The April 25 tragic train crash on the West Japan Railway Co.’s Fukuchiyama Line in Amagasaki, Hyogo Prefecture, was the worst rail accident since Japanese National Railways was privatized in April 1987. It killed 106 passengers plus the driver, Ryujiro Takami, 23, and injured 555 others. Many bereaved family members and survivors are reportedly still suffering from traumas.

An interim report, announced Tuesday by the government’s Aircraft and Railway Accidents Investigation Commission, has disclosed a finding of erratic behavior on the part of the driver of the seven-car “rapid service” (express) train. A decisive factor was the driver’s failure to slow down for a curve, which a commission official said led the train to tilt, derail and slam into a nine-story condominium building.

The commission pieced together the following sequence:

The train destined for Doshisha-mae Station via Amagasaki Station pulled into Takarazuka Station, the starting point, at 8:55 a.m. at a speed of more than 60 kph. As the speed limit was 40 kph, the automatic train stoppage system (ATS) activated twice to stop the train.

At Itami Station, the train overran the platform by 70 meters. The driver used a regular brake and an emergency brake.

Because of this overrun, the train left Itami Station at 9:16 a.m. — 1 minute and 20 seconds behind schedule.

The train reached 125 kph, slightly above the speed limit of 120 kph, several hundred meters before Tsukaguchi Station. The driver applied the brake once just before the train passed that station. Afterward, the brake was not applied for about 40 seconds for some 1,380 meters along a straight section.

The train entered a 304-meter-radius right curve at a speed of more than 110 kph, against a 70 kph speed limit. The driver applied a regular brake only after the train went 25 meters past the start of the curve.

After traveling another 110 meters, the first car tilted to the left, causing derailment, and the first and second cars crashed into a condominium. An emergency brake was automatically activated at impact. The report put the time of the derailment at 9:18:54 a.m.

Although the report did not go into the human factor, the commission detected laxness in JR West’s train operations. In 2004, the ATS emergency brakes activated and stopped trains on 46 occasions. Only an old version of the ATS was in use where the accident happened. The commission recommended that JR West install the latest type of ATS, which can restrain the speed of a train going through such curves and junctions.

Taking a serious view of the fact that the train’s emergency radio system did not work, the commission called on the company to take corrective measures. It also called for installation of a system that records operational factors of each train — train position, speed, position of the brake handle, ATS operation, etc. — as well as accurate speedometers. The speedometer reading for the derailed train was found to be a maximum 4 kph lower than the actual speed.

As the commission moves into the next stage of its investigation, checks of the following factors are indispensable: the working conditions of the driver, his health and mental condition, and any psychological pressures that were exerted on him as a result of JR West’s tight schedule and competition with other railway companies.

It has been speculated that the driver speeded up the train to compensate for the 1-minute-20-second delay caused by overrunning Itami Station because he feared being punished by management. He had been reprimanded for overrunning the platform of a different station by 100 meters in June 2004, and it was reported that he had come to fear that he might lose his position as a driver if he made another operational error. He also might have feared that the delay would cause inconvenience to passengers about to change trains at Amagasaki Station.

It has been reported that JR West’s re-education programs for drivers who have made operation errors involved punitive and humiliating measures such as weeding station grounds and writing many “soul searching” compositions. It is very likely that JR West forgot a passenger-transport company’s basic principle — putting priority on safety.

Symbolic of the lack of public-service spirit is the fact that two other drivers who were aboard Takami’s train did not take part in rescue operations after the accident and instead went to work apparently for fear of being punished.

In order to see the total picture of this tragedy and prevent a recurrence of similar accidents, it is important that the commission, before releasing the final report in about two years, delve further into the human factors behind the accident.

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