The 2005 Amagasaki Rail Disaster: What the Official Report Reveals About Japan’s Deadliest Train Crash

The official investigation into Japan's Amagasaki train crash, revealing how corporate pressure and punitive discipline caused the 2005 tragedy.

A record of the Fukuchiyama Line derailment of 25 April 2005, drawn from the official investigation

I.

At 9:18 and 54 seconds on a clear Monday morning, the first carriage of a seven-car commuter train left the rails on a right-hand bend in the Hyogo city of Amagasaki and went over onto its side. The passengers who survived it described the same thing in different words. A teenage girl in the first car, asleep against the window, woke to the body of the train shaking hard and felt it tip, all at once, before it struck anything.¹ A man standing by the third door watched the curve come up too fast and thought, in the moment, that it did not look like a train that could make the turn. He felt the right side of the carriage go light – ‘floating,’ he said later – and then it never came back down.² A woman standing with a friend heard the windows rattle and then a long, high, metallic shriek she had never heard from a train before. The car tilted to perhaps forty-five degrees and the lights went out.³ From a balcony overlooking the line, a resident watching trains with a child heard a grinding that was not the usual sound, saw the right wheels of the lead car lift, saw a small puff of dust, and then watched the carriage slide off the track towards the apartment block in what looked like slow motion.⁴

The lead car struck the building’s ground-floor mechanical car park and folded. The second car, still coupled, swung in behind it and wrapped around a concrete pillar, its cross-section crushed from a rectangle into a diamond. Cars three, four and five derailed behind them. Six and seven stayed on the rails. The last carriage came to rest at 9:19:04, ten seconds after the first had gone over.⁵

One hundred and six passengers died. So did the driver. Five hundred and sixty-two people were injured.⁶ It was the deadliest railway accident in Japan in more than forty years, and it fell to West Japan Railway, the company that had inherited this stretch of line when the national railway was broken up in April 1987.^6a

The proximate cause was never in doubt. The train entered a curve with a limit of 70 km/h at approximately 116 km/h, and at that speed the physics were unforgiving.⁷ What the investigation spent two years and some 270 pages establishing was why a licensed driver, in good health, with no alcohol in his blood and a clean run that morning until Takarazuka, let a train he had driven many times run 46 km/h over the limit into a bend he knew was there. The answer the Aircraft and Railway Accidents Investigation Commission gave had little to do with machinery. It concerned where his attention had gone in the last fifty seconds, and the company that had built the reasons for it to go there.

II.

The driver was twenty-three. He had joined the company in April 2000, worked a station platform, passed the examination to become a conductor, and then the one to become a driver. He had received his licence in May 2004, eleven months before. He lived at home, the third of four children, and by his family’s account the most cheerful of them. He snowboarded until the snow ran out. He had told them he wanted, eventually, to drive the Shinkansen.⁸

He had spent the night at the company’s crew dormitory at Hanaten, in eastern Osaka, and reported for roll call at 6:08, thirteen minutes early. The supervisor who took it noticed nothing unusual: his voice was normal, he did not look tired.⁹ His roster that day was a long loop. He would take an empty train out to Matsui-yamate, bring it back in service to Kyobashi, continue under a new train number through the underground Tozai Line to Amagasaki, run it empty up the Fukuchiyama Line to Takarazuka, then change ends and drive it back as the 9:03 rapid service to Doshisha-mae: train 5418M, seven cars, the same set he had been driving since dawn.¹⁰ His conductor was a forty-two-year-old veteran of twenty-two years’ service who knew his face from a previous posting but not his name.¹¹

The early legs went normally. The rapid service picked up a minute or so of delay in the rush-hour crush, as it always did. Nothing on the recorders suggests anything wrong with the man in the cab until the empty run to Takarazuka.

That run had more than ten minutes of slack built into it, and he used the slack strangely. Between Kawanishi-Ikeda and Nakayamadera the train dawdled at times below 10 km/h on a stretch with no level crossings, as if he were killing time where it would inconvenience no one.¹² Then, approaching Takarazuka, he accelerated hard, at full power or close to it, towards a platform he was required to enter at 40 km/h across a diverging switch. The train hit the switch at about 65. A track beacon guarding the red signal ahead sounded the safety system’s bell in the cab. He had five seconds to acknowledge it, and the seconds ran out. The automatic train stop applied the emergency brake and the train halted straddling a level crossing, its nose just onto the end of the platform.¹³

The rules for what happens next are explicit. Before resetting the system, a driver must contact the dispatcher and receive instructions. He skipped that step, reset the system, called the conductor over the intercom to ask for a departure signal, and pulled forward. The system stopped him a second time, on a separate safeguard, just as the train reached its proper stopping mark. He arrived at Takarazuka at 8:56:14, forty-four seconds late, having triggered two emergency brake applications in ninety seconds and reported neither.¹⁴

Then he sat in the cab. The conductor, walking the length of the platform to swap ends, took about two minutes twenty to reach him, which is normal. Drivers usually take about a minute to gather their things and leave. This one stayed nearly three, and when the conductor arrived he was still in the seat. He stood up, though the conductor could not say whether it was because he had been noticed. As they passed at the cab door the conductor asked, ‘Did the P stop you?’, mistaking which safety system was in use. The driver gave him a look the conductor later described as ‘I don’t need to tell you,’ or simply sullen, and walked past without a word. At 8:57, while he sat in the cab, a text message had arrived on his personal phone. Whether he read it, the investigators could not determine.¹⁵

He took the rapid service out of Takarazuka at 9:04, fifteen seconds down. The stops at Nakayamadera and Kawanishi-Ikeda came and went, the delay creeping to thirty-five seconds as passengers pressed aboard. Through Kita-Itami without stopping, at about 120. Then he shut off power and let the train coast at 122 km/h for forty-two seconds.¹⁶

Itami was a stop. The train carried a device that knew this. Six hundred and forty-three metres out, at 113 km/h, a recorded woman’s voice said in the cab: ‘Stopping. Stopping.’ He kept coasting. Four hundred and sixty-eight metres out, at 112, a man’s voice and a mechanical alarm cut in together, ‘Stop, stop’, and only then did his hand go to the brake, and hard. The train entered the platform at 83 km/h. It passed the stopping mark at 46. The conductor, leaning from the rear cab with his hand on the emergency switch, saw the speed and pulled it. The train stopped seventy-two metres past where it should have.¹⁷

It reversed, briskly by several passengers’ account, and the doors opened three metres short of the mark. It left Itami at 9:16:10, one minute twenty seconds late.¹⁸ An overrun of that length was, under the company’s own classification, a reportable incident. In the company’s culture, the rest of this account will show, it was also something else: the trigger for a form of discipline drivers dreaded more than any timetable.

III.

The company called it nikkin kyōiku, ‘day-shift education.’ A driver who overran a platform, missed a roll call or triggered a safety system was taken off trains, reclassified from crew to day-duty, and set to writing. Incident reports, letters of apology, ‘why-why sheets’ of root-cause analysis, essays on assigned themes. There was no rule governing how long it lasted or what it contained. That was left to the depot head, who could keep a man at a desk for as long as he judged necessary.¹⁹ Across the Osaka branch in the two years before the accident it was imposed 321 times. The median stay was three days. The longest was forty-four.²⁰

The driver had been through it three times. Four days in 2002, as a conductor, when his train ran through a station it should have stopped at. One day in 2003 for dozing on his feet while supervising a trainee. And thirteen days in June 2004, three weeks into his career as a driver, after he overran the platform at Shimokoma on the Katamachi Line by a hundred metres.²¹ The Shimokoma incident has the same shape as Itami. He was distracted by something else, the company’s record says. The second warning voice sounded. He braked hard, then pulled the emergency, and the tail of the train finished past the end of the platform. He had to call the dispatcher before reversing. The train arrived eight minutes late.²²

For that he was formally reprimanded, lost 50,000 yen from his bonus, and spent thirteen days writing. His essay themes are preserved in the report’s appendix, and the committee’s summary of them is dry: mostly matters of attitude and spirit, little about how a driver distributes his attention, nothing at all about braking.²³ A colleague who was in the room for part of it described the process. The driver had come back to the depot half-smiling and had not gone straight to apologise to the instructors, which enraged his superiors. He was deeply low. He wrote his assigned reports and the supervising staff refused to accept them, so he erased half and rewrote, and rewrote again, until the instructors began suggesting the phrases they wanted. ‘Even if you didn’t believe it yourself,’ the colleague said, ‘you wrote it, because otherwise you thought they wouldn’t let you drive.’ The desk where he worked was in full view of the drivers coming through for roll call, who were handed a notice about his overrun and asked by the supervisor, ‘What would you have done?’²⁴

His friends heard a version of the same thing. ‘Day-shift education is just copying out something like the company creed,’ he told one. ‘I don’t see the point.’ The pay cut hurt. ‘I really hate it.’ To a woman he had known since high school he said that having to ask permission to go to the toilet was what he hated. She thought it was the lowest she had ever seen him.²⁵ He also told her about a Kyobashi driver who had reversed a train in error a month earlier and been moved out of the cab into a vehicle-management job.²⁶ After Shimokoma, he said, another mistake and they would take him off driving.²⁷

Other drivers gave the committee their own accounts. One, taken off for a month, had been made to stand on the Kyobashi platform for an hour and a half each morning and three hours each afternoon, greeting every arriving driver: ‘Good work. Please take care.’ Leaving his seat for the toilet required a supervisor’s permission. What he remembered most was being watched.²⁸ Another, disciplined for passing a red shunting signal, was told on his return that he was ‘unfit for duty’ and might never drive again. He asked to leave the cab and was reassigned five days before the accident.²⁹ The head of the Kyobashi depot defended the system in terms that had little to do with railways. Families no longer scolded their children, he said, and teachers had become salarymen, so the job of instilling discipline had fallen to companies.³⁰

What the committee found more troubling than the humiliation was what the fear of it did to a man at the controls. A driver who had once run this same curve at 80 to 85 km/h, years earlier, explained that he had been composing an excuse for a mistake earlier in the run, a false report he had given the dispatcher without quite meaning to, and thinking about how to sustain it. He never reported the overspeed. ‘Under-reporting how far you overran,’ he said, ‘is an everyday thing in this company.’³¹ Another Kyobashi driver, stopped by the safety system on the Osaka Loop, weighed whether to report it and decided against, because reporting meant nikkin kyōiku.³² A conductor’s testimony confirms the arithmetic from the other side. If an overrun was around five metres, it was understood, the punishment was light.³³

IV.

The company had also built the clock he was running against.

In August 1988, a year into privatisation, a management meeting on Osaka-area services set out a policy. Among the measures listed for raising speeds was a phrase the committee reproduces without comment: ‘the total abolition of margin time.’³⁴ In the national-railway era, timetables had been calculated on the assumption that drivers would run 2 km/h under every limit, which built a small cushion into the running time itself. That practice survived at JR West until around the end of the 1980s.³⁵ In March 1991 the line speed between Amagasaki and Shin-Sanda rose from 100 to 120 km/h.³⁶ In December 1996, to feed the new Tozai Line into Amagasaki, the gentle 600-metre curve north of the station was rebuilt as a 304-metre one.³⁷

Then the running times came down. The standard time for a seven-car rapid service between Takarazuka and Amagasaki was cut by twenty seconds in March 2002, twenty more in March 2003, and ten in October 2004. Fifty seconds in all, over a fifteen-minute run.³⁸ The staff who calculated running times did not initiate these cuts. They were asked for them by the timetable planners, who were carrying out commercial policy: a 2003 board paper promised to bring the morning rapid service from Takarazuka to Osaka down from twenty-six minutes to twenty-three.³⁹

Dwell times went the same way. In December 2003 the planner in charge shortened the stop at Itami from twenty seconds to fifteen. He had gone to watch trains at Itami and timed the stops at seventeen or eighteen seconds without any late-running passengers. Fifteen would be achievable, he reasoned, if passengers could be encouraged to queue in an orderly fashion. He asked the relevant departments to arrange this. It never happened.⁴⁰ At Kawanishi-Ikeda, the timetable allowed twenty seconds and the trains were actually taking twenty-five.⁴¹ At Takarazuka, the planner had set ninety seconds between the departure of the limited express from platform 3 and the rapid service from platform 2, based on a single measurement he made in autumn 2002 and could not otherwise document. The company’s own measurements, obtained by the committee, told a different story. The signalling and level crossing needed about ninety-three seconds to clear, before anyone closed a door.⁴²

The result was a train that was scheduled to be late. Of sixty-five weekdays in the months before the accident for which records survived, 5418M reached Amagasaki more than a minute behind time on more than half. The median delay was eighty seconds.⁴³ When the committee ran the same route through the timetabling method used by a major private railway in the Kansai region, the standard running time came out ten seconds longer than JR West’s, before allowing for the dwell times that were too short.⁴⁴

The company, meanwhile, required drivers to report any delay of thirty seconds. A delay of a minute attributable to a crew member’s error was a reportable incident, and reportable incidents fed nikkin kyōiku.⁴⁵ The committee put the contradiction plainly. An operator that runs trains at 120 km/h without any device to catch a driver’s overspeed error, it wrote, should build corresponding margin into its timetable. This one had abolished it.⁴⁶ In a survey of fifty-one Kyobashi drivers after the accident, more than half said that the greatest psychological burden came from a schedule too tight to keep even with clear signals. Three in five said the delay that weighed on them most was between one and three minutes. Beyond three, several explained, you gave up trying to recover.⁴⁷

V.

The device that would have caught the error was already fitted to the train. Nothing in the track beneath it could yet speak to it.

Japanese railways run two broad kinds of automatic train protection. The older kind, called ATS-SW on this line, works from fixed points. As a train approaches a red signal, a beacon in the track sounds a bell in the cab. The driver must brake and press an acknowledgement button within five seconds or the emergency brake applies. Near the signal itself, a second beacon stops the train outright if it is still moving. It can check speed at a curve only where a beacon has been installed for that purpose, and none had been installed here.⁴⁸ The newer kind, ATS-P, is continuous. Beacons tell the onboard computer where the next restriction is and what it requires, and the computer calculates a braking curve and applies the brakes itself if the train’s speed rises above it. Fitted at a curve, it will slow a train that is approaching too fast whether or not the driver has noticed.⁴⁹

JR West had decided to install ATS-P on its busy Osaka lines in 1989 and had done so, line by line, through the 1990s. From 1998 its medium-term plans carried a line for the Fukuchiyama section: 200 million yen in fiscal 2003, 600 million in 2004, completion by March 2005.⁵⁰ The formal investment decision slipped to September 2003. The work was then handed from the head-office construction department to the Osaka branch, on the reasoning that it was a simple new installation the branch could handle. The paperwork delegating it to the signal depot took until March 2004. The design contract was let in April. In October the signal depot head concluded that the schedule could not be met and pushed commissioning to June 2005. He told the branch electrical manager, who told the branch head in December and two head-office department heads in January. Nobody objected. ‘I didn’t say keep to the deadline,’ the head of safety promotion told the committee, ‘because rushing the work might cause trouble.’⁵¹ On the morning of 25 April 2005, the beacons on the Fukuchiyama Line were still speaking only the older language.

Even a completed installation might not have covered this curve. JR West fitted the curve-speed function only where the radius was under 450 metres, and it regarded the function as an afterthought. ‘I understood that overspeed on a curve could cause a derailment,’ the head of safety promotion said, ‘but I didn’t recognise it as a concrete hazard. The curve-speed function was more a precaution.’⁵² The executive director in charge of the railway division said toppling on a curve was something he had never considered, and that he had been unaware of the past cases.⁵³ There were past cases. Twice, in 1988 and 1996, JR Freight trains had derailed on a 300-metre curve on the Hakodate Line in Hokkaido at roughly 100 and 117 km/h. The transport ministry had briefed JR West on both. The 1996 case appeared in the appendix to the company’s own safety committee papers in March 1997.⁵⁴

There was a smaller sign, too. In October 2004 the operations department drafted a revision of the printed list of prohibitions that every driver carried. The proposed new item read: ‘Do not operate a train in excess of the prescribed speed.’ The reason given was to prevent derailment by overspeed. After discussion the item was dropped. It was, a manager explained, too obvious to need stating, and the list was getting long.⁵⁵ The revised list went up on the Kyobashi depot noticeboard on 30 March 2005. A briefing on it was scheduled at the depot for 10:55 on the morning of 25 April. The driver was down to attend.⁵⁶

VI.

On the lines where ATS-P had already been installed, it had been generating data for years, and after the accident the committee pulled the memory from the onboard units of other trains in the 207-series fleet. On the underground Tozai Line, which the driver had run through that morning, there were six curves fitted with the speed-check function. Across roughly 4,900 passages, the system had applied maximum brake ninety times. Once in every fifty trains. With 162 trains a day, that meant the automatic brake was slamming on about three times a day, every day, on one stretch of line.⁵⁷

Almost all of it was unnecessary. The speed limit at each curve was made up of a base figure plus a small ‘designated speed’ allowance for modern stock, five kilometres an hour. Whoever had programmed the beacons had entered zero. On JR West’s network, sixty-eight of ninety-four curve beacons carried wrong data of one kind or another. The engineer who supervised the later installation on the Fukuchiyama Line, where twenty-two of thirty beacons carried the same error, said he had not known the designated speed was a field to be entered at all. The company said it learned of the errors only after the accident.⁵⁸ The committee’s conclusion was that JR West had been ‘in a position to easily know’ of the fault from equipment already fitted to its trains, and should not have waited for crews to report what its own recorders were logging.⁵⁹

The pattern repeated at smaller scale. In May 2004 the speedometers in two cars of the set that would derail were found at inspection to be reading wrong, one five kilometres high and the other five low, because a switch had been set to feed one car’s wheel diameter into the other’s calculation. The cars went back into service anyway. Drivers complained three times. The switch was corrected in August.⁶⁰ The speedometer in the lead car, the one the driver was watching, under-read by about 2.7 km/h at 120 because of a rounding shortcut in the manufacturer’s software. It did not comply with the applicable standard. The programmer told the committee he had not known the standard existed.⁶¹ Four times in 2004, Kyobashi drivers had reported that the brake handle on certain cars could lodge between the maximum service position and emergency, applying neither. No modification followed.⁶²

The committee set these two halves side by side. A company that demanded reports from its crews, punished those who made them, and punished more harshly those who did not, was at the same time failing to act on anomalies its own machines were recording and its own staff were flagging. A reporting regime built this way, it wrote, ‘may conversely induce accidents.’ Its first recommendation to the minister was for non-punitive incident reporting across the industry.⁶³

VII.

The curve itself was ordinary. A right-hand bend of 304 metres radius, with sixty metres of transition before it, a cant of 97 millimetres to lean the track into the turn, and a lineside sign reading 70.⁶⁴ The question of what speed would tip a 207-series car over on it had a precise answer, and the company got it wrong on the day of the accident.

That afternoon JR West published a figure of 133 km/h, calculated for an empty car and ignoring the effect of the suspension.⁶⁵ The committee reworked it using a standard formula for rail-vehicle overturning, with ninety-three passengers aboard, the springs’ contribution to the effective height of the centre of mass, and the ordinary lateral sway of a train in motion. The answer was 106 km/h. At full standing capacity it was 104.⁶⁶ A separate computer simulation, built from the actual car and track, found that the lead car stayed on the rails at a steady 105 km/h and derailed at 110 and at 115.⁶⁷ The train entered the curve at about 116.

Two details from the simulation give the sequence its texture. Standing passengers thrown outward by the curve may have shifted their combined centre of mass by about twenty-one centimetres in the first 1.9 seconds, and the committee built that into its model.⁶⁸ And the car began to lean early enough that the skirt below its front coupling scraped the ballast some nine to twelve metres before it reached a lineside pole, throwing crushed stone onto the rail head. The white powder found there afterwards was ballast, ground fine under the wheels.⁶⁹

The drivers at Kyobashi had no idea where the edge was. Asked after the accident what speed they had believed would topple a train on that curve, half of fifty put it at 120 km/h or above. Many added that no driver, however late, would knowingly run a curve tens of kilometres over its limit.⁷⁰ The committee agreed, and gave five reasons for ruling out deliberate speeding. Among them: a man consciously taking a 70 curve at 110 would have gone to emergency brake the instant he felt the need, not eased through the service notches one by one.⁷¹

VIII.

At 9:16:10 the rapid service left Itami and accelerated hard. At Kita-Itami it had been at 120. Now it went past that, to 124 or 125, while the speedometer in front of the driver read 121 or 122. At 9:18:09 he touched the brake for two seconds to bring it back under the line limit, then shut off power and let the train coast. It passed through Tsukaguchi at 9:18:22 at about 122 km/h.⁷²

Behind him, in the rear cab, the conductor had made the next-stop announcement: Amagasaki, change for Kobe and Osaka. The intercom buzzed immediately. The driver said something the conductor rendered as ‘Can you knock it down for me?’ The conductor understood him to mean the overrun distance. He thought for a moment and said, ‘You went a long way.’ At that point a passenger knocked on the glass between the saloon and the cab and demanded to know why there had been no apology for the delay. The conductor put the handset down, opened the door, promised an announcement, and made one.⁷³

Then he picked up the radio. At about 9:17:57 he called the dispatcher and reported that the train had overrun the rear limit at Itami ‘by approximately eight metres,’ had reversed with the driver’s agreement, and was running a minute and a half late. He had believed the distance was thirty or forty metres. He chose eight, he told the committee, because five metres was known to carry a light punishment but seemed too small to be credible. He did it, he said, because he knew the driver’s face and thought it would help him. He had not considered that the lie could be found out.⁷⁴ The dispatcher read the figure back, ‘rear limit, eight metres over,’ and asked the driver to respond. Somewhere between that readback and five seconds after it, the train passed the point where braking for the curve should have begun.⁷⁵

The dispatcher called the driver twice. There was no answer.⁷⁶

At 9:18:50, having coasted for thirty-nine seconds after his last touch of the brake, the driver braked. The recorder shows the handle moving through the positions in sequence: the lightest notch, then the middle ones, then the seventh, held for just over two seconds. As the lead car passed pole 41, at about 105 km/h and already leaning, he moved to the maximum service notch. He never reached emergency. At 9:18:54 the car went over.⁷⁷ By the committee’s calculation, the brake application was about sixteen seconds late.⁷⁸

What was he doing in those sixteen seconds? The report is careful here. The driver, it says, may have believed the conductor had answered him coldly and hung up. He was probably listening to the exchange between the conductor and the dispatcher with particular attention. He was likely composing an explanation for his overrun that would be consistent with ‘eight metres.’ He may have been trying to write it down: a special red pencil issued for noting radio instructions was found loose on the cab floor, and his right glove was off, which nearly a quarter of his colleagues said they did when jotting something on the timetable cover.⁷⁹ Nothing in his health, his roster, his sleep or his blood offered a competing explanation.⁸⁰

The committee’s formal finding of cause is three sentences long, and the graded vocabulary matters. The accident ‘is estimated’ to have resulted from the driver’s delayed braking, which took the train into the curve at approximately 116 km/h. The delay ‘is considered’ to have come from his attention leaving the driving, because, believing the intercom call in which he had asked for a false report had been cut off, he was attending to the conductor’s exchange with the dispatcher and thinking up excuses out of concern that he would be sent to nikkin kyōiku. And the company’s method of managing its drivers, which imposed nikkin kyōiku or discipline, taken by some drivers as a penalty, on those who caused incidents, and harsher versions on those who failed to report them or reported them falsely, ‘may possibly have been involved’ in both the false report he sought and the lapse that followed.⁸¹

IX.

The first emergency call was logged at 9:22. Fire crews were on scene at 9:26. Before they arrived, workers from the factories and businesses along the line had already begun pulling people from the wreckage, and they kept at it through the morning. More than thirty companies took part.⁸² What the railway’s own control centre did in that hour is recorded too. A power-district employee reached the site at 9:40 and at 9:59 radioed that members of the public were climbing on the carriage roofs beneath live overhead wires. The order to cut power went out at 10:03, forty-five minutes after the derailment, and the high-voltage distribution line was still live until 10:13, because the power controller had first cleared it with the train dispatchers so as not to strand trains between stations. The committee found in this a lack of regard for human life and told the company to put it in a manual: after a derailment, cut the power, then ask.⁸³

The last survivor was brought out at 7:06 the following morning, twenty-two hours after the crash.⁸⁴ The dead were almost all in the first three cars: forty-two in the first, fifty-seven in the second, three in the third.⁸⁵ In the second car, where the body shell had been crushed into a diamond and the interior space almost eliminated, eleven of the fifty-seven dead had suffocated under the weight of other passengers. Across the whole train, nineteen died that way.⁸⁶ The committee’s survival analysis found that people who kept hold of a strap or rail until the car stopped were injured less severely than those whose grip broke early, and recommended that handholds be designed for gripping hard and that the ends of bench seats be shaped to hold a body rather than pierce it.⁸⁷

The changes that followed were the ones the report had implied. ATS-P went live on the Fukuchiyama Line on 19 June 2005, when the section reopened. The curve limit fell to 60 and the line limit to 95, and forty-five seconds went back into the timetable.⁸⁸ By the end of fiscal 2006, JR West had fitted curve-speed protection at 1,370 sites, up from 105, and the ministry had made such protection compulsory across the industry, along with onboard data recorders.⁸⁹ Drivers were told, as a rule, to make radio contact only once stopped at the next station. Protective radios were rewired to switch to battery automatically. A safety research institute was founded. The Railway Business Act was amended to require every operator to name a safety manager and file a safety management plan.⁹⁰ The committee did not ask the company to abolish nikkin kyōiku. It asked only that it be remade into something that taught drivers to drive.⁹¹

The report closes, as such documents do, with recommendations, appendices and a glossary. It says in its preface that it was written to find causes and prevent recurrence, not to apportion blame, and it holds to that. It never names the driver. It records that he died in the cab of internal bleeding, that his left glove was on and his right was off, and that his shoulder bag held a banana and a bottle of tea.⁹² It records his declaration at the previous day’s sign-on, at 12:16 on the Sunday afternoon: ‘Reporting for holiday roster 75. Mental and physical condition good.’ At 6:08 the next morning the supervisor noted only that he seemed his usual self.⁹³

And it records one more thing. Six days before, on the Tuesday, he had sat down for his routine interview with the depot. Asked what work he hoped to be doing in a year or two, he said he would like to become an instructor. The reason he gave was written into the file. There would be more and more juniors coming through, he said, and he wanted to use his own experience so that none of them made the same mistakes he had.⁹⁴

Notes

1. RA2007-3-1 §2.2.10.1, passenger 1A. ↩
2. §2.2.10.2, passenger 1B. ↩
3. §2.2.10.3, passenger 1C. ↩
4. §2.2.13, eyewitness. ↩
5. §1.1, §2.4.2.1–2.4.2.2. ↩
6. §2.3.1, Table 1 (Hyogo Prefectural Police figures). ↩
7. The comparison with earlier accidents is not drawn from the report. The previous deadliest was the Tsurumi collision of 9 November 1963, 161 dead. ↩
8. §2.2.7, §4. ↩
9. §2.5.1, §2.5.12.1. ↩
10. §2.5.4.1. ↩
11. §2.1.1. ↩
12. §2.6, §2.2.8(1). ↩
13. §2.2.4, §2.14.9. ↩
14. §2.2.4, §2.10.1.8. ↩
15. §2.2.4, §2.13.7.2. ↩
16. §2.2.5, §2.2.8(5), §2.5.4.2, §2.21.8. ↩
17. §2.2.6. ↩
18. §2.2.6, §2.13.3.3. ↩
19. §2.2.6. ↩
20. §2.7.4.1. ↩
21. §2.7.4.3, Table 10. ↩
22. §2.5.7.4, §2.5.11.2, §2.5.11.5, §2.5.11.6. ↩
23. §2.5.11.2. ↩
24. §2.5.7.4, §2.5.10, §2.7.5.3(1). ↩
25. §2.5.7.4, driver F. ↩
26. §2.5.12.2, §2.5.12.3. ↩
27. §2.5.12.2, §2.20.1.12. ↩
28. §2.5.12.2. ↩
29. §2.7.4.9, driver I. ↩
30. §2.7.4.10, driver J. ↩
31. §2.7.4.7. ↩
32. §2.20.1.9. ↩
33. §2.20.1.5, driver K. ↩
34. §2.2.8(6). ↩
35. §2.14.2. ↩
36. §2.14.5.3. ↩
37. §2.10.1.2. ↩
38. §2.8.1. ↩
39. §2.14.3.1, Table 32. ↩
40. §2.14.3.3–2.14.3.4, §3.1.1. ↩
41. §2.14.4. ↩
42. §3.1.2.2. ↩
43. §2.14.7, §3.1.2.1. ↩
44. §2.14.6.3, §3.1.2.3. ↩
45. §2.14.5.4, Table 34. ↩
46. §2.10.10, §2.19.1, §3.1.2.4. ↩
47. §3.1.2.4. ↩
48. §2.21.10.1–2.21.10.2. ↩
49. §2.13.2, Table 28. ↩
50. §2.13.2. ↩
51. §2.13.8.3, §2.13.8.5. ↩
52. §2.13.8.5–2.13.8.6, §3.10.2. ↩
53. §2.13.8.4. ↩
54. §2.19.3.1. ↩
55. §2.20.2.1. ↩
56. §2.7.3.4, Table 9. ↩
57. §2.7.3.4. ↩
58. §2.20.1.1, Table 37, §3.13.1. ↩
59. §2.13.8.9. ↩
60. §3.13.1. ↩
61. §2.9.4.4. ↩
62. §2.9.4.1, §3.3.2. ↩
63. §2.5.11.3, §3.13.2. ↩
64. §3.13.1, §3.14.2, §5(1). ↩
65. §2.8.1, §2.8.2.1, §2.10.1.9. ↩
66. §2.21.6, Table 43 and note 2. ↩
67. §2.21.6, Table 43. ↩
68. §2.21.5.2, Table 42. ↩
69. §2.21.4.2, §2.21.5.1, §3.9.1 (the 21.3 cm weighted figure, hedged 可能性が考えられる). ↩
70. §2.21.5.2(3), §3.9.2.1. ↩
71. §2.21.10.10. ↩
72. §3.8.6.2. ↩
73. §2.2.7, §2.9.4.5, §3.8.6.1. ↩
74. §2.2.8(6), §2.2.10.15, §3.7.1. ↩
75. §2.2.8(6), §2.8.7.2(3). ↩
76. §2.2.7, §2.8.7.2(3). ↩
77. §2.8.7.2(3), §2.2.9. ↩
78. §2.2.7. ↩
79. §3.8.6.2. ↩
80. §3.8.6.2, §2.5.2.1, §2.21.10.9. ↩
81. §3.4, §3.5, §3.6.2. ↩
82. §4. ↩
83. §2.17.4.1–2.17.4.2. ↩
84. §2.17.2.2, §3.11.4, §6.1(3). ↩
85. §2.17.4.3(1). ↩
86. §2.3.2, §2.3.3.3. ↩
87. §2.3.3.3(2), §2.3.3.2(2), §3.11.1.1. ↩
88. §2.3.4.4, §3.11.1.3, §3.11.2.2. ↩
89. §7.1(7). ↩
90. §7.1(2), §7.2(3), §7.2(6). ↩
91. §7.1(3)–(4), §7.1(8), §7.2(7). ↩
92. §6.1(1). ↩
93. §2.5.2.1–2.5.2.2. ↩
94. §2.5.4.1 (24 April 12:16 出勤点呼; 25 April 6:08 発点呼). ↩
95. §2.5.4.1 (19 April 2005 interview record). ↩

Source: Aircraft and Railway Accidents Investigation Commission (航空・鉄道事故調査委員会), Railway Accident Investigation Report RA2007-3-1, West Japan Railway Company Fukuchiyama Line, Tsukaguchi–Amagasaki train derailment, adopted 22 June 2007, published 28 June 2007. All section references are to the Japanese original. Translations are the author’s.

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Photo credits: https://commons.wikimedia.org/wiki/File:Fukuchiyama_joko20051.jpg (捕澤 - AI upscaled) and https://commons.wikimedia.org/wiki/File:Amagasaki_derailment_damage_to_the_first_car.jpg (Japanese Government).