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Yomiuri Shimbun
26-04-2025
- Yomiuri Shimbun
20 years since JR West derailment: Importance of Prioritizing Safety Should Never be Forgotten
The most important duty and responsibility of public transit is to safely transport passengers to their destinations. It is important not to pursue profits or efficiency alone, but to always keep in mind that safety comes first. Friday marked the 20th anniversary of the JR Fukuchiyama Line derailment accident, which claimed the lives of 106 passengers and the driver and injured 562 others. A memorial service organized by West Japan Railway Co. (JR West) near the accident site in the city of Amagasaki, Hyogo Prefecture, was attended by about 340 people, including bereaved family members and other individuals with connections to the accident. The rapid train involved in the accident entered a curve at 116 kph, significantly exceeding the speed limit. Some of the cars derailed and rammed into a condominium building beside the tracks. The driver had overshot the stop line at the previous station, causing the train to fall about one minute behind schedule. At the time of the accident, JR West had a 'work education program' in which employees who made mistakes were severely reprimanded and forced to write reflection statements. The driver is believed to have been distracted by fear of this program. Following the accident, JR West abolished this program. This was done out of reflection that the program had intimidated employees and led to a decline in work quality. To err is human. This incident can be said to have left the lesson that punitive guidance cannot prevent mistakes. Another factor behind the accident, which cannot be overlooked, was the company's corporate culture that overly prioritized profits and efficiency. At the time, JR West was facing intense competition from private railways and had introduced tight schedules with increased train frequencies in an attempt to meet passenger demand. These circumstances are believed to have created an atmosphere in which delays were not tolerated, leading the driver to feel pressured to make up for lost time. Are the lessons from that time still heeded today? In 2017, a problem arose at JR West in which a Nozomi Shinkansen train with a cracked bogie was kept in operation despite the driver and others noticing unusual noises. Last year, data falsification over axle installation work emerged at such operators as East Japan Railway Co. and Japan Freight Railway Co. Every railway company should thoroughly reexamine all its workplaces to ensure that safety consciousness has not waned. Keeping the memory of the accident from fading is also a major challenge. Japan Airlines, which experienced the crash of a Boeing 747 passenger jet in 1985, has made the wreckage of the accident aircraft viewable to the public to ensure the tragedy will be conveyed to the future. JR West will complete a facility to preserve the cars involved in the accident in December, but while it plans to use them for employee training, the railway operator has said there are no current plans for opening it to the public. To ensure that the accident, which claimed many lives, is not forgotten, should the possibility of future public access to the facility be considered? With Japan's declining population, railway companies are facing increasingly challenging business circumstances. Labor shortages are also a serious issue. They must renew their commitment to ensuring that safety is never neglected. (From The Yomiuri Shimbun, April 26, 2025)
Asahi Shimbun
25-04-2025
- Asahi Shimbun
JR West says non-punishment policy for errors improves safety
The wreckage of a derailed train in Amagasaki, Hyogo Prefecture, on April 25, 2005 (Asahi Shimbun file photo) West Japan Railway Co. (JR West) has drastically changed the way it handles errors committed by its train drivers, shifting from humiliation and punishment to human science and learning. The non-punishment approach has improved safety on the company's lines, according to officials. The changes were made following the disaster on the JR Takarazuka Line that killed 107 people in Amagasaki, Hyogo Prefecture, 20 years ago on April 25, 2005. The driver of the express train, who was killed in the crash, was apparently desperate to avoid further disciplinary action for committing errors of the job. In 2004, about a year before the derailment, the driver, who was 23 years old at the time, overshot the platform at a station in Kyoto Prefecture by about 100 meters. He was berated by three supervisors, who told him such things as, 'You have failed as a member of society' and 'You must be taking the job of a driver lightly.' He was given a warning and a reduction in his year-end allowance. During his 13 days of internal retraining, he was ordered to write reports on 20 topics, including 'my conceit that I have recently become a full-fledged driver.' On April 25 the following year, while driving on the JR Takarazuka Line, he stopped about 70 meters too far at Itami Station, forcing him to back up the train to the correct position. According to a report by the transport ministry's railway accident investigation committee, the driver then used a phone in the train to ask a conductor to make a false report about the distance of the mistake. In an apparent attempt to make up for lost time caused by his error, the driver accelerated the train, entered a sharp curve at an excessive speed and failed to brake properly. The train derailed and slammed into an apartment building. Multiple post-accident reports said JR West's strict demands for punctuality and its disciplinary actions against error-making drivers have 'conversely induced accidents.' Shigeru Haga, professor emeritus of traffic psychology at Rikkyo University who advised JR West on human error issues, said the conventional view of mistakes is that they are caused by carelessness, and that punishment will prevent a recurrence. He said this view still persists in Japanese society today. However, around the 1960s, a new way of thinking about errors emerged in Europe and the United States. It held that everyone makes mistakes, no matter how good they are. And it is crucial for safety and other reasons to report such errors without concealment. JR West adopted this approach after the accident. In addition to providing more practical training to drivers, the company has, in principle, not taken disciplinary measures for mistakes. JR West said many employees were concerned that the non-punishment approach could lead to complacency. In response, the company expanded the scope of errors that are not punishable in three stages: five months after the accident, in 2008, and in 2016. Over that period, JR West checked to ensure that number of accidents and problems did not increase because of the change in policy. Overruns, speeding and missed stops used to be subject to penalties, but now, in principle, they are not. Unless the error was intentional or a result of negligence, drivers are not subject to disciplinary action, including for mistakes that result in accidents. Reports of errors are compiled in a database, and safety measures are implemented where necessary. For example, at stations where many mistakes have occurred, JR West sounds a warning announcement in the driver's room when approaching these stops. JR West also conducts interviews with drivers who have overrun platforms and analyzes the causes and background that led to the error. Retraining can include having an instructor accompany the driver to check on brake operations. Takeshi Urushihara, a top official of the company who is in charge of safety promotion, said the non-punishment approach has led to improvements. 'The decision not to take disciplinary action has increased the number of reports of errors that only the train driver knows about, and it is certain that safety measures have advanced,' Urushihara said. However, he referred to an incident in 2017, when JR West ran a train with a cracked undercarriage. 'We failed to stop the train even though we were aware of the abnormality,' he said. 'There are still things that need to be done to ensure safety.'
The Mainichi
25-04-2025
- General
- The Mainichi
Editorial: 20 yrs after west Japan derailment disaster, safety efforts remain paramount
April 25 marks 20 years since a morning rush hour train derailed on the JR Fukuchiyama Line in western Japan, killing 106 passengers and the driver and injuring 562 others. The accident was attributed to the driver's delay in applying the brakes, causing the train to hurtle around a steep curve far over the speed limit. Forming the backdrop to the deadly derailment was a reeducation program punishing train crew who made errors on duty. Dubbed "day-shift education," employees subject to the program were tasked with writing letters of remorse and continuing other work while being rebuked by superiors. The driver of the derailed train had been through this program three times in the past. As his train had overrun a station shortly before the derailment in Amagasaki, Hyogo Prefecture, it is likely he was worried about facing the program again and lacked concentration. In the wake of the disaster, West Japan Railway Co. (JR West) scrapped the controversial program. The railway operator also stopped imposing disciplinary measures on crew members for their errors, including when those errors led to accidents. We urge the railway company to revisit the lessons learned from the 2005 accident while striving to keep the memory of the disaster alive. To prevent serious accidents, it is essential to maintain an environment where mistakes are not covered up. Sharing and analyzing on-site information will help reduce risks. As a result of prioritizing greater speed, investment in safety had been delayed and there was no automatic train stop system (ATS) at the derailment site. Measures need to be adopted on the assumption that anyone can make mistakes. The bereaved families of the victims of the derailment played a significant role in propelling JR West's endeavors to prevent a recurrence. They took part in the review of the accident and were given an opportunity to discuss countermeasures. These unprecedented attempts became a driving force helping officials to dig deep into the railway operator's organizational problems. Efforts to pass down the memory of the disaster are also important. More than 70% of JR West members employed today joined the firm after the accident. The company plans to establish a facility to preserve the derailed train at the end of the year. It is hoped that the facility will be utilized to raise safety awareness among employees. However, other trouble that could have led to major accidents has occurred in recent years. In 2017, a crack emerged in the undercarriage of a Nozomi superexpress bullet train on the Tokaido-Sanyo Shinkansen line, but despite the crew having noticed abnormalities, the train continued to operate. In East Japan Railway Co. (JR East)'s service area, meanwhile, two cars of the Hayabusa-Komachi superexpress decoupled in 2024 and then again in 2025 while running on the Tohoku Shinkansen line. For public transport operators that are responsible for passengers' lives, ensuring safety is paramount. They should constantly inspect the status of their operations and promote both physical and procedural countermeasures. Such efforts have no end point.
