safety-related human resource development

and system improvement

New perspective II

Taking sure steps

to reduce risks

Promoting active installation

of safety facilities

Prevention of accidents by evaluating risks in advance

New perspective I

Safety Vision 2013 　 Approach safety through independent thinking and acting 　

Safety Vision 2013 　 Approach safety through independent thinking and acting 　

9

　　　 Train accident (all JNR and All JR)　　　 Train accident (all JNR and All JR)

All JNR

0

20

40

60

80

100

120

140

160

1962 1967 1972 1977 1982 1987 1992 1997 2002 2007 2012

（件）

年度

列車衝突 列車脱線 列車火災

All JR

　　 　 　Collisions

Derailments

Fires

Fiscal year

(No. of accidents)

10

11

5 8142 3 7 1 3 3 4 3 1 2 3 1 3 2 6 4 2 2 2 1 2 1 4

247

176156123116958673727571695184 564046 577432424343363634

124

130116115128

10812292908486668965

646847575657 699290106107108

11

1

11 2

1

1

376

315287

240247210209

168165164160136142152

12111196

121136

92113

134144144147

- 0.5

0.0

0.5

1.0

1.5

2.0

0

100

200

300

400

500

600

87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10 11 12

件

年度

鉄道運転事故の推移

鉄道物損事故鉄道人身障害事故踏切障害事故列車事故列車走行100万㌔あたりの件数

100万㌔あたり

Number of Railway Operation Accidents

[Fiscal year]

Reduced by approximately one-third since JR established

　

[Number of accidents]

0.48

Accidents causing personal injury Crossing obstacle accidents Train accidentsAccidents per million operating km

Railway damage accidents

Number of accidentsper million kilometers

Trend of railway operation accidents

　 Major past accidents （１）　　 Major past accidents （１）　

1951 　 Sakuragicho train fire 　　 106 deaths

1962 　 Mikawashima train collision 　 159 deaths

1963 　 Tsurumi train collision 　　　 161 deaths 12

　 Major past accidents （２）　　 Major past accidents （２）　

2005 　 Fukuchiyama Line derailment

　　　　　　　　　　　　　 107 deaths

1988 　 Higashinakano Station train collision 　 2 deaths

2005 　 Uetsu Line derailment 　 5 deaths13

One misstep...One misstep...

Operator related(Train collision at Otsuki Station on the Chuo Line)

Passengers: approximately 550 (78 injuries)

Train car related(Fire on the Arcadia on the Joetsu Line)

Passengers: 80 (no deaths or injuries)

Work related(Track upheaval near Takadanobaba Station on the Yamanote Line)

Passengers: approximately 2,000 (3 injuries)

Disasters (earthquakes)(Derailment accident on the Joetsu Shinkansen Line between Urasa and Nagaoka)

Passengers: 151(no deaths or injuries)

Signal related(Derailment accident at Sendai Railyard)

Passengers: 159(no deaths or injuries)

Track maintenance related(Backhoe collision near Oimachi Station on the Keihin Tohoku Line)

Passengers: approximately 150 (no deaths or injuries)

14

○1951 Sakuragicho train fire　　　　→ Improvements to train body structure, window structure and connecting doors; train announcements; safety manifesto

○1962 Mikawashima train collision　　　　→ ATS improvement, radio alarms for train protection, regulation revisions, establishment of railway labor science institute

●1987 Japanese National Railways privatized and divided, and JR established○1988 Higashinakano train collision　　　　→ ATS-P improvement, safety research institute, training center, Midterm Plans for Safety

○1988 Rokuhara derailment → disaster prevention information system○1991 Shigaraki Kogen Railway collision → substitute blocking on single tracks prohibited as general rule

○1992 Osuga crossing accident → obstacle detection equipment, OH warning device○1995 Great Hanshin Earthquake → anti-seismic reinforcement measures on elevated bridges○1997 Accident at Katahama on the Tokaido Line→blocking instructions operations○2004 Shinkansen derailment caused by the Chuetsu Earthquake　　　　→ train breakaway prevention measures, early earthquake detection system, power outage detection equipment

○2005 Fukuchiyama Line derailment → ATS equipment for curved tracks○2005 Uetsu Line derailment → expansion of anemometers, gale warning systems, 　　　　　　 disaster prevention research center, operating regulations and Doppler radar research using weather information

〇 2011 Great East Japan Earthquake → anti-seismic reinforcement measures expanded, behavioral guidelines for tsunami occurence

History of railway accidentsHistory of railway accidents

15

276550

813 885 892 892 895 886 979 970 889 872 944 1,023 1,017

1,679

1,3491,638

2,130

2,773

2,189

2,459

2,753

3,153

3,234

3,6373,544

3,074

4,044

4,450

1,6761,5191,560

1,818

1,1771,1121,0801,063

3,211

2,3552,414

2,2702,2232,2362,146

2,2382,2342,262

2,0962,038

1,961

1,749

1,301

829

0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

4,500

5,000

87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10 11 12 13（年度）

（億円）

16

Investment results

(Hundred millions of yen)

Safety Priority Investment PlanSafety Priority

Investment PlanSafety Basic

PlanSafety Basic

Plan Safety Plan 21Safety Plan 21Safety Plan

2008Safety Plan

2008

Fiscal Year

Safety Vision 2013Safety Vision 2013

Approximately JPY 845 billion

(Five years)Trend in safety investmentsTrend in safety investments

　 Total of over \2.8 trillion in safety investment

Inve

stme

nt in

Sa

fety

Oth

er In

vestm

en

ts

17

Occurred: Friday, March 11, 2011 at around 14:46

Epicenter: Sanriku Oki (approximately 130 km east-

southeast of Oshika Peninsula (N38.0, E142.9))

Earthquake magnitude: M 9.0

(maximum magnitude of 7 = Kurihara City, Miyagi

Prefecture)

Number of aftershocks

Magnitude of approximately upper/lower 6: 1 time

Magnitude of approximately upper/lower 5: 14 times

(as of 15:00, 3/31)

Observed Si value: 85.4 kine at Shin-Sanbongi

(Shinkansen)

98.5 kine at Yabuki (conventional line)

44.0 kine at Shin-Urayasu (conventional line) 　　

[Reference] Shinkansen operations suspended at 18

kine or aboveMap of estimated distribution of seismic intensity

Source: Japan Meteorological Agency (March 11, 2011 16:00)

Tokyo

Niigata

Morioka

Sendai

Fukushima

Omiya

TakasakiNagan

o

Epicenter

Overview of the Great East Japan Earthquake Overview of the Great East Japan Earthquake

18

仙台

青森

盛岡秋田

郡山

福島

山形

新潟

川部

大館

東能代

八戸

好摩

花巻

北上

一ノ関

小牛田前谷地

石巻

岩沼

米沢

会津若松

いわき

新庄余目

坂町

大曲

横手

茂市

宮古

野辺地

大湊

久慈

岩泉

盛

女川左沢

仙石線

気仙沼線

釜石線

常磐線

山田線

岩泉

八戸線

東北本線

奥羽本線

陸羽東線

仙山線

磐越東線

Damage caused by the Great East Japan Earthquake (trains and train cars)

Sendai Station on the Tohoku Shinkansen Line: Derailment

Shinchi Station on the Joban Line: Overturning

Tsugaruishi Station on the Yamada Line: Derailment

Between Matsuiwa and Saichi on the Kesennuma Line:

　 Overturning

Onagawa Station on the Ishinomaki Line: Overturning

Nagacho Station on the Tohoku Line: Derailment

Hamayoshida Station on the Joban Line:

　 Flooding and overturning

Sendai Shinko: Derailment and flooding

Between Tomei and Nobiru on the Senseki Line: Derailment

Ishinomaki Station on the Senseki Line: Flooding

19

長岡

仙台

青森

盛岡秋田

郡山

福島

山形

松本

長野

高崎

新潟

千葉東京

大宮

八王子

水戸

宇都宮

川部

大館

東能代

八戸

好摩

花巻

北上

一ノ関

小牛田前谷地

石巻

岩沼

米沢

会津若松

いわき

小山

小淵沢

渋川

新庄余目

坂町

大曲

横手

茂市

30km

20km

宮古

野辺地

大湊

久慈

岩泉

盛

女川左沢

日光 烏山

仙石線

気仙沼線

釜石線

常磐線

山田線

岩泉線

八戸線

東北本線

奥羽本線

陸羽東線

仙山線

磐越東線

水郡線

Damage caused by the Great East Japan Earthquake (ground equipment)

Between Sakunami and Yatsumori on the Senzan Line: Embankment runoff

Slippage

Between Fukushima and Higashifukushima on the Tohoku Line:

Bridge girder angle portion damage

Between Nagacho and Miyagino on the Tohoku Freight Line: Retaining wall landslide and embankment runoff

Between Shin-Hanamaki and Morioka on the Tohoku Shinkansen Line: Elevated bridge pillar damage (reinforcements

exposed)

Hitachitaga Station on the Joban Line: Platform retaining wall collapsed

Between Sendai and Shinkansen General Railyard Center on the Tohoku Shinkansen Line: Electric pole breakage

Between Niwasaka and Akaiwa on the Ou Line: Retaining wall

tilting and track bed runoff

Between Nobukata and Kashimajingu on the Kashima Line:

Bridge girder slippage

Between Yabuki and Izumisawa on the Tohoku Line: 　Embankment sinking

19

20

(1) Structural reinforcements

Seismic reinforcement of elevated bridges

(2) Emergency train stops

Improvements in the Shinkansen early　　　　　　 earthquake detection system

Installation of train stop detection equipment in train cars

(3) Measures to keep train close to track in case of derailment

L-shaped car guide

Countermeasures against rail rollover

Existing countermeasures against earthquakesExisting countermeasures against earthquakes

Anti-seismic reinforcement measures in preparation for earthquakes directly under the Tokyo metropolitan area, and anti-seismic reinforcement measures in other regions

　 Anti-seismic reinforcement of bridges, electric poles, station and platform ceilings and walls, etc. 　 Anti-seismic reinforcement of embankments, slopes, iron girders, brick arch bridges, etc.

21

Further strengthening through anti-seismic reinforcement measures

Speedy search and rescue after the occurrence of an earthquake and measures to ensure the maintenance of the functions of the Countermeasures Headquarters

Strengthening communication functions, enhancing capacity of batteries at communications offices ,etc.

Reinforcement of anti-stress after occurrence of an earthquake 　

Establishment of guidelines on operating regulations and evacuation guidance during tsunami warnings

　 Improvement of facilities aiding evacuation guidance such as ladders for train cars and signs displaying evacuation routes

Operating regulations and evacuation guidance during tsunami warnings

Expanding countermeasures against earthquakeExpanding countermeasures against earthquake

10s

15s

20s

25s

Early detection and early stopping

地震発生

地震発生緊急停止

迅速な検知

自動でブレーキ

Countermeasures for large earthquake in Tokyo metropolitan area

Countermeasures for large earthquake in Tokyo metropolitan area

Times indicated on circles indicate time until seismic shock reaches city center(An earthquake in the north of Tokyo Bay used as calculation example)

Jr201r.icoJr201r.icoJr205y.ico

　 Chuo Line (Ochanomizu to Suidobashi)

Embankment (retaining walls, etc.)

Reinforcement example (ground anchor)

Reinforcement of particularly weak sections

Expanding anti-seismic reinforcements

15s25s

Earthquakeoccurs Prompt detection

　Emergency stop

whenearthquake occurs

Automatic braking

22

1. Introduction of JR East Group.

2. Safety efforts in the JR East Group

3.“Soft” measures for Safety in the

JR East Group

4.Raising up a Culture of Safety

Contents Contents

23

・ “ Hard” measures: Installation of equipment or facilities for safety purposes.

・ “ Soft” measures: Other non-structural measures.

・ Tazan-no-ishi: Utilization of the experience of another department or workplace.

・ Events requiring attention: Serious events which can cause train operation accidents.

Notation Notation

24

“Soft” measures for Safety“Soft” measures for Safety

We invest in safety, but ・・・We cannot measure unexpected situations!

・ We are sure that front-line employees can act according to situations.

“Hard” measures

・ Cooperation between system (“hard” measures) and man (“soft” measures) is very important.

And, management resources are limited.

In the Great East Japan Earthquake, there were no injuries or fatalities along lines which were affected by the tsunami.

25

The activation of Challenge Safety CampaignThe activation of Challenge Safety Campaign

・ To move “maintaining the present level of safety” to “rising to a higher level of safety.”・” each employee thinks and acts for themselves”

In each operating organization, expand the discussion of safety

26

The Safety Action for setting “Sangen shugi”The Safety Action for setting “Sangen shugi”

See with one’s own eyes, listen with one’s own ears. Feel and think.

The actual location : We should go to the actual location to understand what happened and how it happened.

The actual object : We should examine the actual objects, such as rolling stock, equipment, machines and tools to understand the circumstances.

The actual people : We should meet face to face with the people actually involved, to understand their circumstances.

The actual location : We should go to the actual location to understand what happened and how it happened.

The actual object : We should examine the actual objects, such as rolling stock, equipment, machines and tools to understand the circumstances.

The actual people : We should meet face to face with the people actually involved, to understand their circumstances.

・ Safety issues are on-site issues.

Is it unnecessary to go on-site?

　・ The answers to the issues are also on-site.

JR East Group’s standards for action in safety

27

Safety-related human resource developmentSafety-related human resource development

Key Safety Leaders

Cooperating to utilize results from training centers for education at operating organizations.

Mutual cooperation in training program

Training

Safety Professionals

Enhanced training

programs to suit real

situations.

General Training Center

しっかりと連携

Sharing information and consulting

Strong cooperation

28

Building the safety culture of JR East Group Building the safety culture of JR East Group

Correct and quick reporting is very important and the starting point for the prevention of accidents.Correct and quick reporting is very important and the starting point for the prevention of accidents.

If we are aware of the hidden signs leading to accidents and share this information, we can prevent accidents.If we are aware of the hidden signs leading to accidents and share this information, we can prevent accidents.

By coming over the fear of discussing what people don’t want to discuss, we can all be aware of the background of incidents or events and can take proper countermeasures against them by discussing them thoroughly.

By coming over the fear of discussing what people don’t want to discuss, we can all be aware of the background of incidents or events and can take proper countermeasures against them by discussing them thoroughly.

Learning from accidents continually through the Challenge Safety Campaign or from the data book of past accidents will help us prevent them.

Learning from accidents continually through the Challenge Safety Campaign or from the data book of past accidents will help us prevent them.

Safety is guaranteed only if we relate reporting, awareness, discussing and learning to safety action. Standard behavior and pointing for confirmation are safety actions. “Thinking and acting for ourselves” is the source of support for safety.

Safety is guaranteed only if we relate reporting, awareness, discussing and learning to safety action. Standard behavior and pointing for confirmation are safety actions. “Thinking and acting for ourselves” is the source of support for safety.

Culture of Correct reporting

Culture of Awareness

Culture of Discussion

Culture of Learning

Culture of Action

29

1. Introduction of JR East Group.

2. Safety efforts in the JR East Group

3.“Soft” measures for Safety in the

JR East Group

4.Raising up a Culture of Safety

Contents Contents

30

　

Mai hyatto

Train accidentsCollisions, derailments, firesAccidents at level crossings(Collisions or contact with trains at crossings)Accidents resulting in injuries or fatalities(Accidents causing deaths or injuries to people [excluding suicides])Accidents causing damage to property(Accidents causing JPY 5 million or more in property damage)

Train accidentsCollisions, derailments, firesAccidents at level crossings(Collisions or contact with trains at crossings)Accidents resulting in injuries or fatalities(Accidents causing deaths or injuries to people [excluding suicides])Accidents causing damage to property(Accidents causing JPY 5 million or more in property damage)

Events causing an impact or delay in train operations

Events causing an impact or delay in train operations

Events that could lead to a railway operation accident, events causing a major impact on passengers, and events caused by human error

Events that could lead to a railway operation accident, events causing a major impact on passengers, and events caused by human error

Events that were caught in advance, and for which the stipulated handling was conducted as a resultEvents causing concern on a regular basis

Events that were caught in advance, and for which the stipulated handling was conducted as a resultEvents causing concern on a regular basis

Transportation disruption

Events requiring attention

Events requiring reporting

Events with high possibility of passenger or employee death or injuryEvents with high possibility of passenger or employee death or injury

* Defined in Train Accident Report Regulations

　 Kind of railway accidents occur 　　 Kind of railway accidents occur 　

Train operation accidentsTrain operation accidents

31

　　　そのうち、繰り返し発生しているもの（過去の同種発生を含む）

0

2

4

6

8

10

10月 12月 2月 4月 6月 8月 10月 12月 2月 4月 6月 8月 10月 12月 2月 4月 6月 8月 10月 12月 2月 4月 6月 8月 10月 12月 2月

Understanding of the current situation Understanding of the current situation F

requ

ency

of

occu

rren

ce

Month of occurrence

Events requiring attentionwhich were similar to past events

40% of events requiring attention were similar to past events. 32

Accident

Forgetting

Tim

e

Distance

33

Time of accident

Awareness of accidents decreases exponentially with both time and distance

Awareness of accidents decreases exponentially with both time and distance

Party directly related to accident

Accident

Forgetting

Tim

e

34

Look back toserious accident

of the past

Make the best use of “tazan-no-ishi”

Action to prevent forgetting

Awareness of accidents decreases exponentially with both time and distance

Awareness of accidents decreases exponentially with both time and distance

Party directly related to accident

Time of accident

Distance

Symposium on Safety Symposium on Safety

Theme

Important views gained from 21st symposium

Each employee utilizes and understandsex. ） Each employee will be encouraged to think independently and express their thoughtsex. ） By using a support tool of “tazan-no-ishi,” each employee utilizes and understands experience from other departments or workplaces.

Engrave in the heart by “Sangen shugi” and experiencesex. ） We make reconnaissance surveys at sites of accidents.

ex. ） Use a “Serious Accident Encyclopedia,” recording serious accidents of past based on senior employees’ experiences.

ex. ） We propose to single out only events that are likely to occur in related workplace.ex. ） We provide the opportunity to discuss what the fatal problem of accidents or events are, and now to keep them in mind so as not to repeat them. 　ex. ） We make use of reference materials made in each department or workplace for review, selected from accidents or events in the past.

「 We learn from these serious events or accidents to prevent accidents which could lead to train accidents involving fatalities or injuries of passengers or employees 」～ Each employee utilizes and understands experience from other departments or workplaces, and takes action. ～

Regarding incidents which could lead to fatalities or injuries of passengers or employeesSingle out accident cases

35

Caravan in Safety Caravan in Safety

Our company Employees ofour company

Assistant directorsof our company

Group companies Partners, etc.

18 organizations 121 people 110 people 20 places 76 people 26 companies 46 people

36

【 Single out important events】◇Head office and branch office handle a large amount of information, so cannot provide customized information due to time constraints.◇When we researching events to study from, materials are often unavailable, leading to resignation.【 Understand events which are singled out】◇Even if we have the information through “ tazan-no-ishi,” we cannot comprehend it sufficiently without understanding differences of operation or background. Information is often wordy and difficult to understand.【 Utilize experience and think thoroughly】◇We want to decide the theme of our workplace, but it is difficult to make the materials. It would be helpful to customize common materials based in our company.

【 Theme】“Why ‘tazan-no-ishi’ style thinking is not sufficiently utilized on site.” ～ To prevent “events requiring attention” that tend to be repeated. ～Problems and issues in operating organizations

○It is difficult to make the best use of others’ experience to prevent accidents involving passenger’s fatality or injury.○Operating organizations have trouble, singling out understanding the singled-out experience, or utilizing the experience.

Found from visits and discussions

Participants of discussion

36

Summary• Recently, in JR East, the frequency of major accidents has

greatly decreased.• On the other hand, events have occurred which could lead to

serious train accidents involving passengers or employees, including fatality.

• These events are often caused by human error, i.e., operative failure, or by blind spots within the system.

• We need to learn from these serious events to prevent accidents. It is thus important to cultivate a culture of safety.

37