On the 25th of April, 2005, a seven-car commuter train passing through the Japanese city of
Amagasaki catastrophically derailed.
The accident would almost entirely destroy the train, cause severe damage to a nearby
apartment building, and cost more than a hundred commuters their lives.
A later investigation would reveal the cause: fear and uncertainty on the part of the driver
over a delay of just 90 seconds.
Japan’s railway network is known the world over for its speed and efficiency.
Japan pioneered high speed rail transport with the Shinkansen bullet train… and is
known for having a rail network that is extremely punctual and reliable.
While train services in other parts of the world measure delays in minutes, most of Japan’s
rail companies measure their delays in seconds.
The West Japan Rail Company (also known as JR West) came into existence in 1987, following
the breakup of the state-owned rail company Japan National Railways.
It took over operation of a small number of high-speed rail lines, and a much larger network
of regular, commuter rail routes.
One of these commuter routes is the Fukuchiyama Line, which runs from the city of Fukuchiyama
to the city of Osaka.
Amagasaki – an industrial city home to around half a million people – is officially the
last stop on the Fukuchiyama Line, with trains running onto another line to complete their
journey to Osaka and beyond.
On the day of the disaster, train 5418M departed Takarazuka Station bound for Amagasaki at
9:03am.
It was 15 seconds late.
Just a few minutes earlier the driver (23-year-old Ryūjirō Takami) had accidentally passed
a red signal at low speed, causing the train’s automatic braking system to kick in and bring
it to a halt.
As a result of this the service was now running very slightly behind schedule.
This minor delay was exacerbated by a rush of passengers at Ikeda Station a little further
down the line.
With the train more crowded than had been anticipated, it took a few extra moments to
close the doors and move away, pushing the delay up to almost a minute.
This was problematic, as JR West stipulated that a delay of more than 28 seconds on this
route was unacceptable.
To try and reduce the delay back down to an acceptable level Driver Takami ran the train
at close to its maximum speed as it passed through the next stations.
As the train approached Itami Station, an alarm sounded in the driver’s cab, indicating
that the train was travelling too fast for its upcoming stop.
Driver Takami was slow to react and when he eventually brought it to a halt at the station
he found that he had overshot the platform by the length of three carriages.
Backing up to the platform so that passengers could embark and disembark pushed the total
delay up to a minute and a half.
At this point Driver Takami made a phone call to the conductor at the rear of the train.
He knew that the conductor had to report the overshoot, but Takami asked him to play down
the distance involved, perhaps saying that it was one carriage length rather than three.
The conductor, displeased by this, ended this conversation abruptly by telling Takami that
he was driving too fast.
Despite this, Driver Takami attempted to make up time and reduce the delay on the service
by running the train as close as possible to maximum speed through the next few stations.
As the train approach Amagasaki Station it was travelling at 116 kilometres per hour
(or 72 miles per hour).
As it entered a curved section of track it derailed, with the frontmost cars smashing
into a nearby apartment building.
Because the rail network in Japan is generally considered extremely safe, very little distance
is left between buildings and railway lines in metropolitan areas.
Damage to the apartment building and to the train was extensive.
The front two cars were almost completely destroyed, resulting in the death of every
single person on board, Driver Takami included.
In the remaining five cars, hundreds of people were injured, many seriously.
The wreckage created a short circuit in the track, causing all local signals to default
to red.
This gave time for an approaching train to apply its emergency brake and come to a stop
just 50 metres (or 165 feet) from the wreckage.
Local residents who had witnessed or heard the crash converged on the site of the wreck
and began extricating injured passengers.
The emergency services were soon on the scene.
While ambulances transported the most seriously injured to hospital, those with less severe
injuries were moved using taxis, police cars and flatbed trucks.
The Japanese Self Defence Force was called in to assist with the rescue operation.
It was a slow and painstaking process.
The apartment building had contained a parking garage, and the train had destroyed several
cars as it passed directly through it, resulting in a massive spillage of gasoline.
No tools that might create sparks could therefore be used during the initial part of the rescue
operation.
There had been 700 people on board the train as it approached Amagasaki Station.
107 of them lost their lives in the crash, and 562 people were injured.
As soon as the rescue and recovery operation had concluded, an investigation began to try
and determine the cause of the accident.
Suspicion swiftly fell on Driver Takami, who had been driving the train at a speed wholly
inappropriate for the curve it was navigating when it derailed.
Driver Takami had been fit and well.
At 23 years old, his sight was good, and he had not suffered a medical emergency.
The brakes on board the train had also been functioning perfectly.
What, then, had been the reason for his excessive speed?
As the investigation went on it was speculated that Takami was concerned about the 90-second
delay in the operation of the service, and that he had been driving the train at high
speed to try and reduce this delay.
Punctuality is extremely important for the Japanese rail network.
Not only have users of the network come to expect the trains to run precisely on time,
but the scheduling of trains often depends on trains arriving simultaneously, to allow
passengers to transfer smoothly between different services.
If one train is late, it can delay others, creating a ripple effect that’s costly for
the network.
Because of this, JR West was extremely hard on its drivers, pushing them to keep to schedule.
Drivers who accumulated too great a delay while navigating a route – or who overshot
station platforms as Driver Takami had done – could be subjected to disciplinary measures.
Within JR West, these disciplinary measures were known as “Dayshift Education”, and
were unusually harsh.
Workers responsible for delays could be forced to endure weeks of punitive duties such as
weeding gardens, trimming grass, cleaning toilets, and copying out railway policy documents
by hand.
They were often subject to verbal abuse, and financial penalties, and might not be told
how long it would be before they could return to their normal duties.
Driver Takami had already been reprimanded once before, and would have been keen to avoid
a repeat of the experience.
With this in mind, he may have felt compelled to drive the train at a higher speed than
normal to reduce the delay he’d accrued.
It was also noted that, he had briefly activated the service brake in the final moments before
the crash, but had not used the emergency brake.
Pulling the emergency brake would have required him to justify its use to his superiors, which
would have forced him to reveal that he had been driving at excessive speed.
It is possible that his fear of punishment not only prompted him to drive too fast, but
also deterred him from using the emergency brake.
As details of JR West’s re-education program came to light, the company was heavily criticised.
A wave of resignations followed, including the company’s president Masao Yamazaki.
He was also charged with negligence for his role in creating the conditions that lead
to the crash.
He was ultimately found not guilty, as it was believed that the crash had been impossible
to predict.
The company as a whole, however, was heavily criticised by the court.
Staff who had been subject to “Dayshift Education” brought a lawsuit against JR
West, and 61 employees were awarded monetary compensation for the treatment they had endured.
JR West revised their treatment of employees going forward – while punctuality would
remain important to the company, drivers would not face harsh or humiliating penalties for
small delays.
Following the crash, the Ministry of Land and Transportation asked rail companies across
the country to install new controls on their networks to limit speed on sharply curved
sections of track.
This type of new control was implemented on the curve where the accident had taken place,
and the overall speed limit for that section was also reduced.
The apartment complex which had been hit by the train was mostly demolished, although
one corner of it was retained and incorporated into a memorial to the 107 people who died
in the derailment.
JR West went on to found a Safety Research Institute, which conducts ongoing study into
hazards on the railway network.
One of the main duties of this institute is to consider how the dangers caused by human
factors can be reduced or neutralized.
They cover everything from how to respond to intoxicated passengers on a platform, to
how to foster a workplace environment where workers feel able to provide critical feedback.
The 25th day of every month is designated a “safety day”, and the company maintains
details of the derailment on their website, taking full responsibility for it, and considering
their responsibility to victims and their relatives going forward.
It seems as though, in the aftermath of the Amagasaki derailment, the culture which caused
the accident is, for now, no more.