The 25th anniversary commemorates the tragic JR Fukuchiyama Line derailment, claiming 106 lives including the driver’s. The accident was linked to JR West’s disciplinary “day shift training” for crew members, reflecting a corporate culture that emphasized blame for errors. As nearly two decades have passed, what transformation has occurred regarding this detrimental practice?

The final report released by the Japan Transport Safety Board in 2007 detailed the day shift training conducted by JR West. This training was mandated for drivers who had committed errors on duty, such as overshooting or tardiness. Known for assigning these individuals to day shifts, the training involved rigorous tasks like creating bulletins, self-reflection, and compiling reports. This punitive approach included severe reprimands from superiors and isolated tasks, serving as a visible example within the company to deter similar mistakes by other employees.

The accident report concluded that the cause of the accident was a delay in brake operation by the deceased driver, who was 23 years old at the time. It is reported that the driver, who had recently overshot a station, was concerned about facing day shift training and became distracted while contemplating an excuse. The report highlighted that drivers had been subjected to day shift training on three prior occasions. It questioned the organization’s approach, suggesting, “The stringent day shift training and disciplinary actions against drivers may have contributed to the incident.”

Approximately nine years after the accident, a report compiled by a meeting involving bereaved families, JR West, and other stakeholders aimed to analyze the accident’s causes and background. It urged improvements in corporate culture to prioritize accident prevention over punitive measures against employees. This led JR West to initiate a review of its day shift training. In 2016, JR West introduced a “non-disciplinary” system, wherein drivers are not penalized for mistakes like tardiness or speeding.

Training has also undergone transformation towards more practical applications, incorporating the use of simulators. In efforts to foster a more transparent workplace culture, JR West has implemented measures like providing managerial training for supervisors and conducting regular management meetings.

In a 2022 survey of workplaces conducted by JR West’s largest union, the JR West Japan Passenger Railway Labor Union, which included approximately 22,000 respondents, over 80% indicated that the environment facilitated reporting of mistakes. However, more than 40% felt that their company’s support in areas such as physical health management to mitigate human errors was either inadequate or lacking. When it came to hardware measures aimed at accident prevention, around 30% reported that such measures were either not implemented or still in progress. JR West responded by committing to ongoing monitoring of safety practices and initiatives, with a focus on resolving issues related to safety management. [Chinatsu Ide]

The Fukuchiyama Line derailment accident

The Fukuchiyama Line derailment accident occurred on April 25, 2005, on the JR West Fukuchiyama Line in Amagasaki City, Hyogo Prefecture. A rapid train derailed and collided with an apartment building adjacent to the tracks, resulting in the tragic deaths of 106 passengers and one 23-year-old driver. This accident remains one of the deadliest train derailments in JR West Japan, with many others severely injured.

The Ministry of Land, Infrastructure, Transport and Tourism’s Aviation and Railway Accident Investigation Committee (at that time) determined that the accident’s cause was primarily attributed to “a delay in the driver’s application of the brakes.” Following the incident, four former presidents of JR West faced criminal charges related to safety measures, although all were eventually acquitted in court.

Accident summary

The accident took place at approximately 9:18 a.m. on April 25, 2005, between Tsukaguchi and Amagasaki on the JR Fukuchiyama Line in Amagasaki City, Hyogo Prefecture. A seven-car high-speed train entered a right-hand curve with a speed limit of 70 km/h at a speed of approximately 116 km/h. As a result, cars 1 to 5 of the train derailed, and the first and second cars crashed into an apartment building located adjacent to the tracks.

According to the accident investigation report, a total of 107 people died, including 106 passengers and one driver. Additionally, 562 people were injured, although the Kobe District Public Prosecutors Office confirmed that 485 people were injured. Among the 106 passengers who died, 102 were in cars 1-3. Four individuals who perished couldn’t be identified with certainty regarding the specific cars they were in at the time of the accident.

The cause of the accident was determined to be the delay in the driver’s use of the brakes, which resulted in the rapid train entering a curve at an excessive speed and derailing. Additionally, the accident investigation highlighted concerns regarding JR West’s driver management practices, including “day shift training,” a form of punitive retraining for crew members who commit errors, which may have contributed to the incident.

In July 2009, the Kobe District Public Prosecutors Office charged former JR West president Masao Yamazaki with professional negligence resulting in death and injury. Additionally, three former presidents were also indicted on the same charges following a complaint from their families to the Public Prosecution Commission. However, all of them were ultimately acquitted of these charges.

Damage situation

The apartment complex that the first and second derailed cars collided with was constructed alongside the tracks just before the curve. The first car completely flew off the tracks and came to a stop after hitting the apartment building, bending along with the second car into an angular shape. The third car derailed and straddled the tracks, while the fourth car also veered off the rails to the right.

The accident site was located in a densely populated area with residential buildings and factories nearby. Notably, there was no Automatic Train Stopping System (ATS) installed at the curve where the accident occurred.

The accident investigation report also included passenger statements that shed light on the circumstances during the incident. A man who was in the first car and suffered a serious pelvic fracture described, “When the car tipped over, it felt like someone was falling from behind, hitting me. The inside of the car was chaotic, like being inside a washing machine. It felt like being hit with a sandbag,” he recalled.

A man who was in the first car and later had both legs amputated recounted, “When I regained consciousness, I found myself thrown through the glass window behind the driver’s seat, possibly landing on the equipment in the driver’s seat.” He was rescued 22 hours later.

Cause of accident

According to the accident report, the driver of the train drove over the speed limit and applied the brakes too late due to several factors. Just before the accident, the driver had overrun the train by approximately 72 meters at Itami Station. Instead of accurately reporting this overrun distance, the driver asked the conductor over the onboard phone to under-report it. The conductor, focusing on attending to passengers, dismissed the conversation abruptly after acknowledging the significant overrun. He then falsely reported to the control center that the overrun was only “8 meters.” About 34 seconds later, despite the warning signs, the driver entered a curve at a speed of approximately 116 km/h, resulting in the derailment of the train.

According to the accident report, the driver’s delay in applying the brakes was attributed to several factors:

1. He believed that the on-board phone call requesting a false report of an overrun had been prematurely cut off.
2. He was preoccupied with monitoring communication between the conductor and the transport dispatcher.
3. He had not undergone day shift training, which may have influenced his decision-making under pressure.
4. Concerned about potential legal consequences and thinking about excuses, his attention was diverted from the task of driving.

The report highlighted that the request for false reports stemmed from JR West’s punitive re-education system, including day shift training, and a company culture that emphasized disciplinary actions against employees who made mistakes. These factors collectively contributed to the driver’s distracted state and ultimately to the tragic derailment accident.

The driver had undergone day shift training three times prior to the accident. He reportedly expressed dissatisfaction to friends, stating, “Day shift training is just copying company guidelines, so I don’t see the point,” and “During that time, my pay is cut, and I really dislike it.” The accident report noted that some drivers perceived day shift training as a punitive measure that did not effectively improve their driving skills, highlighting a lack of practical training in driving skills.

In a concerning revelation, it was disclosed before the Accident Investigation Commission’s report was published in June 2007 that Koichi Yamaguchi, a former member of the commission, had provided a draft of the report to former president Yamazaki.

Former president Yamazaki requested that the description in the draft report regarding ATS be softened or deleted, likening it to a trivial matter that could be overlooked later. In response, former committee member Yamaguchi expressed his disapproval during a meeting of the accident investigation committee, stating, “I disagree with softening it as if it’s something trivial.” Reflecting on the incident, Former President Yamazaki acknowledged, “While I fully cooperated with the accident investigation, I received the draft report early to understand the investigation progress and respond promptly.

I regret that this was a thoughtless and inappropriate action.” He apologized, saying, “I take full responsibility.” Former committee member Yamaguchi clarified his perspective, explaining, “I aimed to support proactive safety measures when I saw the efforts being made.”

Legal Proceedings Involving Former President Yamazaki

In July 2009, the Kobe District Public Prosecutors Office brought charges against former president Yamazaki in the Kobe District Court. The allegations stated that he was negligent in failing to install an ATS despite being in a position to foresee the accident resulting in death or injury.

From 1996 to 1998, during his tenure as the head of the Railway Headquarters overseeing JR West’s safety measures, former President Yamazaki undertook initiatives including (1) reducing the curve radius at the accident site from 600 meters to 304 meters, and (2) implementing measures to prevent freight trains from traversing the curve on the JR Hakodate Line. Despite his awareness of the increased risk posed by more rapid trains following schedule revisions, he faced charges alleging that his failure to mandate the installation of an ATS contributed to the occurrence of the derailment accident.

In addition to former president Yamazaki, nine other individuals associated with JR West, including drivers, were referred to prosecutors for scrutiny. Apart from Mr. Yamazaki, the Kobe District Public Prosecutors Office declined to indict the other 12 people involved, including three former presidents who were sued by their families. The decision was based on the assessment that the primary responsibility for the accident lay with the deceased driver, and the remaining 11 individuals were not deemed culpable as they could not have reasonably predicted the occurrence of the accident.

Former president Yamazaki’s trial commenced in December 2010 at the Kobe District Court. During the trial, he expressed remorse, stating, “I deeply regret the loss of 106 lives and the injuries inflicted on many others. I apologize.” However, concerning the specifics of the charges against him, he asserted, “The allegations regarding awareness of the danger are entirely inconsistent with the facts.” He denied the accusations and maintained his innocence throughout the proceedings.

The defense argued, “During that period, it was standard practice in the railway industry to establish safe speed limits on curves for safety reasons and rely on drivers to comply with these limits. There was no established norm mandating the immediate installation of ATS on curves.” They claimed that former president Yamazaki was unaware of the specific danger, could not have predicted the accident, and therefore bore no responsibility. The company echoed this stance, asserting that Yamazaki was not culpable for the incident.

In its opening statement, the prosecution highlighted that in 1993, when former President Yamazaki headed the Safety Measures Office, he directed the consideration of reducing less critical ATS installations on the Tokaido and Sanyo Lines to save costs. During this period, the company had received reports indicating the risk of accidents due to excessive speed on curves. It was a recognized practice in the industry to mitigate human errors by drivers through equipment. Moreover, reports of accidents on the JR Hakodate Line underscored the foreseeability of such risks.

During the trial, bereaved families who lost loved ones in the accident expressed their sentiments. Kazuaki Nishio, who suffered severe injuries including 38 stitches and compound fractures, conveyed his statement through prosecutors. Former President Yamazaki expressed remorse, acknowledging the long-term impact of the accident on his life, saying, “No matter how hard I try, things will never return to normal.” He also questioned his responsibility, stating, “Isn’t it my duty as someone in charge to have installed an ATS?” Hiroshi Ueda, who lost his 18-year-old son in the tragedy, criticized Yamazaki’s statements, stating, “Despite promising to seek truth as a form of redemption, his testimony remains contradictory.

Is this truly repentance?” Shigemi Omori, who lost her 23-year-old daughter, expressed dissatisfaction, stating, “Attributing sole blame to the driver for such a major accident highlights the shortcomings of justice.”

During the trial, witnesses including officials from JR West, other industry companies, and railway experts testified. Former subordinates of Yamazaki, who were employees at the time of the accident, contradicted their earlier statements made during the investigation, now claiming in court that they had never perceived the dangers associated with the curves.

In January 2012, the Kobe District Court acquitted former president Yamazaki of the charges against him. While addressing the foreseeability of the accident, Yamazaki emphasized, “Among the numerous curves on JR West lines, it cannot be concluded that the risk of derailment and overturning at the specific curve in question was foreseeable.” However, regarding JR West’s organizational responsibilities, he acknowledged, “There were shortcomings in the analysis of the risk of train overturning on curves and in the maintenance of the Automatic Train Stop (ATS) system, which in some instances did not meet the expected standards for a major railway operator.”

Following the district court’s ruling, the defense argued that “There are numerous curves with a radius of 304 meters or less,” and timetable revisions were “not recognized as increasing the risk of derailment and overturning.” Additionally, they asserted that the derailment on the Hakodate Line involved different circumstances, such as a freight train overturning on a long downhill section, and thus couldn’t serve as a basis for recognizing the danger in this case.

Regarding the installation of the Automatic Train Stop (ATS), they pointed out that “There was no legal requirement at the time, and only some railway operators, including JR West, were installing it on curves,” rejecting the prosecution’s argument that it should have been separately installed at the accident site.

After the Kobe District Court’s verdict, the bereaved families filed an appeal with the Kobe District Public Prosecutors Office. However, the prosecutors decided not to pursue the appeal, stating, “After thoroughly reviewing all the evidence, we concluded that overturning the district court’s findings on appeal would be challenging.”

Summary of the Judgment:

The Kobe District Court found former president Yamazaki not guilty based on the following points:

1. There is no evidence that former president Yamazaki was aware of the risk of a derailment accident due to excessive speed at the curve where the accident occurred.
2. The court concluded that it cannot be asserted that former president Yamazaki should have ordered the installation or maintenance of Automatic Train Stop (ATS) systems at the specific curve to prevent the accident.
3. Despite acknowledging that JR West had deficiencies in analyzing the risk of train overturning on curves, the judgment maintained that former president Yamazaki could not reasonably have foreseen the accident. Therefore, he was not found to be at fault for the accident.

In summary, the court acquitted former president Yamazaki, determining that he could not have predicted or prevented the Fukuchiyama Line derailment accident through his actions as the head of JR West.

Trial of three past presidents

In addition to former president Yamazaki, three other JR West presidents were also indicted on charges of professional negligence resulting in death or injury, and the case proceeded to the Supreme Court.

Those indicted are former chairman Masataka Ide, former chairman Shojiro Minamitani, and former president Tsuyoshi Kakiuchi. In 2009, the families of the victims filed a lawsuit against Chairman Ide and the other three at the Kobe District Public Prosecutors Office. Initially, the prosecutors decided not to pursue charges, citing that “safety measures were under the responsibility of the head of the railway headquarters, and they were not in a position to foresee the accidents.” Dissatisfied with this decision, the bereaved families appealed, leading the Kobe First Public Prosecution Board to file a petition for review. Subsequently, in 2010, the Public Prosecution Committee passed a binding indictment resolution, prompting the district attorney’s office to reconsider the case.

The three individuals were charged with failing to mandate the installation of an ATS despite foreseeing the potential for a derailment. Their trial commenced at the Kobe District Court in July 2012, where all three asserted their innocence, stating, “We could not have envisioned an accident occurring.”

In September 2013, the Kobe District Court acquitted them, with a verdict of not guilty (sentence: 3 years in prison), citing, “It cannot be established that the risk of a train derailing and overturning due to excessive speed at the site’s numerous curves was specifically foreseeable.” In March 2015, the Osaka High Court upheld the initial verdict, and in June 2017, the Supreme Court’s Second Petty Bench rejected the appeal, thus finalizing the judgment.

JR West’s response

After the accident, JR West prioritized the implementation of safety technologies and enhanced employee training. The critical issue identified in the derailment was the absence of ATS (Automatic Train Stop) installed before the curve where the incident occurred. By March 2006, JR West had deployed ATS at 1,234 locations, including over 1,000 turnouts for route switching. In 2007, the Railway Safety Research Center was inaugurated at a training facility in Suita City, Osaka Prefecture. This center featured a model depicting the accident scene and exhibited messages from victims, providing visitors with insights into historical railway accidents.

In 2018, the “Prayer Forest Fukuchiyama Line Train Accident Site” memorial facility was established at the location of the tragic accident. Alongside a cenotaph, the facility includes a “memorial space” exhibiting letters and documents, and a “space for reflecting on the accident” displaying relevant materials. Additionally, plans were announced to preserve the accident vehicle in a dedicated facility to be constructed in Suita City.

However, concerns have arisen about the potential for the incident to fade from memory as generational turnover affects JR West’s workforce. As of April 2020, approximately 14,150 JR West employees (excluding group companies) had joined the company post-accident, surpassing half of the workforce for the first time. A survey by the JR West Labor Union in January of the same year revealed that about 75% of employees expressed a commitment to ensuring the accident remains remembered and preventing its significance from diminishing.

Initiatives of the bereaved family

In June 2005, two months following the tragedy, the families of the victims established the “April 25 Network.” This committee convenes monthly to (1) investigate the accident’s causes, (2) provide support for grief, (3) hold JR West accountable, (4) advocate for public transportation safety, and (5) exchange updates on negotiations with JR West. In 2014, they formed the “Study Group on Corporate Accountability” to explore legal repercussions for companies involved in accidents.

This effort culminated in the launch of the “Association for Realizing Corporate Accountability” in 2016, advocating for legislation imposing criminal penalties on corporations responsible for accidents. Shigemi Omori, who lost her 23-year-old daughter in the tragedy, emphasized, “Ensuring corporate executives cannot evade responsibility is crucial for a safe society. I want my daughter’s death to catalyze meaningful change.”

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