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An Accident Investigation Case with the Aircraft and Railway Accidents Investigation Commission in Japan. Susumu Hashizume Transport Safety Department East Japan Railway Company. JR Group Map. JR Hokkaido. JR East. JR West. Tokyo. JR Kyushu. Osaka. JR Freight. JR Central.

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Susumu Hashizume Transport Safety Department East Japan Railway Company

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Susumu hashizume transport safety department east japan railway company

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

Susumu Hashizume

Transport Safety Department

East Japan Railway Company


Susumu hashizume transport safety department east japan railway company

JR Group Map

JR Hokkaido

JR East

JR West

Tokyo

JR Kyushu

Osaka

JR Freight

JR Central

JR Shikoku


Susumu hashizume transport safety department east japan railway company

JR East Outline

(As of 1 April 2007)

Number of employees

Working kilometers

Number of stations

Total trains in operation

Number of vehicles

63,140

7,526.8 km

1,702

12,671/day

13,179

Hachinohe

Akita

Morioka

Shinjo

Niigata

Nagano

Sendai

Tokyo

The Shinkansen

Shinkansen lines

Conventional lines

The Shinkansen


Contents

Contents

  • Summary of the Aircraft and Railway Accidents 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

Foundation of the ARAIC

1971

Foundation of the Aircraft Accidents

Investigation Commission

2001 

Foundation of the Aircraft and RailwayAccidents Investigation Commission


Susumu hashizume transport safety department east japan railway company

About ten years ago

Technical standards are provided

by laws and regulations,

and the Government certified the compliance.

Deregulation in 2001

Railways can regulate their own technical standards and certify the compliances with their standards.

Big accidents and incidents

   →The ARAIC investigates, and makes proposals.


Investigation objects of the araic

Investigation Objects of the ARAIC

  • Accidents

     ・Train collision accidents

     ・Train derailment accidents

     ・The train fire accidents

     ・Others

  • Incidents

    Not accidents, but close to accidents


Susumu hashizume transport safety department east japan railway company

Organization and Authority

【Commission】

Air Sub-committee

Member

Chairperson

Railway Sub-committee

9 persons


Susumu hashizume transport safety department east japan railway company

Deputy-Chief Aircraft

Accident Investigator

Aircraft Accident

Investigator-General

Aircraft Accident

Investigator

22 persons

Organization and Authority

【Secretariat】

Deputy-Chief Railway

Accident Investigator

Railway Accident

Investigator-General

Railway Accident

Investigator

7 persons

Director General

General Affairs

Director

General Affairs

Deputy Director

Administration

Section

Documents

Section

Equipment

Section

Planning

Section

General Affairs

Deputy Director

Research and

planning officer

Research and

Statistics Section


Train crash accident on jr fukuchiyama l ine

Train Crash Accidenton JR Fukuchiyama Line

  • Date : at 9:19, April 25 in 2005

  • Scene:

    JR West

    Fukuchiyama Line

Tokyo

Osaka


Susumu hashizume transport safety department east japan railway company

←Amagasaki

No.4

Radius:304m

No.2

No.1

Fukuchiyama→

No.5

an apartment house

No.6

No.3

No.7

Killed:106 passengers and the motorman

Injured:562 passengers


Susumu hashizume transport safety department east japan railway company

Amagasaki

Fukuchiyama


Series 207 emu

Series207EMU


Susumu hashizume transport safety department east japan railway company

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 Technical

Benchmark tests Research Institute

Information

  →Hyogo Prefectural Police Department and

Fire bureaus


Contents of the investigation

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


Susumu hashizume transport safety department east japan railway company

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

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 20071

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 final report released on june 28 20072

The Final Report (Released on June 28,2007)

  • The cause of the death

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


O utline of ats system

Outline of ATS System

Automatic Train Stop System

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


Susumu hashizume transport safety department east japan railway company

Continuous brake pattern for red signal

Service brake works

The train speed

Train stops in front of red signal

Proceeding Train

wayside coil transmitting “the distance

to the red signal” by digital message

Red signal for Danger


Susumu hashizume transport safety department east japan railway company

Continuous brake pattern for curve or junction

Service brake works

The train speed

Speed Limit

Train reduces speed for the curve

Curve

Train reduces speed for the junction

Junction

wayside coil transmitting “the distance

to the curve of junction” by digital message


Train s emergency radio system

Train’s Emergency Radio System

Run

About1km

Stop

Motorman / Conductor

pushes a button on board

Stop


The cause of the accident

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 accident1

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 accident2

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 proposals to the land infrastructure and transport minister by the araic

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

On September 6, 2005

The ARAIC made proposals (the first time)

to the Minister as follows:

・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.


The proposals to the land infrastructure and transport minister by the araic1

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

On June 28, 2007

The ARAIC made proposals (the second time)

to the Minister as follows:

・Understanding and utilization of incidents

・The restriction of radio communications

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


Revision of technical standards by the ministry

Revision of Technical Standards by the Ministry

On June 1st, 2006

The Ministry added the following provisions to the technical standards, based on the proposals by the ARAIC.

・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

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

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

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


Susumu hashizume transport safety department east japan railway company

Thank you for your hearing!!


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