Between Tsukaguchi Station and Amagasaki Station, train No. 5418M entered a rightward curve with a radius of 304 m at approximately 116 km/h—greatly exceeding the speed limit of 70 km/h for the corner. As a result, the first through fifth train cars derailed, causing the first and second cars to collide with an apartment building on the left side of the direction the train was traveling. In this derailment, 106 passengers and the train driver were killed. Furthermore, 562 passengers and 1 pedestrian walking near the scene were injured.

From the Railway Accident Investigation Report issued by the Aircraft and Railway Accidents Investigation Commission (now the Japan Transport Safety Board), the cause of accident is as follows:

It is considered highly probable that the train driver’s delay in applying the brake resulted in the entry of the train into a 304 m-radius rightward curved track at a speed of approximately 116 km/h, which was far higher than the specified speed limit of 70 km/h, and the running of the train along the curved track at the high speed caused the first car of the train to fall left and derail, which caused the second to fifth cars to derail. It is considered probable that the train driver’s delay in applying the brake is attributable to the diversion of his attention from driving the train to (1) listening to the dialogue between the conductor and the train dispatcher by radio communication, which was caused by his belief that he had been hung up on by the conductor while he had been talking to the conductor on the intercom to ask him to make a false report and (2) making up an excuse to avoid being put on an “off-the-train” re-training course.

It is considered probable that the West Japan Railway Company’s train driver management system in which drivers who caused an incident or a mistake are put on an “off-the-train” re-training course that can be considered as a penalty or are subjected to a disciplinary action and drivers who did not report an incident or a mistake they had caused or made a false report about such an incident or mistake are put on an even harder “off-the-train” re-training course or subjected to an even harder disciplinary action may have (1) caused the driver to make the call to the conductor on the intercom to ask him to make a false report and (2) caused the diversion of the driver’s attention from driving the train. 

Continuing reflection and passing on the lessons of the accident:

No matter how much time has elapsed since the accident, and no matter how many generations pass, we must never let it be forgotten, instead making the derailment accident on the Fukuchiyama Line the starting point for all of our safety initiatives. Looking to the future, to ensure that we pass on the serious reflections and lessons that this accident has taught us, we have reviewed the problems that were present in our corporate culture and safety management at the time and formulated “Achieving Railway Safety into the Future,” which outlines what we should hand on as a compass for safety in the future. This was announced in March 2021.

Points to reflect on, and their background:

At the time of the accident, JR-West had not put in place systems to identify and deal with risks when planning and implementing management policies, and we did not have an ATS (Automatic Train Stop) system with speed check functions installed on the curve where the derailment occurred. Moreover, our understanding of human factors was insufficient, and we had reeducation measures in place that were seen as being punitive. Further, there were problems within our organization, including stagnating technical capabilities and a decreasing awareness of safety, As this shows, at the time of the accident, there were a slew of issues in every aspect of our safety management, and we had been unable to build a company-wide framework for ensuring safety and establish a corporate culture in which safety is the highest priority. We have deeply reflected on our failure to fulfill our responsibilities as a company entrusted with the lives of our passengers.

The place where the Fukuchiyama Line accident occurred holds great importance. It recalls the sorrow felt by those who lost their lives, the grief of their families, and the painful memories of those injured. It also preserves traces of the aftermath of where the train derailed and crashed. It is thus the site of Memorial Grove, which serves as a place to remember and lay to rest the souls of those who perished, while also leaving a record of the accident for those who come after. The site will keep the accident from being forgotten and will convey the preciousness of life to society and future generations. It will help JR-West reflect on the accident and will act as a physical pledge to ongoing safety as the company continues to carefully and responsibly preserve the site for all future generations.

In order to never forget the Fukuchiyama Line accident and to build a corporate culture that prioritizes safety above all else, we have made the 25th of each month Safety Day to mark the accident’s occurrence on April 25, 2005. Company-wide activities are held on this day. Besides visiting Memorial Grove, employees of each workplace plan and implement a range of activities, including first-aid training for customers, discussions among employees in different jobs, viewings of interviews with victims of the accident, and talks by employees who were there at the time.

Abstracted by Mr. Wang Guangyuan

Department of International Cooperation and Rescue, Ministry of Emergency Management, China