An Accident Investigation Case with the Aircraft and Railway Accidents Investigation Commission in Japan

Susumu HashizumeTransport Safety DepartmentEast Japan Railway Company

JR EastJR East

JR HokkaidoJR Hokkaido

JR CentralJR Central

JR WestJR West

JR ShikokuJR Shikoku

TokyoTokyoOsakaOsakaJR KyushuJR Kyushu

JR FreightJR Freight

JR Group MapJR Group Map

NaganNaganoo

Shinkansen linesShinkansen lines

SendaiSendai

NiigataNiigata

TokyoTokyo

MoriokaMoriokaAkitaAkita

HachinoheHachinohe

JR East OutlineJR East Outline

ShinjoShinjo

Conventional linesConventional lines

(As of 1 April 2007)(As of 1 April 2007)Number of employees Number of employees Working kilometers Working kilometers Number of stationsNumber of stations 　 　 Total trains in Total trains in operation operation Number of vehicles Number of vehicles

63,14063,1407,526.8 km7,526.8 km1,7021,70212,671/day12,671/day13,17913,179

The ShinkansenThe Shinkansen

The ShinkansenThe Shinkansen

ContentsContents Summary of the Aircraft and Railway Accid

ents Investigation Commission (ARAIC) The Investigation of Train Crash Accident

on JR Fukuchiyama Line Revision of laws (technological standards)

by the Ministry of Land, Infrastructure and Transport

Response of JR East to the Revision

Foundation of the ARAIC

１９７１　　　　 Foundation of the Aircraft Accidents

　　　　　　　　　　　　 Investigation Commission

　２００１　　　　　 Foundation of the Aircraft and Railway

　　　　　　　　 Accidents Investigation Commission

About ten years ago 　　Technical standards are provided by laws and regulations, and the Government certified the compliance.

Deregulation in 2001Railways can regulate their own technical standards a

nd certify the compliances with their standards.

　　 Big accidents and incidents　　　→ The ARAIC investigates, and makes

proposals.

Investigation Objects of the ARAIC

Accidents

　・ Train collision accidents

　・ Train derailment accidents

　・ The train fire accidents 　　・ Others Incidents 　 Not accidents, but close to accidents

Organization and Authority【 Commission 】

Chairperson Member

Air Sub-committee

Railway Sub-committee９　persons

Organization and Authority

【 Secretariat 】

Director General

Aircraft AccidentInvestigator-General

Deputy-Chief AircraftAccident Investigator

Aircraft Accident Investigator

Railway AccidentInvestigator-General

Deputy-Chief RailwayAccident Investigator

Railway Accident Investigator

AdministrationSection

DocumentsSection

EquipmentSection

PlanningSection

General AffairsDirector

Research andplanning officer

General AffairsDeputy Director

General AffairsDeputy Director

２２　persons

７　 persons

Research andStatistics Section

Train Crash Accidenton JR Fukuchiyama Line Date ： at 9:19, April 25 in 2005 Scene ： JR West 　 Fukuchiyama Line

OsakaTokyo

←Amagasaki

Fukuchiyama→

No.1

No.2

an apartment house No.3

No.4

No.5

No.6

No.7

Killed ： 106 passengers and the motorman

Injured ： 562 passengers

Radius ： 304 ｍ

Fukuchiyama

Amagasaki

Series 　 207 　EMU

Appointment of Investigators 　　 Four investigators to the scene immediately　　→ In all,12 investigators have been working.Commission for Investigation　 Some parts of investigation of rolling stock → a professor of the University of Tokyo　 Computer simulation　 Running tests 　　　　　　→ the Railway Technic

al　 Benchmark tests Research Institute　 Information　 → Hyogo Prefectural Police Department and Fire bureaus

Contents of the Investigation The investigation at the scene of the accident The detailed investigation of the rail facilities and

the rolling stock The running tests of actual rolling stock The tests of the scattered ballast The tests of the movement of center of gravity of

passengers by centrifugal force Computer simulation of the derailment Hearing from passengers and an eyewitness Questionnaire survey from motormen and

conductors

On December 20,2006

→The ARAIC released a draft of the report.

On February 1st,2007

　 → The ARAIC held a hearing from experts

The Final Report (released on June 28,2007)

A 304-meter-radius curve at 116km/h, against a 70km/h speed limit

The first car tilted to the left, causing derailment. The motorman applied a regular brake, not an

emergency brake. At a previous station, his train overran by 70 meters,

causing it to be 1 minute behind schedule. The motorman asked the conductor to tell the control

center the overrun was shorter than it really was. The time when the train entered the curve and the time

when conductor reported to the center were almost coincident.

The Final Report (released on June 28,2007)

When the motorman had operated a train on an earlier occasion, he made two mistakes.

ⅰ: an operational mistake with ATS

ⅱ: traveling too fast at a junction Ten months before the accident, his overrun at a

different station by about 100 meter caused him a re-education program and a penalty.

After the crash, the conductor pushed a button for the train’s emergency radio system, but it did not work. He didn’t know about a spare battery.

The cause of the death

The first car could have been derailed at a speed of more than 110km/h.(computer simulation)

The Final Report (Released on June 28,2007)

Loss ofblood10%

Cervicalvertebraedamare

13%Internalorgan

damage16%

Suffocation18%

Crashsyndrome

3%Brain and

headdamage

40%

Outline of ATS Systemutline of ATS System

ATS system which can check its train speed continuously with on-board brake patterns

Automatic Train Stop System Automatic Train Stop System

Service brake works

Train stops in front of red signal

The train speed

Continuous brake pattern for red signal

wayside coil transmitting “the distance

to the red signal” by digital messagedigital message Red signal for Danger

Proceeding Train

Service brake works

The train speed

Continuous brake pattern for curve or junction

wayside coil transmitting “the distance to the curve of junction” by digital messagedigital message

Junction

Curve Train reduces speed for the curve

Train reduces speed for the junction

Speed Limit

Train’s Emergency Radio System

About 　 1km

Stop

Stop

Run

Motorman / Conductorpushes a button on board

　

The Cause of the Accident

　 The motorman applied the brakes too late as the train entered a 304-meter-radius-curve at 116km/h

→ The first car tilted to the left, causing derailment

→ The following cars from the second to the fifth were derailed.

The Cause of the Accident

　 The motorman applied the breaks too late, because

● Distracted with the radio communications between the conductor and the control center because he had asked the conductor to report a false statement about the overrun at a previous station to the control center

or ● Thinking about how to excuse his overrun to his

supervisor after the duty

The Cause of the Accident

It is possible that JR West’s management of motorman would make the motorman of this train ask the conductor to make a false statement.

giving a heavy penalty to motormen who make mistakes on the job

・ The ATS system should have a support function for the speed limit for curves and junctions (not only for signals).

・ The emergency radio system should always be available even in an accident.

・ Monitoring devices that record operational history and recorders of the conversations between motormen and the control center should be installed.

・ Speedometers should be accurate.

On September 6, 2005 The ARAIC made proposals (the first time) to the Minister as follows:

The Proposals to the Land, Infrastructure and Transport Minister by the ARAIC

・ Understanding and utilization of incidents

・ The restriction of radio communications

・ Full understanding of laws and regulations by Manufacturers and Subsidiary Companies

The Proposals to the Land, Infrastructure and Transport Minister by the ARAICOn June 28, 2007 The ARAIC made proposals (the second time) to the Minister as follows:

・ the installation of ATS system to prevent excess speed at curves and junctions

・ the installation of the spare battery for the train’s emergency radio system

・ the installation of the monitoring devices that record operational history of each train

Revision of Technical Standards by the MinistryOn June 1st, 2006 The Ministry added the following provisions to the technical

standards, based on the proposals by the ARAIC.

These are required to be installed on major rail lines in five years or ten years, depending on the line’s traffic volume and frequency.

JR East’s Response to the Revision In progress of installing ATS systems　　・ on about 900 curves　　・ at junctions in about 110 stations

Monitoring devices on board　　→ 87 ％ of JR East’s rolling stock already had the

devices at that time. → In progress of equipping the rest of the rolling stock

Spare battery for the train’s emergency radio system →already installed at that time

◎ This equipment must be installed by 2016. ◎ Already spent about US ＄ 23million. Will need more.

Conclusion

・ The largest investigation since the ARAIC was founded

・ The investigation covered multilateral points of views, including human factors.

・ The cause of the accident was the motorman’s failure to brake.

・ Some people say

・ the cause should be the JR West’s management

・ the commission should be independent of the Ministry

Thank you for your hearing!!