Background to the accident: JR West’s “day shift training” The bad habits that made crew members feel weak are now being solved.

 The 25th marks 19 years since the JR Fukuchiyama Line derailment that killed 106 passengers and the driver. The background to the accident was said to be JR West’s punitive training for crew members called “day shift training,” and the company’s corporate culture of blaming people for mistakes was severely questioned. Nearly 20 years have passed since then. How has that bad habit changed?

Background to the accident: JR West's "day shift training" The bad habits that made crew members feel weak are now being solved.

 Creating bulletins, reflections, and reports. This is the content of day shift training revealed in the final report released by the country’s Air and Railway Accident Investigation Commission (currently the Japan Transport Safety Board) in 2007.

 The training was being carried out as a refresher for drivers who had made mistakes while on duty, such as overrunning or being late. The name derives from the fact that they are removed from regular crew duties and forced to work on day shifts.

 He was severely reprimanded by his superiors and forced to do simple tasks such as document creation for days on end, and was feared within the company as a demonstration to other employees who had made mistakes.

 The accident report concluded that the cause of the accident was a delay in brake operation by the deceased driver (23 years old at the time). It is said that the driver who had overran the train just before the accident was worried about being forced to undergo day shift training and was distracted while thinking of an excuse. Drivers had undergone day shift training three times in the past, and the report called the organization’s structure into question, saying, “It is possible that the harsh day shift training and disciplinary measures against drivers may have played a role.”

 The report, which was compiled approximately nine years after the accident by a meeting attended by the bereaved family, JR West, and others to discuss the causes and background of the accident, called for improvements to the corporate culture to prioritize preventing recurrence and avoid punishing employees. This prompted JR West to begin reviewing its day shift education. In 2016, a “non-disciplinary” system was introduced in which drivers are not punished even if they make mistakes such as being late or speeding.

Background to the accident: JR West's "day shift training" The bad habits that made crew members feel weak are now being solved.

 Training has also been changed to more practical content, including the use of simulators. In order to create a more open workplace environment, he has begun efforts such as providing managerial training to his superiors and holding meetings with management.

 In a survey of workplaces conducted in 2022 by JR West’s largest union, the West Japan Passenger Railway Labor Union (approximately 22,000 people), over 80% of respondents answered that the environment made it easy to report mistakes. .

 On the other hand, more than 40% of respondents answered that their company’s support, such as physical health management to reduce human error, was “not very fulfilling” or “not fulfilling.” Regarding hardware measures to reduce the risk of accidents, about 30% of respondents answered that they have not been implemented or have not yet been implemented in many cases, indicating that safety measures are still in progress.

 JR West said, “We will continue to monitor safety practices and initiatives and work to resolve issues related to safety management.” [Chinatsu Ide]

Fukuchiyama Line derailment accident

 The Fukuchiyama Line derailment accident occurred on April 25, 2005, on the JR Fukuchiyama Line in Amagasaki City, Hyogo Prefecture, when a rapid train derailed and crashed into an apartment building next to the tracks, killing 106 passengers and one driver (23 years old at the time). This was a train derailment accident that killed 562 people and seriously injured 562 people. The Ministry of Land, Infrastructure, Transport and Tourism’s Aviation and Railway Accident Investigation Committee (at the time) estimated that the cause of the accident was “a delay in the driver’s use of the brakes.” Four past presidents of JR West were brought to trial for criminal charges over safety measures, but all were found not guilty at trial.

Accident summary

Background to the accident: JR West's "day shift training" The bad habits that made crew members feel weak are now being solved.
Accident nameJR Fukuchiyama Line derailment accident
Date and time of occurrenceApril 25, 2005, around 9:18 a.m.
placeJR Fukuchiyama Line between Tsukaguchi and Amagasaki (Amagasaki City, Hyogo Prefecture)
victim106 male and female passengers and the driver (23 years old at the time) were killed, and 562 others were seriously injured.
FeaturesIt has also been pointed out that JR West’s harsh re-education program called “day shift training” for drivers who made mistakes on the job was behind the accident.

 The accident occurred at around 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 approximately 116 km/h. Cars 1 to 5 derailed, and the first and second cars crashed into an apartment building next to the tracks.

Background to the accident: JR West's "day shift training" The bad habits that made crew members feel weak are now being solved.

 According to the accident investigation report, a total of 107 people died, including 106 passengers and one driver, and 562 people were injured (the number of injured confirmed by the Kobe District Public Prosecutors Office was 485). Of the 106 passengers who died, 102 were in cars 1-3, excluding 4 people whose vehicles could not be identified at the time of the accident.

 The cause of the accident is that the driver was delayed in using the brakes, and the rapid train entered a curve at overspeed and derailed. It also pointed out that JR West’s driver management methods, such as “day shift training,” which is a form of punitive retraining for crew members who make mistakes, may have played a role.

 In July 2009, the Kobe District Public Prosecutors Office indicted former JR West president Masao Yamazaki on charges of death and injury due to professional negligence. In addition to former president Yamazaki, three past presidents were also forcibly indicted on the same crime after their families filed a complaint with the Public Prosecution Commission, but all were found not guilty.

Damage situation

Background to the accident: JR West's "day shift training" The bad habits that made crew members feel weak are now being solved.

 The apartment complex that the first and second derailed cars collided with was built on the side of the track just before the curve. The first car flew completely off the track, and the impact of hitting an apartment building caused it to come to a halt, bent along with the second car into a dogleg shape. The third car came off the rails, straddling the tracks, and the fourth car also jumped off the tracks to the right.

 The area surrounding the site was a densely populated area of ​​housing and factories. There was no automatic train stopping system (ATS) installed at the curve at the accident site.

 The accident investigation report also included statements from passengers, revealing the circumstances at the time of the accident. A man who was in the first car and suffered a serious pelvic fracture said, “When the car tipped over, it felt like someone was falling from behind, hitting me.The inside of the car was like a washing machine. It felt like being hit with a sandbag,” he said.

 A man who was in the first car and had both legs amputated said, “When I woke up, my body was thrown through the glass window behind the driver’s seat, and I think my body was on top of the equipment in the driver’s seat.”Rescue It was 22 hours later.”

Cause of accident

Background to the accident: JR West's "day shift training" The bad habits that made crew members feel weak are now being solved.

 Why did the driver drive over the speed limit and apply the brakes too late?

 According to the accident report, the driver had overran the train by approximately 72 meters at Itami Station just before the accident. At that time, he asked the conductor over the on-board phone to under-report the overrun distance. The conductor replied, “We’ve gone a long way (quite a bit too far),” and cut off the conversation with the driver in order to attend to the passengers.

 The conductor falsely reported to the general control center over the train radio that the overrun was “8 meters.” Approximately 34 seconds later, the driver entered a curve at approximately 116 km/h, causing the derailment.

 According to the accident report, the reason for the driver’s delay in applying the brakes was that (1) he believed that the on-board phone call requesting a false report of an overrun had been cut off, and that he was paying special attention to communication between the conductor and the transport dispatcher; (2) that he had not received day shift training; Based on the fact that he was worried about being taken to court and was thinking of excuses, it was assumed that his attention was diverted from driving.

 It was pointed out that behind the request for false reports was JR West’s usual punitive re-education system for drivers who made mistakes, such as day shift training, and a company culture in which disciplinary action was taken.

 The driver had received day shift training three times before the accident. He is said to have told his friends, “The day shift training is just copying company guidelines, so I don’t understand the meaning,” and “During that time, my pay is cut, and I really don’t like it.”

 Regarding the day shift training, the accident report said, “Some drivers perceived it as a penalty that had no effect on improving their driving skills,” and “there was a lack of training in practical driving skills.”

 Regarding the Accident Investigation Commission’s report, it was discovered that before its publication in June 2007, Koichi Yamaguchi, a former member of the Accident Investigation Commission, had given a draft of the report to former president Yamazaki.

 Former president Yamazaki requested that the description in the draft report regarding ATS be “a piece of rock-paper-scissors put out later, and I would like the wording to be softened or deleted.” In response to this, former committee member Yamaguchi reportedly said at a meeting of the accident investigation committee, “I don’t like it because it’s like rock-paper-scissors that is put out later.”

 Former President Yamazaki said, “While fully cooperating with the investigation into the accident, I received the draft report in advance with the intention of understanding the investigation status and responding promptly.I regret that this was a thoughtless and inappropriate act. “I’m doing it,” he apologized. Former committee member Yamaguchi explained, “I wanted to help when I saw them proactively promoting safety measures.”

Trial of former president Yamazaki

 In July 2009, the Kobe District Public Prosecutors Office indicted former president Yamazaki in the Kobe District Court on charges of death or injury due to professional negligence, alleging that he was negligent in not installing an ATS even though he was in a position to foresee the accident.

Background to the accident: JR West's "day shift training" The bad habits that made crew members feel weak are now being solved.

 From 1996 to 1998, when former President Yamazaki was the head of the Railway Headquarters and was in charge of JR West’s safety measures, he carried out work to (1) halve the radius of the curve at the accident site from 600 meters to 304 meters, and (2) prevent freight trains from crossing the curve on the JR Hakodate Line. Although he was aware of the risk of an accident occurring at the curve at the site due to the derailment accident (3) – an increase in the number of rapid trains due to the schedule revision, he was indicted on charges that he caused the accident by not instructing the installation of an ATS. Ta.

 In addition to former president Yamazaki, nine other people affiliated with JR West, including drivers, were referred to prosecutors, and three past presidents were also sued by their families, but the Kobe District Public Prosecutors Office decided against indicting 12 people other than Mr. Yamazaki. It was concluded that the suspect’s death was the reason for the driver’s death, and that the other 11 people were not suspected of the accident because they could not have foreseen the accident

 Former president Yamazaki’s trial began in December 2010 at the Kobe District Court. Former president Yamazaki apologized, saying, “I took the precious lives of 106 people and injured many others.I apologize.”However, regarding the contents of the indictment, he said, “The indications such as recognition of danger are completely different from the facts.” He denied the charge and maintained his innocence.

 The defense said, “At the time, it was common sense in the railway industry to set a comfortable speed limit for safety measures on curves and leave speed compliance to the drivers, and there was no sense of the norm that ATS should be quickly installed on curves.” ‘ he claimed. The company stated that former president Yamazaki was not aware of the danger, could not have foreseen the accident, and was not at fault.

 In response, the prosecution stated in its opening statement that in 1993, when former President Yamazaki was the head of the Safety Measures Office, he directed consideration of reducing less important ATS installations on the Tokaido and Sanyo Lines in order to cut costs. At that time, the company had received reports about the risk of accidents caused by excessive speed on curves.

 At that time, human error by drivers was common, and it was common knowledge in the industry to compensate for it with equipment. He also said that he had received reports of accidents on the JR Hakodate Line, and it was clear that it was foreseeable. .

 At the trial, bereaved families who lost family members in the accident gave their opinions. Kazuaki Nishio, who received 38 stitches all over his body and suffered compound fractures in his left leg in the accident, has entrusted his statement to prosecutors.

 Former President Yamazaki expressed his regret, saying, “I have been disabled for a long time to come. No matter how hard I try, things will never go back to normal.” He also said, “Isn’t it my duty as a person in charge to install an ATS?” touched on the responsibility of

 Hiroshi Ueda, who lost his 18-year-old second son in the accident, said, “Even though I promised him that telling the truth would be the way to make amends,’ he is giving contradictory testimony. Is that really atonement?” .

 Shigemi Omori, who lost her 23-year-old eldest daughter, complained, “If this major accident is held solely by the driver, then we have seen the limits of justice.”

 Officials from JR West, other companies in the same industry, and railway experts appeared as witnesses at the trial. Employees at the time, who were former subordinates of former president Yamazaki, repeatedly contradicted their statements made during the investigation in which they acknowledged the danger of curves, testifying in court, saying things like “I never felt the danger of curves.”

 In January 2012, the Kobe District Court found former president Yamazaki not guilty (he was sentenced to three years in prison). Regarding the foreseeability of the accident, he pointed out, “Out of the many curves that exist on JR West, it cannot be acknowledged that the danger of derailment and overturning at the curve at the scene could have been recognized.”

 On the other hand, regarding JR West’s responsibilities as an organization, he stated, “There were problems with the analysis of the risk of capsizing on curves and the way the ATS was maintained, and in some cases fell short of the standards expected of a large-scale railway operator.”

 In addition, regarding the construction of curves, it said, “There are quite a number of curves with a radius of 304 meters or less,” and that the timetable revisions were “not recognized to have increased the risk of trains derailing and capsizing.”

 Furthermore, it said that the Hakodate Line derailment was “an accident in which a freight train overturned as it accelerated on a long downhill section of a quiet section, and its appearance is different from the present accident” and that it cannot be recognized as a basis for recognition of the danger.

 Regarding the installation of ATS, “At the time, there was no law requiring it, and only some railway operators, including JR West, were installing it on curves,” and the prosecution argued that it should have been installed separately on curves at the site. rejected the claim.

 Following the district court’s ruling, the bereaved families filed an appeal with the Kobe District Public Prosecutors Office, but the district prosecutor gave up on the appeal, stating, “After examining all the evidence, we came to the conclusion that it would be difficult to overturn the findings even on appeal.”

<Summary of the Judgment>

・There is no evidence that former president Yamazaki was aware of the risk of a derailment accident due to excessive speed at the curve at the accident site.

・It cannot be said that former president Yamazaki should have ordered ATS maintenance at the on-site curve to avoid the accident.

・Although JR West had problems with analysis of the risk of capsizing on curves, the judgment remains that former president Yamazaki could not have predicted the accident, and former president Yamazaki was not at fault.

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 went all the way to the Supreme Court.

Background to the accident: JR West's "day shift training" The bad habits that made crew members feel weak are now being solved.

 Those indicted are former chairman Masataka Ide, former chairman Shojiro Minamitani, and former president Tsuyoshi Kakiuchi.

 In 2009, the family sued Chairman Ibe and three others at the Kobe District Public Prosecutors Office. The district attorney’s office decided not to prosecute, stating that “safety measures were left to the head of the railway headquarters, and he was not in a position to foresee accidents.” However, the bereaved families appealed the decision, and the Kobe First Public Prosecution Board filed a petition for review. It was decided that the charges amounted to prosecution. The district attorney’s office decided not to prosecute again in the same year, and the Public Prosecution Committee passed a binding indictment resolution in 2010.

The three were charged with not instructing the installation of an ATS even though they could have foreseen the possibility of a derailment, and a trial began at Kobe District Court in July 2012.

 All three men maintained their innocence, saying, “We could not have imagined that an accident would occur.” In September 2013, the Kobe District Court found the court not guilty (sentence: 3 years in prison), stating, “It cannot be recognized that the risk of a train derailing and overturning due to excessive speed at the curve at the site, which has many curves, could have been specifically foreseen.” ) was announced. In March 2015, the second instance, the Osaka High Court, also upheld the first instance judgment. The Supreme Court’s Second Petty Bench also issued a decision in June 2017 to dismiss the appeal, making the judgment final.

JR West’s response

Background to the accident: JR West's "day shift training" The bad habits that made crew members feel weak are now being solved.

 After the accident, JR West focused on introducing safety technology and training employees. In the derailment accident, the problem was that ATS was not installed in front of the curve at the scene. As of March 2006, JR West had installed ATS at 1,234 locations, and more than 1,000 locations including “turnouts” (points) for switching routes.

 In 2007, the “Railway Safety Research Center” was opened at a training center in Suita City, Osaka Prefecture. A model of the accident scene and messages from the victims were displayed, allowing visitors to learn about past railway accidents.

 In 2018, a memorial facility called “Prayer Forest Fukuchiyama Line Train Accident Site” was established at the accident site. In addition to the cenotaph, a “memorial space” where letters and other documents are displayed, and a “space to communicate the accident” where materials are displayed were set up. In addition, the company has also announced plans to preserve the accident vehicle in a special facility planned to be built in Suita City.

 On the other hand, there are concerns that accidents may be forgotten due to generational changes in employees. As of April 2020, approximately 14,150 JR West employees, excluding group companies, had joined the company after the accident, exceeding half for the first time. In a survey conducted by the JR West Labor Union in January of the same year, approximately 75% of employees answered that they were “conscious of preventing accidents from being forgotten.”

Initiatives of the bereaved family

Background to the accident: JR West's "day shift training" The bad habits that made crew members feel weak are now being solved.

 In June 2005, two months after the accident, the bereaved families formed the “April 25 Network.” The committee has been holding regular meetings once a month to (1) investigate the cause of the accident, (2) discuss grief, (3) pursue JR West’s corporate responsibility, (4) think about the safety of public transportation, and (5) exchange information on negotiations with JR West.

 In 2014, he established the “Study Group on Organizational Punishment” to study punishment for companies that cause accidents. In 2016, the “Association for Realizing Organizational Punishment” was launched, calling for the creation of a legal system that would impose criminal penalties on companies that cause accidents.

 Shigemi Omori, who lost her eldest daughter (23 years old at the time), said, “If we don’t prevent corporate executives from escaping responsibility, we won’t have a safe society. I don’t want my daughter’s death to be in vain.”

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