Amagasaki Train Accident April 25th 2005
People
Environment
Equipment
Organisation
Train driver on third delay penalty if late to Amagasaki station
Strict protocols regarding train punctuality
Y50000 penalty applicable to driver for causing train delay
Train driver 23 years old
Train driver driving with excessive speed
Process
Accident occurred just after local rush hour (Monday morning)
Seven car commuter train
Approx. 700 passengers on train
Red light breach on-route resulted in ATS activation, stopping train (delay)
Train speed in excess of 120km/hr on curve, recommended speed was 60km/hr
Train had overshot stopping location at previous station, resulting in it being backed up into position (delay)
Train driver pre-occupied with thoughts of potential disciplinary action
Express and local trains meeting on same side of platform allow commuters to transfer between at stations
Congestion on Fukuchiyama line (linked to train speeds and company profits for Japan Railways West)
Cumulative changes had reduced leeway in schedule from 71 to 28 seconds between Amagasaki and Takarazuka
Driver re-education program as punishment for late drivers - including weeding and grass cutting duties (employees unaware of how long program will last for)
Culture of verbal abuse from management integral to re-education program (described as bullying)
Service brake, not emergency break applied by train driver just prior to derailment (maximum breaking power not applied)
Use of emergency break required justification/reporting from train drivers to management
Residential apartment building in vicinity of derailment
207 series electric multiple unit train
Train driver had 11 months experience as a driver
Tight curves inherit to design in Japanese railways (curve at derailment location was 300m in radius)
Train driver asked conductor to 'overlook' distance overshot at previous station
No mechanical failure of braking system(s)
Train driver had already had to participate in re-education program (for 11-13 days, 3 weeks after starting as a driver)
No government assessment for train driver competency, only company assessments
Cars constructed of light-weight stainless steel compared with heavier, older car construction
No regulated distance between train lines and residential buildings in Japan
Breaking system (ATS) was older style of system in vicinity of Amagasaki station (considered less effective in stopping trains)
Train running 90 seconds behind schedule on approach to Amagasaki station
Weather clear and fine
No system in place on Fukuchiyama line in vicinity of Amagasaki station to prevent drivers from speeding