Susumu Hashizume Transport Safety Department East Japan Railway Company

1. An Accident Investigation Case with the Aircraft and Railway Accidents Investigation Commission in Japan Susumu Hashizume Transport Safety Department East Japan Railway Company

2. JR Group Map JR Hokkaido JR East JR West Tokyo JR Kyushu Osaka JR Freight JR Central JR Shikoku

3. 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

4. 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

5. Foundation of the ARAIC １９７１ Foundation of the Aircraft Accidents Investigation Commission ２００１　 Foundation of the Aircraft and RailwayAccidents Investigation Commission

6. 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.

7. Investigation Objects of the ARAIC • Accidents 　・Train collision accidents 　・Train derailment accidents 　・The train fire accidents 　・Others • Incidents Not accidents, but close to accidents

8. Organization and Authority 【Commission】 Air Sub-committee Member Chairperson Railway Sub-committee ９　persons

9. 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

10. Train Crash Accidenton JR Fukuchiyama Line • Date ： at 9:19, April 25 in 2005 • Scene： JR West Fukuchiyama Line Tokyo Osaka

11. ←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

12. Amagasaki Fukuchiyama

13. Series207EMU

14. 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

15. 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

16. On December 20,2006 →The ARAIC released a draft of the report. On February 1st,2007 　 →The ARAIC held a hearing from experts

17. 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.

18. 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.

19. 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)

20. Outline of ATS System Automatic Train Stop System ATS system which can check its train speed continuously with on-board brake patterns

21. 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

22. 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

23. Train’s Emergency Radio System Run About1km Stop Motorman / Conductor pushes a button on board Stop

24. 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.

25. 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

26. 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

27. 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.

28. 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

29. 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.

30. 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.

31. 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

32. Thank you for your hearing!!