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