Notes about the derailment of the Rapid Up train “5418M” on the Fukuchiyama Line between Tsukaguchi and

Amagasaki Stations, Amagasaki City, Hyogo Prefecture, Osaka, 25 Apr. 2005

107 dead (including the driver), 562 injured, for a grand total of 669 (including the driver)

1. A condensed history of the Japanese railway system

i. “Japan’s first steam train ran in 1872 as a potent sign of the nation’s emerging
modernity, and now 7.2 million people ride on some of the country’s 17,000 miles of
track every day.” (Denver Post, 27 Apr. 2005)
1. The specific date of the first Japanese railway service is 12 June 1872, during
the Meiji Restoration Era
a. The idea of a Japanese railway was floated mostly by foreigners, but
also by some Japanese government officials
i. “In 1869, Harry Parkes, the British Minister to Japan,
advocated that railways would help modernize Japan,
insisting that the government build them as soon as possible.
1869 was another poor year for the rice harvest in Tohoku
and Parkes explained that railways could carry rice quickly
from other areas to Tohoku thereby minimizing the effects of
famine.” (Aoki, 1994, pg. 28)
b. The construction of the first Japanese railway happened between
Tokyo, the capital, and Yokohama, one of the few Japanese ports open
for international trade at the time
i. Surveying began in Apr. 1870
ii. This was a 29 km distance (approximately 18 miles) and
construction began in Sept. 1871
c. There was a fair bit of opposition and corruption in the beginning
stages
i. The person that Parkes hired to help finance the railway and
hire contractors, Horatio Nelson Lay, was trying to turn a
profit of 3% on the bonds (he signed a contract with the
Japanese government at 12% interest but was selling the
bonds at 9% interest). “This led to distrust and the Japanese
government consulted the head of the Yokohama branch of
the Oriental Bank (a British bank) with the result that the
government terminated the contract with Lay, and appointed
the bank as its representative in London.” (Aoki, 1994, pg. 28)
1. The opposition to the railway came from the
Japanese military and also from the Japanese
people, who didn’t like the idea of foreigners
building what they saw as a strange foreign tool
a. Remember, this was not even two decades
since Commodore Matthew Perry had
forced Japan to open its ports to the world
(8 July 1853)
b. Japanese people were still very isolationist
at this point in their history
d. 12 June 1872: Two daily train services started running between Tokyo
and Yokohama
i. Opening ceremony was on 14 Oct. 1872 and was attended by
the Meiji Emperor, who made a round trip on the train
between the two terminals
 ii. It took 35 minutes from one terminal to the other and the
trip had four stations, including the terminals
iii. Freight services on the line started on 15 Sept. 1873
iv. Under government control, specifically the Ministry of Public
Works
e. 25 Aug. 1870: Surveying for a line between Osaka and Kobe begins
i. 11 May 1874: Regular service begins
1. Responsible for the first wrought-iron bridge and
railway tunnel under a river in Japan
ii. 1876: Line was extended to Kyoto
iii. 1880: Extended again, this time to Otsu
1. This section included the Osakayama Tunnel, which
was the first mountain tunnel built in Japan and also
the first tunnel in Japan that was designed and built
by Japanese engineers
ii. 1880: The railways were mostly privatised by the new curtailment policy
1. The massive influx of foreign technology into the Japanese economy and the
Japanese treasury printing more money to combat inflation only made inflation
worse
2. Former samurai were rioting in the streets
3. 1881: Nippon Railway authorised to run between Tokyo and Tohoku, making it
the first privately owned railway service in Japan
a. There were a lot of foreigners in the country helping to build the
Japanese rail system, but the number of foreigners fell after 1874 and
especially under the curtailment policy of 1880
i. During the years between 1874 and 1881 the foreigners
trained Japanese engineers in techniques and technical
knowledge
ii. By 1880 there were enough Japanese engineers to replace
the foreign engineers when it came to engineering tracks and
stations, but foreign engineers still helped design railway cars
and locomotives into the 1890s and some stayed as late as
the early 1900s
4. 1895: First street car in Japan starts service in Kyoto
iii. In 1906 the railways were nationalised again, though private railway lines still existed
1. This was mainly because of complaints by the military during the Russo-
Japanese War of 1904-5 that the mix of privately-owned railways contributed
to the delay in troop and supply movements to the war front
2. The Railway Nationalisation Act of 1906 nationalised all major railways
3. However, the Japanese government didn’t have enough money to expand the
railway networks and so 3 Aug. 1910 they passed the Light Railway Act, which
encouraged private railway companies to take up the slack when it came to
bringing train service out into the countryside
iv. 1927: the first underground was introduced in Japan
1. Literally just called the Tokyo Subway
v. World War II: “Though Japan opened Kanmon tunnel that connected Honshu and
Kyushu in 1942, Second World War caused severe damage to Japanese railways.”
(Orient Rail Journeys, 2020)
1. Military transport increased while civilian transport was cut back
vi. After World War II the Japanese rebuilt their railway system
1. 1956: Electrification of the Tokaido main line was completed
2. 1964: The first shinkansen line between Tokyo and Shin-Osaka was opened
3. 1975: All steam locomotives were retired from Japan National Railway service
 vii. The Japanese railway system was mostly government run until 1987, when it was
completely privatised and sold off to six different companies
1. National Japanese Railways had run up $85 billion in debt and sold off
everything to repay the debts
2. West Japan Railways Company (hereafter known as JR West) was one of the six
companies formed by this privatisation on 1 Apr. 1987
a. 21 July 1989: They started operation of the Twilight Express
i. Ran from 1989 to 2016 and was basically a railroad hotel
with sleeper cars
b. 20 Aug. 1990: They started using ATS-P on the line between Tennoji
and Otori Stations
c. 1 Oct 1991: They purchased the Sanyo Shinkansen facilities from
Shinkansen Holding Corp.
d. 17 Jan. 1995: The Great Hanshin Earthquake, aka the 1995 Kobe
Earthquake, killed over 6,000 people and cost more than $100 billion
in damages
i. It also caused major damages to JR West’s railways, such as
the Sanyo Shinkansen Line and the JR Kobe Line
ii. The JR Kobe Line was reopened on 1 Apr. 1995
iii. The Sanyo Shinkansen Line was reopened on 8 Apr. 1995
iv. 28 Apr. 1995: JR West introduced the Urgent Earthquake
Detection and Alarm System (aka UrEDAS)
v. 28 Apr. 1998: JR West introduced the Earthquake Early
Warning Systems on all lines
viii. Train accidents with a death toll aren’t common in Japan, but they do happen
1. 15 July 1949: Six people were killed and 20 injured when an unmanned
runaway train ran over the track-end bumper and crashed into Mitaka Station.
The right-wing government blamed the crash on Japanese leftists and
communists even though it was a complete accident.
2. 9 Nov. 1963: A freight train collided with a truck and then was T-boned by two
passenger trains from opposite directions in Tsurumi near Tokyo. 161 people
were killed and 120 were injured.
3. “In December 1986, an out-of-service train plummeted off the Amarube
railway bridge onto a factory along the Sanin Line in Hyogo Prefecture. The
train’s conductor and five factory workers were killed. Strong winds were
blamed for the accident.” (factsanddetails.com., 2012)
4. 14 May 1991: In Shiga Prefecture a JR West train collided with a Shigaraki
Kogen Railway train on a single-track railway. 42 were killed and over 600 were
injured. On the JR West website the incident is little more than a footnote, and
JR West did not claim responsibility until 2003.
2. Timeline of derailment
a. Map of the area where the derailment took place
 i. 08:53: Driver Takami Ryujiro got to the end of the rapid train line at Takarazuka Station;
he ran a red light and the ATS-P stopped the train. He went to the other end of the train,
switching with 42-year-old conductor Matsushita Masatoshi for the return trip to
Amagasaki Station. The train left Takarazuka Station 15 seconds late.
ii. 09:11: Stopped at Kawanishi-Ikeda Station to take more passengers on
iii. 09:13, Itami Station: A speeding alarm sounded in the carriage as Takami was pulling
into Itami Station. Matsushita prepared to deploy the emergency brake but Takami beat
him to it. The train still overshot the platform by two carriage lengths (approx. 131 ft)
and had to back up but overshot the back of the platform by 3m, which delayed the
train by 90 seconds.
1. College student Chatani Tomokazu, 19: “I never felt a train brake as hard as
that one did at Itami Station. Ever.” (Seconds from Disaster, S 6 Ep 5)
iv. 09:16: Train left Itami Station 1 min 30 sec behind schedule
1. Multiple witnesses noted that the driver seemed to be in a hurry and that the
train was violently shaking and rattling
2. Just after leaving Takami got on the inter-train phone with Matsushita and
asked him something along the lines of “Will you overlook (my mistake)?”
a. Matsushita was going to answer but was interrupted by a passenger
tapping on the glass to complain about the delay and demand an
apology announcement and so he put the phone down
i. Later in an interview he said that Takami might have thought
“The phone was hung up because the conductor is mad”
(ARAIC, 2007, pg. 41)
3. Right after Matsushita hung up he made an apology announcement to the
passengers, which went out over the train’s intercom
4. Then he called the train dispatcher to report the overrun
a. According to the testimony of the train dispatcher as well as the logs
in the black box, Matsushita said that the train had overrun by 8 m
and was “one minute and a half late”. The dispatcher was confused
because the “crew generally says ‘1 minute 30 seconds late’”.

Dialogue from Fig 24 of the Aircraft and Railway Accidents Investigation Commission (hereafter referred to by the
acronym ARAIC) report (the entirety of which lasts about a minute)
[CALLING TONE]

TRAIN DISPATCHER: This is control, over.

MATSUSHITA: This is the conductor of 5418M over.

TRAIN DISPATCHER: Conductor of 5418M, please go on.

MATSUSHITA: Uh, the train overran. The train stopped at about 8 m beyond the rear limit marker, and… with the
driver… Uh, discussed and reversed the train. Uh, we left the station one and a half minute behind schedule.

TRAIN DISPATCHER: The train stopped at about 8 m beyond the rear marker. Uh, the train reversed, and let
passengers get on and off. Uh, regarding the delay, how many minutes? Over.

MATSUSHITA: Uh, one and a half minute. Over.

TRAIN DISPATCHER: Delay of one and a half minute. Uh… Well then. Can I speak again to the driver of 5418M?
Over.

(Around this point (09:18:55) is where the derailment began, according to Fig. 24 in the excerpt of the ARAIC
report. The TRAIN DISPATCHER did try to contact Takami four seconds later, but by that time the derailment and
collision with the apartment building had already happened and Takami was either instantly killed or dying.)

i. Train dispatcher: “When I heard the delay was 1 minute 30

seconds, I figured it might contain a delay consequent upon
the boarding and alighting of passengers at the station, but I
never imagined the conductor of the accident train had
reported a shorter distance than the actual one.” (ARAIC,
2007, pg. 13)
v. 09:18: Express train didn’t stop at Tsukaguchi and so Takami sped through at 120 kph
(74.6 mph)
v. 09:19 near end of morning rush hour
1. Train was supposed to arrive at Amagasaki Station at 09:20 so that passengers
could make their connecting train at 09:23
2. Takami took the right 304 m turn just after Tsukaguchi Station at 116 kph
a. By this time he had made up 30 seconds and so was only behind by 1 minute
b. Takami applied the service brakes 4 seconds before he entered the turn instead of the
emergency brakes, possibly because he had to report the usage of the emergency
breaks and he could potentially get a warning from the company if it turned out
emergency brakes weren’t needed, but even if he had applied the emergency brakes it
would’ve been too late
3. The first two carriages tilted on their left wheels and then jumped the tracks
about 200 ft from a 9-story apartment building at the address of 3-27 Kukuchi
that was right next to the track
a. Sliced through a white car and injured one passerby before plunging into the apartment
building
b. The 1 carriage of the train plunged into the basement parking garage of the apartment
st

building and the front part was crushed by the impact with the back wall of the parking
garage while the back part was partially wrapped around the support of the apartment
building by the force of its collision with the building and the 2 carriage; the 2 carriage
nd nd

wrapped itself around the back of the 1 carriage and a support pillar of the apartment
st

building in an L shape with the bogies (the framework that holds the train wheels and
connects to the undercarriage) facing outward, the carriage was almost completely
 flattened, crushed between the apartment building, the back of the 1 carriage, and the
st

3 carriage; the 3 carriage was severely damaged, crushed in the middle by its impact
rd rd

with the 2 carriage; the 4 carriage was off the tracks but comparably less damaged
nd th

than the first 3 carriages; the 5 car derailed slightly but was not severely damaged;
th

carriages 6 and 7 remained on the tracks

4. “Survivors said the force of the derailment sent passengers tumbling through
the inside of the cars. Photos taken by an NHK reporter aboard the train
showed passengers piled on the floor and some clawing to escape from the
busted shells of the cars.” (CBS News, 25 Apr. 2005)
5. Akashi Tatsuya (survivor): "I didn't know what happened, and there were many
people bleeding. There was a violent shaking, and the next moment I was
thrown to the floor ... and I landed on top of a pile of other people." (The
Guardian, 25 Apr. 2005)
6. Ogura Satoshi, 35 (survivor): “It was so quiet at first, you couldn’t imagine
anyone else was alive. There was one person, she was right in front of me. She
said ‘My child is here; please find my child.’ After a little while, I got the
impression that people were starting to move. After enough of them had
moved, I was able to free my leg. I pulled out a train seat off my leg, and after
that I was able to free my leg easily. […] [After saving the child of the woman
searching for her] Of course it’s wonderful the child was saved, but in that
situation people survived purely by chance.” (Seconds from Disaster, S 6 Ep 5)
7. People who were living in the apartment building reported a loud boom that
sent everyone at home into a panic
a. “‘There were people everywhere covered in blood - too many of them
to count,’ said Ayumi Tanaka, 36, who along with other residents of
the building have since been temporarily staying at a hotel.” (Sydney
Morning Herald, 28 Apr. 2005)
8. Images of the derailment: https://www.cbsnews.com/pictures/japan-train-
derailment/14/
3. Aftermath
i. Rescue efforts
1. Accident was recognised by the Amagasaki City Fire Dept at 09:22 and the first
rescuers were on the scene by 09:24
a. First report of the accident was from a resident of the apartment building: “It
appears that a train has derailed and rolled.” (Amagasaki City Fire Dept.
Powerpoint, pg. 7)
2. Rescuers didn’t realise that the first car was buried in the parking garage and so
initial rescue efforts started at the front of the second carriage
a. The first carriage was crushed on both ends with a pocket in the middle
3. Rescuers were severely hampered in the parking garage under the apartment
building because the first train carriage had crashed through the back wall of
the parking garage and damaged a lot of cars. Some of them were leaking fuel
so there was cause to fear an explosion
a. Dr. Akitomi Shinji: “I remember it was very hot, and fuel was leaking from the
cars in the parking space. Reinforcement steel was exposed and there was
shattered glass everywhere. Iron frames were bent and the edges were as
sharp as knives. It was very dangerous as soon as I entered. It looked like all
those things could fall on you at any time, and also evaporated gasoline could
catch fire and explode at any moment.” (Trapped, S 1 Ep 6)
b. “There was concern that the carriages lost [their] strength due to the crash-
causing danger for rescue activities.” (Amagasaki City Fire Dept PowerPoint, Pg.
10)
c. “Operations were restricted by gasoline leaks.” (Amagasaki City Fire Dept.
PowerPoint, Pg. 10)
4. 09:41: Tenants and rescuers created a makeshift treatment centre for injured
passengers in the lobby of the apartment building while the rescuers worked in
and around the carriages
a. Helped by doctors from Shiga University of Medical Science Hospital who
specialised in working in cramped conditions
b. Dr. Akitomi Shinji: “I believed the rescuers would need us, that we’d be able to
help them.” (Trapped, S 1 Ep 3)
5. Rescuers created fixed supports on the first floor of the apartment building and
on the crushed train itself in order to carry out rescues from the cars outside of
the apartment building
a. They also used temporary steel supports to shore up the building column that
the first and second carriages were wrapped around, as they didn’t know how
much the crash had structurally compromised the apartment building
6. Rescuers used CSRM (Confined Space Rescue Medicine) to help keep survivors
trapped in the carriages alive and as safe as they could under the circumstances
until they could be rescued
a. Worried about the onset of crush syndrome
i. “Also termed rhabdomyolysis, involves a series of metabolic changes
produced due to an injury of the skeletal muscles of such a severity as
to cause a disruption of cellular integrity and release of its contents
into the circulation.” (National Library of Medicine, 2010)
1. Basically when cells are crushed for an extended
period of time, when the object crushing the victim
is removed the cells release a bunch of chemicals,
including myoglobin, phosphate, and potassium.
These chemicals are essential for cell function but
when released into the circulatory system in large
amounts, as they would be in a massive crush injury
situation like a train crash, they can be toxic.
2. Symptoms include but aren’t limited to kidney and
renal failure, cardiac arrest, nausea and vomiting,
and hypovolemic shock (when the volume of the
circulatory system is too condensed to allow
adequate circulation; caused by severe trauma or
severe dehydration)
ii. Doctors working with the rescuers had infusions to try and
prevent the onset of crush syndrome, such as Meylon (a
solution with sodium hydrogen carbonate) and saline drips
7. 99 of 107 deaths were in the first two cars
a. Most victims’ bodies were so damaged that they were unidentifiable
8. “’The possibility of finding more survivors is getting lower now, but we will
continue our operation as long as there is a possibility,’ said a fire department
spokesman in Amagasaki, a western industrial and commuter town.” (Al
Jazeera, 26 Apr. 2005)
a. Rescuers were using a computer programme to detect heartbeats and
breathing patterns
9. Hayashi Hiroki was the last person pulled from the rubble alive on Tuesday
after surviving in the wreck for 22 hours
10. While recovery efforts took place a few rescue workers reported the eerie
ringing of victims’ phones across the crash site
 a. One rescuer, Sato Koji, reported hearing phones ringing 10-20 times, then
stopping for a moment, and then ringing again. Some of the phones indicated
that the calls were coming from “home”
b. “Sato, 43, told the Yomiuri Shimbun he was tempted to answer a phone but
stopped himself. ‘I didn't know which one belonged to whom, and there was no
way I could tell the callers if the holders were okay,’ Sato told the daily.” (The
Age, 28 Apr. 2005)
11. 29 Apr. 2005: The body of Takami Ryujiro was recovered from the front of the
train
a. Still in his uniform with hand on the brake
b. Rescuers called off the search for any more survivors, with one person from the
fire department citing “no visible sign of survivors” and another saying “The
search for victims is finished. Police are now doing an investigation and our
rescue operation is suspended unless the police need our help.'' (Sydney
Morning Herald, 30 Apr. 2005)
12. 30 Apr. 2005: A woman pulled from the wreckage died in the hospital, bringing
the death toll to 107
13. Many rescuers were treated for PTSD because of the horrific state of the crash
a. A team of 7 psychiatry experts was dispatched for the police and firefighters
who attended to the scene (24 rescuers, 7 ambulance crews, 4 firefighters total
treated)
b. Many of the apartment building residents also suffered from PTSD
afterward
14. After the wreckage was removed the Fukuchiyama Line reopened in June 2005
ii. Subsequent train crashes
1. These incidents, combined with the Amagasaki derailment, shattered the view
that many people had of the Japanese rail system being one of the safest in the
world
a. 26 Apr. 2005: Passenger train hit a trailer truck at a crossing in Nimori
and then jumped the tracks
i. Truck had a broken wheel and tried to warn the train but the train was
unable to stop in time
ii. Driver of truck was severely injured but survived, and no one
on the train was hurt
b. 27 Apr. 2005: Car hits a moving passenger train near Tokyo
i. Broke through the railway crossing bar and ploughed into the 4 car of
th

an 8-car train
ii. Driver of car, 70, was severely injured but survived, and none of the
130 people on the train were hurt
iii. This was the third accident involving a train in as many days
iii. Investigation into the incident
1. On the day of the accident ARAIC put together an investigation committee
composed of 1 investigator-in-chief and 4 railway accident investigators, which
grew to 12 railway accident investigators by Feb. 2006. In addition they
appointed Professor Suda Yoshihiro of the Centre for Collaborative Research at
the University of Tokyo as an expert adviser.
2. “The authorities swarmed eight offices of JR West on Tuesday, carting away
cardboard boxes of documents in their investigation into possible professional
negligence.” (Al Jazeera, 27 Apr. 2005)
a. JR West suspected of professional negligence, both because of company
policies and because of the driver’s actions that led to the crash
3. “Government investigators examining the accident site said they had found
the train's ‘black box,’ a computer chip that stores information about the time
 and train's speed in the final seconds before an accident. They said the
contents would take time to analyze.” (China Daily, 27 Apr. 2005)
4. Kitagawa Kazuo, former Minister of Transportation, talked about making JR
West change its training programmes after the investigation concluded
a. “‘The driver had only 11 months of experience and we can only say
that JR West's employee training and its tests to evaluate the
suitability of drivers had problems,’ Kitagawa said in Parliament. ‘I
would like to issue instructions to them based on the results of our
investigation.’” (NBC News, 24(???) Apr. 2005)
i. The article seems like it comes from the 28 or the 29 of April
th th

2005 given the sequence of events written in the article but

I’m not entirely sure since the article is dated to the 24 .
th

b. He also talked about having a new train driver certification programme

that was given by the state instead of the railway companies
i. "I wonder if we should be leaving driver qualification to train
operators […] Perhaps the Government needs to be more actively
involved in driver qualification and training." (Sydney Morning Herald,
30 Apr. 2005)
ii. At the time a state exam was required for aeroplane pilots
and ship captains to operate commercial flights and vessels,
but the same was not required for railway drivers.
5. After the fire department made a final check for any survivors they turned the
carriages over to the police department, who took the carriages to a
warehouse for investigation
a. Reports say there were still pieces of bodies inside the mangled carriages
6. Tests by the investigators, some of which were done using a dummy train, were
able to prove that the first carriage of the train was going at least 105 kph
around the 304 m curve, which was the maximum speed at which derailment
could possibly be avoided
a. So essentially at 106 kph is when derailment of the first car would become
inevitable.
7. Surveys were also sent out to drivers of JR West regarding multiple topics
related to the investigation
a. On a survey about the correlation between delay time and
psychological stress they asked 51 drivers about how willing they
would be to recover the delay at certain times
i. Most drivers said that they would not recover a delay if it exceeded
three minutes
ii. All drivers who were surveyed indicated that the reason for their
stress was in some way or another related to the inflexible time
schedules that the railway companies ran on
iii. “At the time of the questionnaire, many train drivers added
that they recognised the critical overturning speed to be tens
of kilometres higher than the speed limit of 70 kph, and that
they would never intentionally run the train at tens of km
higher than the speed limit no matter how hasty they are.”
(ARAIC, 2007, pg 40)
b. All of these surveys plus the observations of Takami in the minutes
leading up to the accident indicate that he was running the train at
120 kph unintentionally and didn’t realise his error until it was too late
because he was paying attention to the communication between
Matsushita and the train dispatcher and probably very worried about
being sent to Nikkin Kyoiku again.
 i. According to the ARAIC report: “As mentioned in the statement of the
train conductor […] that the train driver of the accident train had no
idea of what is happening in the seventh car [where Matsushita was
stationed] and he may have figured, “The phone was hung up. The
conductor is mad,” it is considered that the train driver of the accident
train had no idea of the complaint from the passenger. Accordingly,
taking that his on-train telephone asking for a false report was turned
down by the negative response ‘It was some overrun,’ he was likely
paying special attention to the apology announcement and
subsequent communications between the conductor of the accident
and the train dispatcher.” (ARAIC, 2007, pg. 42)
ii. “Also, the train driver of the accident train, who had gone through
retraining 3 times for 18 days […] and been given reprimands, etc. 4
times […] may have been looking for an excuse, etc. worrying about
the possibility of retraining […].” (ARAIC, 2007, pg. 42)
iii. “[…] There was a red pencil in the driver’s cab, which is
believed to be a possession of the train driver of the accident
train, [and the driver did not have a glove on his right hand
when found,] (and […] it is prescribed that when the train
driver of the rapid train ‘receives an operation notification by
a radio, etc during train operation,’ ‘he is basically required to
stenograph required matters on an expedient sheet of paper,
portable timetable, etc. and write them in the predetermined
Operation Notification Receipt after stopping at the next
stop.’)” (ARAIC, 2007, pg. 44)
8. After tests and research the investigators also found that in some 207 series
train cars (the type of train car that was involved in the accident) the brake
handle would sometimes get stuck between the regular brake notch and the
emergency brake notch
a. It’s possible, given this information, that when Takami finally realised
his mistake he was trying to use the emergency brake but was unable
to because the brake handle got stuck and so this delayed the usage of
the emergency brake until it was already too late.
4. Causes of derailment, actual and debunked
i. Rocks placed on the rails (debunked)
1. This was their first theory on what might have happened
2. This had happened before in 1980 when 5 boys in junior high placed concrete
on the tracks of the Keihan Line (linking Kyoto and Osaka). The subsequent
derailment destroyed a few houses next to the tracks, injured many people,
and ended with the parents of the boys being sued for ¥61,441,590 (or
¥214,377,461.69 in 2022) (equivalent to $490,000 USD in 1980, or
$1,709,671.84 USD in 2022)
3. There was evidence of pulverised ballast (the rocks that go under the train
tracks) on the rails so at first they thought vandals might be the cause
4. No evidence of rocks deliberately placed on rails by vandals
5. Only evidence of rocks on the rails was ballast kicked up from the tracks by the
train during the derailment
ii. Driver: Takami Ryujiro, 23 (can’t find picture)
1. At first JR West tried to only focus on Takami’s errors
a. “After the incident, JR West focused on the behaviour of the train driver, who
reportedly drove the train beyond the designated speed limit and did not
operate the train properly [...]. In this regard, JR West presumed that the
incident was caused by human error, particularly active errors associated with
 the performance of the ‘front-line’ operators of a complex system [...].”
(Chikudate, 2009, pg. 1268-9)
2. 11 months experience
3. Joined JR West right out of high school on 1 Apr. 2000 and got his train
operator’s licence on 18 May 2004
4. Had previously received warnings for being late (by company after he overran a
station in June 2004) and for looking inattentive at his job (from passengers)
a. Warning for overshooting the station involved 13 days of “re-
education”, during which he complained to a friend that “I must write
text all day long and need permission even to go to the toilet” (Atsuji
et al., Mar. 2013)
i. “The record of Takami’s re-education program was written by
his superiors and comprise 10 pages, the sources said. On
June 8, Takami overshot a stop line by 100 meters at
Shimokoma Station on the Katamachi Line in Seikacho, Kyoto
Prefecture, when he was operating a rapid train bound for
Kizu Station from Sasayamaguchi Station. Due to this mistake,
he was suspended from regular duty and ordered by the
office head to undergo the program starting the next day. […]
Three instructors, a deputy station master-level official and
two subsection chiefs, repeatedly asked him why he had
overshot the stop line and what he would do in future to
prevent a recurrence. Takami answered that his behavior
lacked proper regard for safety and he had not fulfilled his
responsibilities as a driver. Takami also was asked why his
train was late by 10 seconds when it arrived at Shimokoma
Station. He answered that a large group of primary school
children on a school trip had boarded the train at Miyamaki
Station, the station before Shimokoma Station, and had been
slow in boarding, causing a delay of more than 10 seconds. In
response, the superiors criticized him for failing to make up
for the delay. In the essays, he simply admitted that he was at
fault, saying, ‘I’ll try to improve my driving.’ He did not
attempt to defend his actions. Takami, who became a driver
one month before the re-education program was ordered,
had his year-end bonus cut.” (Sun Journal, from the Yomiuri
Shimbun, 22 May 2005)
1. A fellow driver noted his severe depression after this
re-education period was up
b. No one knows for sure, but the ARAIC investigation report hypothesises that he
was probably rushing because of the fear of Nikkin Kyoiku. (Yomono Osamu (VP
of Japan Confederation of Railway Workers’ Unions): "I believe he desperately
wanted to recover the lost time and escape punishment. Fear prevented him
from making a rational judgment.") (The Guardian, 28 Apr. 2005)
5. Was driving the train at 116 kph at the time of the accident
a. According to the ARAIC report, it’s highly unlikely that he was
intentionally doing so and it’s theorised that he unintentionally went
40 kph over the speed limit because he was distracted
i. Not known whether he was distracted by the communication
between the train conductor at the other end of the train and
the train dispatcher or by trying to come up with an excuse
for accidentally overshooting Itami Station by “8 m”
 1. It’s possible Matsushita downplayed the amount
overrun because as an experienced JR West
employee he knew the severity of the punishment
that Takami might get for overrunning and he knew
how anxious Takami must be.
b. According to a friend, he told them that he’d been taught by other
drivers to speed along certain places on the track and delay brake
usage until the last minute if he needed to make up time
6. “According to the forensic examination, he had not taken alcohol, medication
or other drugs, and there was nothing notable about his medical records
[according to the ARAIC report]. Furthermore, psychopathic indications were
not found [...].” (Chikudate, 2009, pg. 1275)
iii. JR West
1. Japanese trains are very punctual; drivers were pressured to make sure they
were exactly on time to the second, especially during rush hour
a. “To many, the driver's single-minded focus on making up the 90
seconds seemed to reveal the weak points of a society where the
trains really do run on time, but where people have lost sight of the
bigger picture.” (Herald Tribune, 27 Apr. 2005)
i. “‘Japanese believe that if they board a train, they'll arrive on
time,’ said Yasuyuki Sawada, a 49-year-old railway worker,
who had come to look at the crash site. ‘There is no flexibility
in our society; people are not flexible, either.’” (Herald
Tribune, 27 Apr. 2005)
b. JR West known to be especially strict with drivers about time
schedules
i. Japan Confederation of Railway Workers’ Unions VP Yomono Osamu:
“The accident is a result of JR West’s ... high-pressure management,
which uses terror to force its employees to follow orders.” (World
Socialist Website, 11 May 2005)
ii. Early Apr. 2005: JR West issued statement to employees that “delays
would betray customers’ confidence” (Herald Tribune, 27 Apr. 2005)
iii. JR West was the only one of the railway companies in Japan that
linked pay raises to performance
1. Good performance got a raise, bad performance
could see your pay reduced
iv. At the time of the accident they had a programme called
Nikkin Kyoiku (trans.: Day Shift Education)
1. Held at the main office every day during normal
working hours (09:00-17:45)
2. Often described by employees who had to go
through it as punishment and psychological torture
3. Instead of improving the drivers’ technical know-
how in order to help them not make the same
mistakes again offenders were forced to cut grass,
clean toilets, and stand on the platform wishing
other drivers a safe journey as a way to humiliate
them, among other arbitrary punishments
a. “One driver [Nakao Takuya] was made to stand on a
platform in his uniform, greeting trains as they
arrived and wishing the drivers a safe journey.”
(World Socialist Website, 11 May 2005)
b. “The tactics behind these practices effectively
exploited the Japanese concept of haji or shame and
embarrassment, rather than the Christian concepts
of sin and guilt. Standing on the platform or weeding
may appear as daily station maintenance duties in
the eyes of commuters and outsiders, but these
practices appear as signs of failure in the
intersubjectively shared lifeworld of JR West
members. [...] By being exposed to the public eye
within a relatively limited social space where the
identities of the subjects are disclosed and known to
each other, such concepts are sustained and
enforced among the Japanese. Public humiliation
degrades one’s reputation in a relatively limited
social space.” (Chikudate, 2009, pg. 1280)
4. Punishments also included writing endless self-
reflective essays about their mistakes
a. Takami had been forced to write 19 essays about his
overrun in June 2004
b. Another driver talked about how these essays
worked: “The writing started with a chronological
description of my mistake and proceeded to a
description of the cause of the mistake. For example,
if I wrote, ‘Human beings are creatures that tend to
take the easiest route… however, we need to
prioritize safety in every way if we take our duty
seriously’ in the first essay, then the assigned topic
for the second essay was, ‘Why are human beings
creatures that tend to take the easiest route?’ Such
revolving topics in essays continued endlessly.”
(Chikudate, quoting the JCRWU report, 2009, pg.
1280)
5. Verbal abuse, insults, and beratement from higher
ups, being forced to admit their own
“incompetence”
a. Pressure and humiliation had led to some
rail workers committing suicide
i. “One, Masaki Hattori, was reportedly
placed in a tiny office and continuously
yelled at by managers after he made an
unscheduled 60-second stop to conduct
routine safety checks in 2001. At the end of
the third day 44-year-old Mr. Hattori, a
driver with 20 years on the job and a
hitherto unblemished record, told friends
he was near breaking point. He was found
hanged at his home the following day.” (The
Guardian, 28 Apr. 2005)
ii. His family lost their lawsuit against
JR West in Nov. 2006 and the high
court said that many drivers
actually found Nikkin Kyoiku
appropriate
 b. Was incredibly punitive
c. Drivers were forbidden from carrying out
their normal duties and were not told how
long “re-education” would last
i. JCRWU chief secretary Yasuda
Masashi: “I think it can be said that
it violates the rights of the driver
who caused the accident and that
it’s bullying.” (Seconds from
Disaster, S 6 Ep 5)
d. In Chikudate Nobuyuki’s article “If human
errors are assumed as crimes in a safety
culture: A lifeworld analysis of a rail crash”,
he says about this sort of “safety” culture
that “there was a certain incubation period
in which disaster-provoking events
accumulated because they were ignored or
misinterpreted as merely a result of habit
and routine, false assumptions, poor
communication, disregard for rule and
instructions and misplaced optimism.”
(Chikudate, 2009, pg. 1269)
i. Essentially, there was a long period
of time without an incident and so
JR West thought the way they
were doing things worked and
refused to think otherwise, even
though there was evidence to the
contrary.
c. JR West said that it strived for a safety culture, but with the term
safety culture “though achieving a perfect safety culture is ideal, the
acquisition of the safety culture itself is a process of collective
learning.” (Chikudate, 2009, pg. 1270)
i. Instead of the learning being a collective effort, Chikudate
goes on to basically say that JR West was really trying to
eliminate variability in its human employees, especially train
crews, to the point that any variability, such as overruns or
lateness, was met with punishment (Nikkin Kyoiku) instead of
the company taking a look at its own procedures and
amending the unreasonable and unsafe aspects (such as its
unreasonably tight timetable or the fact that Nikkin Kyoiku
focused on the individual’s faults to the point where the
larger problems were overlooked). “Thus, the actual content
of learning practises in the JR West produced subjugation,
humiliation, and traumatic effects rather than corrective
effects [...] on those who experienced them first-hand,”
(Chikudate, 2009, pg. 1282) and therefore the traumatised
drivers would try to hide and make excuses for their mistakes
instead of honestly reporting them.
iv. Rail privatisation in 1987
1. JR West was in constant competition with the other companies who took over
the Japanese railways
a. The Fukuchiyama Line was among its most profitable lines
 i. Achieved by increasing the speed and number of the trains
ii. Amagasaki Station is the connecting point for four different
lines, and a late train on one line could potentially delay
trains on all the other lines
1. This is believed to be one of the reasons that Takami
was speeding
2. Profit incentives could have led to lax safety standards due to reduction in cost
of labour
a. Design of carriages was blamed
i. “In the past, railway carriages were assembled from heavy
steel, which worked to give them more stability. Newer
carriages, however, are being made from less costly,
lightweight stainless steel. Hiroshi Kubota, an expert who
once worked for the National Railways, told the Asahi
Shimbun on May 4: ‘Past railway cars made of steel were
more stable at curves. The derailed train had heavy air
conditioning systems atop the roof of the cars that are just as
heavy as the bottom frames of the cars. That probably
unbalanced the cars and made them prone to topple.’”
(World Socialist Website, 11 May 2005)
b. JR West modified the curve where the derailment took place from a
softer 600 m curve to a sharper 304 m one in 1997
i. They were modifying the tracks to accommodate a new
railway line
c. Braking system
i. JR West uses two different braking systems called ATS
(Automatic Train Stop) systems
1. ATS-SW
a. A type of ATS used specifically by JR West; an older
form of ATS that is placed every 20 m (65.6 ft) in
front of any signal (sign, light, etc)
b. Does not have an onboard speed control mechanism
c. Just gives the drivers a warning that they’re speeding
2. ATS-P
a. Newer form of ATS that includes a pattern
renewal transponder
i. Basically how it works is that the main box
is located 600 m (1968.5 ft) in front of any
signal (lights, signs, etc), with departure,
block, and home transponders placed at
regular intervals within those 600m
ii. Together they collect data about
the train’s speed and send them to
the main box, which can decide to
slow the train down or stop it
completely.
ii. JR West used the ATS-P and ATS-SW alone and together on
some parts of the tracks, but there was no kind of ATS at all
on the curve where the derailment occurred
1. Therefore the warning that the driver was speeding
on the curve didn’t happen, and even if there had
been ATS on that stretch of track it may or may not
have prevented the accident.
v. Consequences
1. The investigators made several recommendations for JR West and the Ministry
of Transportation.
a. One suggestion was for JR West to restructure the re-education
programme to be less punitive, as “it is considered there was
involvement of the Company’s system that the reports of these
incidents, etc. may have led to retraining regarded as a penalty by part
of the train drivers.” (ARAIC, 2007, pg. 49)
i. “In order to grasp the incidents, etc., the Company [JR West]
should not only consider appropriate retraining and
disciplinary actions, but improve a system to recommend
positive reports from the crew, etc. such as developing a non-
punitive report system from a viewpoint of preventing serious
accidents.” (ARAIC, 2007, pg. 50)
b. Another suggestion to JR West basically boiled down to “JR West has
ATS systems installed for a reason; use them instead of just relying on
reports from the crew.”
i. Also, more needed to be installed
c. ARAIC suggested that while it is sometimes necessary for the driver to
pay attention to the radio while the train is running, the driver
absolutely should not be taking notes while the train is running
because “generally, making notes could delay the train driver in
recognising a stop signal from an obstruction warning signal,
hindrance at a level crossing, etc.” (ARAIC, 2007, pg. 52)
i. They also said that the driver should only communicate on
the radio in an emergency and that there should be a device
installed on trains so that the dispatcher can “understand
accurate traffic information at real time” (ARAIC, 2007, pg.
53) and doesn’t have to unnecessarily distract the driver from
the task of operating the train.
d. Another suggestion was to take the Kuha-207 cars out of commission
since the brake sticking was identified as a possible cause of the
accident
i. It had happened on other cars of the same model
ii. The commission also noted that JR West had known about
this deficiency but did nothing about it, and therefore “the
crew could take it meaningless to report and accurately
report an incident, etc. or consider it unnecessary to comply
with the laws and regulations because the Company does
not,” (ARAIC, 2007, pg. 51) basically accusing the company of
creating an atmosphere that prioritised profits over safety.
e. For the Ministry of Land, Infrastructure, Transport, and Tourism the
investigation suggested that they promote positive reporting instead
of negative reporting
i. Basically confirming that there are no problems by asking
instead of assuming that there are no problems because
you’re not being told about the problems that do exist
2. Actions taken by the Ministry of Land, Infrastructure, Transportation, and
Tourism
a. 28 Apr. 2005: The Ministry ordered JR West to come up with a safety
improvement plan, which they did on 31 May 2005
b. 6 May 2005: “Directed railway operators to inspect their train
operation plans to check whether they were appropriate ones in
 which the necessary time margins had been added.” (ARAIC, 2007, pg.
61)
i. JR West responded to this directive by adding an additional
45 seconds to the running time on the JR
Takarazuka/Fukuchiyama Line.
c. 27 May 2005: The Ministry ordered railway companies to install ATS
systems with speed check functions on curves within their service
areas
i. This was done by the end of the fiscal year in 2006
d. 6 Sept. 2005: The Ministry ordered train companies to “inspect their train
protection manuals and repeatedly provide train protection training courses for
their train drivers and conductors.” (ARAIC, 2007, pg. 62)
e. These are only a few of the many actions taken by the government to ensure
that train companies were operating their railway systems up to the
government’s standards.
3. Trials
a. In 2006 258 JR West staff brought a lawsuit against JR West for their
practice of Nikkin Kyoiku
i. 27 July 2011: A judge ruled in the employees’ favours and
ordered JR West to pay a total of ¥6.2 million to 62 of them
1. “Judge Satoshi Nakamura found JR West acted
‘beyond the company's discretion’ when it ordered
staff to clean toilets or cut grass and weeds. ‘It
infringed on personal rights and was illegal,’ the Jiji
Press news agency quoted Nakamura as saying. The
judge also ruled that it was ‘inappropriate as a form
of education’ when JR West ordered an employee to
attend retraining for over five months for running
three minutes late at work, public broadcaster NHK
said.” (Japan Today, 28 July 2011)
b. 6 Sept. 2008: After ARAIC finished their investigations on the
derailment the police turned the case over to prosecutors
i. “Hyogo police said Friday they will hand over to prosecutors early
next week their case against 10 West Japan Railway Co. officials in
connection with a 2005 train crash in Amagasaki, Hyogo Prefecture,
that claimed 107 lives, including the driver. In a rare step, Hyogo
Prefectural Police officials said Friday the next of kin of the dead
passengers were notified of their plan to press charges against 10 JR
West employees for professional negligence resulting in death,
including the late driver, Ryujiro Takami, 23. The police said their move
was in consideration for the sentiments of the families.” (The Japan
Times, 6 Sept. 2008)
1. A lot of family members and survivors were upset
about the amount of time it took for charges to be
levelled and a case to be presented
2. The police also sent letters to the 562 injured to let
them know of the actions being taken against JR
West
ii. Besides Takami, the ten JR West employees against whom charges
were being considered included former JR West president Yamazaki
Masao, who had been a chief safety officer during the time that the
curve where the accident happened was modified, as well as three
 other former presidents of JR West (Ide Masataka, Nanya Shojiro, and
Kakiuchi Takeshi)
1. All former presidents charged had been in some way
shape or form part of the safety operations.
iii. “Since operator died because of the accident, he was not criminally
charged.” (Matsui, 2020, pg. 325, note 159)
iv. It was decided that Yamazaki would be formally charged, but
“the prosecutors declined to file charges against three former
JR presidents who failed to adopt appropriate safety
measures to prevent the derailment [...].” (Matsui, 2020, pg
325, note 159)
1. The court declined to prosecute Ide, Nanya, and
Kakiuchi but they ended up being prosecuted
anyway because of an appeal made by the survivors
and the victims’ families
2. “A Committee for the Inquest of Prosecution, a panel
of citizens tasked with reviewing criminal cases, later
decided twice that the three should be indicted for
professional negligence resulting in death and injury,
prompting their mandatory indictment by court-
appointed lawyers serving as prosecutors.” (Kyodo
News, 13 June 2017)
c. July 2009: Ide, Nanya, and Kakiuchi officially indicted on professional
negligence charges
i. “Prosecutors had sought jail terms for the men, arguing that they had
contributed to the accident by neglecting their duties. Prosecutors also
argued that the men should have taken greater safety precautions,
such as installing devices that could prevent trains from going too fast,
AFP news agency reported.” (BBC, 27 Sept. 2013)
ii. Essentially the prosecutors were saying that the presidents
between the time of the curve being tightened (1997) and the
derailment (2005) had neglected to install ATS on the 304m
curve and had revised timetables on the Fukuchiyama Line to
a shorter run time, which made it harder for the drivers to be
both safe and on time. Therefore, their actions were
negligent and they deserved jail time.
d. Sept. 2009: “Disclosure that there was pressure to leak information
related to the government’s accident investigation”(JR West, 2019, pg.
8)
i. Oct. 2009: Two executives resigned after evidence came to light that
they’d been trying to throw the trial
1. They obtained copies of the report early
2. They were also accused of paying experts to testify
in their favours
ii. 11 Jan. 2012: The court cleared Yamazaki of any wrong-doing.
iii. Sept. 2013: The court cleared Ide, Nanya, and Kakiuchi of any wrong-
doing.
1. “[...] The court ruled that the three men did not have
adequate opportunities to recognise the risks and
were not legally obliged to install such devices [ATS
systems] when the crash occurred, AFP reported.”
(BBC, 27 Sept. 2013)
 iv. The prosecutors of the original case filed an appeal to the
Supreme Court on behalf of the victims and their families in
Apr. 2015
1. Their appeal was thrown out by the top court’s
Second Petty Bench in June 2017
a. “Rejecting an appeal filed by lawyers who served as
prosecutors in the case, the top court's Second Petty
Bench, led by Justice Tsuneyuki Yamamoto, said in
its decision dated Monday that the former JR West
presidents ‘could not have foreseen that the curve at
the site of the accident posed a high degree of
danger,’” (Kyodo News, 13 June 2017) specifically
because there were over 2,000 similarly tight curves
in the area where the derailment occurred
b. Also, at the time of the accident there were no laws
mandating the installation of ATS systems so even
though they didn’t have ATS systems installed on a
lot of curves JR West was still technically exceeding
expectations by having ATS at all.
c. This decision angered the victims and their
families, who wanted to see someone face
justice for their losses
i. “‘I can't understand why the
appeal (made in April 2015) was
rejected all of a sudden after so
long,’ said Hiroshi Ueda, 62, who
lost his 18-year-old son Masaki in
the accident. ‘Despite causing such
a grave accident, the probe into
the cause of the accident was
insufficient and nobody is taking
responsibility. How can we expect
public transportation to ever
become truly safe,’ he said.”
(Kyodo News, 13 June 2017)
4. Restructuring within JR West
a. At first JR West defended their policy of Nikkin Kyoiku vigorously
i. “JR West has begun re-examining the re-education program since the
derailment occurred. But it still maintains that Takami’s reeducation
had been conducted properly.” (Sun Journal, from The Yomiuri
Shimbun, 22 May 2005)
ii. On 2 Feb 2007 during public hearings on the ARAIC report JR
West VP Maruo Kazuoki made the argument that “the utility
of Nikkin Kyoiku was confirmed in a legal trial before [the trial
for Mr. Hattori’s suicide], and I have judged that it is a
necessity to raise awareness and to motivate train drivers.”
b. After the ARAIC report was released criticising JR West for treating
their workers inhumanely, the company revamped their re-education
programme to be more safety conscious and less punitive.
i. From their pamphlet “Strategy of Value Creation for Our
Vision”: “Because JR-West had never predicted an accident of
this great magnitude before, we did not have an ATS [...]
system with speed check functions installed on the curve
 where the derailment occurred and we did not sufficiently
take into account human factors in our employee training and
similar programs.” (JR West, 2019, pg. 6)
1. They also acknowledged that their punitive system
“led to personnel directing their attention toward
covering up and making excuses for errors,” (JR
West, 2019, pg. 6) that top-down communication led
to the individual responsibility being elevated above
the company’s responsibility, meaning that “top-
down communication became excessive and frank
discussion was difficult,” (JR West, 2019, pg. 7) and
that their generally good safety record since their
founding in 1987 had led them to become
complacent and arrogant.
a. “We will strive for dialogue between management,
technical, and operational personnel;
communication between supervisors and
subordinates; and reciprocal collaboration between
specialised fields and between workplaces; and we
will further establish an environment conducive to
each employee reporting safety-related
information.” JR West, 2019, pg. 7)
2. Currently in the “What are ‘human errors’?” section
of their about page for the Research Safety Institute
they emphasise the need for acknowledging human
error without penalising the person.
3. They also have made the 25th of every month a
safety day.
a. “In addition to having study sessions and
cross-departmental discussions on safety at
each workplace, we hold ‘think-and-act’
safety training at the Railway Safety
Education Centre and Memorial Grove
(Inori no Mori) at the accident site for the
purpose of acknowledging the lessons and
points of reflection from the accident, using
those insights in safety improvement
initiatives, and connecting this to the work
tasks of each employee.” (JR West, 2019,
pg.9)
c. In accordance with the requirements of the Ministry of
Transportation, JR West revised their train schedules to add 5 seconds
each to the stop times of Rapid trains at Nakayamadera and Itami
Stations, increasing the stop time at each from 15 seconds to 20
seconds.
i. This came after company acknowledgement that their time schedule
suffered because of “a lack of resilience from minimal leeway built
into the train timetable.” (JR West, 2019, pg. 6)
ii. They also revised the regular running time between the Rapid
train terminals at Takarazuka and Amagasaki Stations and
added 45 seconds for a new total of 16 minutes and 20
seconds.
 d. They were forced by new laws to put ATS boxes with speed check
functions on every stretch of track, including curves
i. Before the Fukuchiyama derailment the number of curves on
JR West tracks with ATS had been 105; after the derailment
the number grew to 1,370 curves
1. 1,195 curves were equipped with just ATS-SW, 96
with just ATS-P, and 79 were equipped with both
e. 23 June 2006: JR West established a safety laboratory
i. JR West safety page: “The Institute promotes research and
investigations from three perspectives: Safety improvements from the
safety management viewpoint, Prevention of human error based on
psychology and physiology, and Prevention of human error based on
ergonomics.”
ii. 3 Apr. 2007: JR West established the Railway Safety
Education Centre
1. As of now the centre includes the remains of the 7-
car train along with safety simulators and the
research laboratories
f. In spite of all these actions taken, it’s clear that JR West still hasn’t
really learned the lessons taught by the Fukuchiyama Line derailment.
i. Something that I find very interesting and telling is their
language in the beginning of their 20 year anniversary review,
which was published in March 2008.
1. “The objective of the privatization reforms was to
revitalize the railway business- to achieve this, we
quickly established an independent and responsible
management system and addressed a wide range of
issues in order to gain the trust of our customers.
However, this was all undone when the Fukuchiyama
Line disaster on 25 April 2005 -costing 106 lives and
injuring more than 500 others- lost the trust of our
customers and Japanese society in general.” (JR
West, 2008, pg. 31)
a. I find it interesting that they say their hard work
“was all undone”, which I feel is indicative of the
company mindset. Instead of them saying “in spite
of our best efforts this accident happened and it
shows us how far we still have to go,” which I feel
would be more contrite and productive, this bit
sounds kind of like “Well we had a profitable system
but then this accident had to go and ruin
everything,” which sounds more like self-
victimisation and trying to push the blame onto an
individual incident in order to try to hide the many
little problems in the organisation of the company
that led to the derailment.
b. Within all the JR West literature I’ve read
I’m constantly noticing how when they talk
about the total count of victims they don’t
include the driver. I can kind of understand
because Takami’s mistakes were the direct
cause of the derailment, but at the same
time when you look at everything Takami
 was just as much a victim of JR West
policies as the train passengers. So in part I
think they might be excluding him from the
victim count as the direct cause of the
tragedy, but I think they’re also excluding
him in an attempt to scapegoat him for
their own poor organisational decisions.
ii. 11 Dec. 2017: Shinkansen train Nozomi 34, run by JR West,
was forced to stop more than halfway through its five hour
run from Fukuoka to Tokyo due to a crack in the
undercarriage
1. Transport Minister Ishii Keiichi to reporters on 19
Dec. 2017: "Besides structural complications in the
ageing equipment, contributing to the spate of
recent incidents is the increasing lack of young
engineers who want to do such jobs." (The Strait
Times, 19 Dec. 2017)
2. The Shinkansen left Hakata Station in Fukuoka for
Tokyo Station 5 hours away, and about 20 minutes
after the start of the trip a conductor noticed a
burning smell
3. As the train approached Okayama Station
passengers complained of the air inside the train
being foggy
4. Maintenance staff at Okayama Station “confirmed
an abnormal groaning sound and insisted that train
service should be discontinued” (Murata and
Karwowski, 2021, pg. 4)
a. However, the Shinkansen general command centre
ignored its maintenance staff and ordered that the
train continue service
b. The train continued service in spite of the sounds
and odd smells. People at Kyoto Station complained
about the smells before the shinkansen was finally
forced to stop at Nagoya Station.
5. When the undercarriage was examined a crack of
approximately 44 cm from one side to the other was
found and oil was leaking from the damaged
undercarriage
a. “The steel frame of the undercarriage was just 3cm
away from snapping into two, train operator West
Japan Railway Company (JR West) said on Tuesday,
admitting that this could have caused a major high-
speed derailment.” (The Strait Times, 19 Dec. 2017)
b. The situation was explained by JR West and the
Ministry of Transportation as a lack of maintenance
on the railways and “added that the problem has
been exacerbated by the many veterans who have
reached retirement age, resulting in the inadequate
transfer of know-how between generations.” (The
Strait Times, 19 Dec. 2017)
c. However, it is obvious that one of the
bigger problems in the context of JR West is
 that they still have a very top-down
communication structure similar to the one
that partially caused the Fukuchiyama Line
derailment
i. “The maintenance staff members
at Okayama Station were unable to
disobey the decision of the general
command center, owing to
asymmetry of authority, [and] the
staff members with the greatest
authority were unwilling to heed
the proposal by the maintenance
and inspection experts, thus
indicating that asymmetry of
authority hindered open
communication regarding the risk
of train crash and the recognition
of the risk.” (Murata and
Karwowski, 2021, pg. 7)
iii. 11 Nov. 2021: A train driver sued JR West for penalising him
for a 2 minute delay on 18 June 2020
1. “The driver says he was scheduled to deadhead an
empty train at the Okayama Station depot that
morning [move it to the depot without passengers or
cargo so that it could be put into service], and was
waiting at one of the station platforms for the train
to arrive. When the train arrived, he realized he was
waiting at the wrong platform, and by the time he
met the driver at the correct platform, the start of
the transfer between drivers was delayed by two
minutes, leading to a one-minute delay in departure
and a one-minute delay in warehousing the train at
the depot. As a result, JR West deducted 85 yen from
the driver’s July pay, saying there was no actual
labor performed during the two minutes when the
transfer was delayed.” (Japan Today, 11 Nov. 2021)
a. He went to the Okayama Labour Standards
Inspection Office, who forced JR West to restore a
minute of his pay
b. However, that wasn’t enough for him since
“the error caused no damage to the
company and [there was] no disruption to
train timetables as the train was empty,”
(Japan Today, 11 Nov. 2021) so in March of
2021 he took his case to the Okayama
District Court
i. “The driver is now seeking
compensation of 43 yen, which
was deducted for the one-minute
delay, 13 yen in overtime created
by the delay, and 2.2 million yen
for mental anguish.” (Japan Today,
11 Nov. 2021)
 c. JR West has countered by saying that he
wasn’t paid for that time because he wasn’t
working, but it looks to a lot of people like
the company is still sanctioning drivers for
being delayed even a little bit by simple
human error
i. A lot of people are criticising JR
West by saying that everyone
makes mistakes, workers are
basically being criminalised for
making mistakes, this is the same
kind of thing that led to the
Amagasaki derailment, etc.
iv. It would seem to me, given the fact that JR West has done a
lot of research and made technological advancements but
still treats its workers like garbage, that JR West seems to be
relying too much on technological advancement and
disregarding its employees except when throwing them
under the bus to save face for the company.
1. “[The problem] is the lack of understanding between
members of the organization, which forbade
questions regarding organisational policy and
objectives and concealed facts. These flawed
traditions and customs led to ‘organizational inertia’.
That is, the organizational climate and culture
reduced the mental horizons of its members, who
were unable to think of anything except their own
self-protection.” (Atsuji et al., 2013, pg. 8)
5. Victims and survivors
i. According to the investigation report released by ARAIC, 106 people died (not including
the driver) and 562 were injured, making for a total of 668 (again not including the
driver)
1. 91 casualties in 1 car (42 dead, 49 injured)
st

2. 32 casualties in 2 car (57 dead, 75 injured)

nd

3. 160 casualties in 3 car (3 dead, 157 injured)

rd

4. 102 casualties in 4 car (no deaths, 102 injured)

th

5. 70 casualties in 5 car (no deaths, 70 injured)

th

6. 58 casualties in 6 car (no deaths, 58 injured)

th

7. 41 casualties in 7 car (no deaths, 41 injured)

th

8. 14 casualties whose car numbers could not be identified (4 dead, 10 injured)

9. There is no comprehensive list of the victims’ names in the press, although the
memorial includes them all on the sculpture in Inori no Mori
a. “Prior to 2005, it was common practice for the police to release the
names of the victims to the press […] Now, the police exercise their
discretion to refuse to disclose the names of victims in exceptional
cases.” (Matsui, 2020, pg. 324-5)
i. This specifically changed because of the Amagasaki derailment
ii. Police didn’t disclose the victims’ names because of the express wishes
of their family members
iii. Obviously this pissed off the press and they complained but
the police held the families’ wishes over the presses
1. “Although victims do not have the right to prevent
the police from disclosing names, the police are
 likely to respect a request of nondisclosure,
especially when there is a compelling reason for
seeking nondisclosure, unless there are overriding
public interests at play.” (Matsui, 2020, pg. 325)
ii. Memorials
1. First memorial put up after the crash was a makeshift shrine near the tracks
where the derailment occurred
a. Built within a few days of the accident
b. People came to pray, burn incense, leave chrysanthemums and lilies,
leave bottles of beer and water
i. Beer and water in Japanese culture are believed to nourish
the souls in the land of the dead
2. On the 10 anniversary of the crash on 25 Apr. 2015 there was no real
th

memorial to speak of, although preparations were being made for the
permanent memorial
a. Survivors and family members got on a train and clasped their hands
and prayed as the train went by at the minute that the derailment
occurred.
i. “‘I cannot believe a period of 10 years has passed,’ Mitsuko
Fujisaki, 75, who lost her daughter in the crash, told Japanese
media. ‘I have not been able to accept the reality.’” (Bangkok
Post, 25 Apr. 2015)
3. Inori no Mori (trans.: Memorial Grove, or literally Forest of Prayers) is the
permanent memorial to the accident
a. Created by JR West to honour the victims with input from the survivors and
families of the deceased
b. Opened to survivors and families of the deceased on Friday 14
September 2018 and then to general public on 21 September
i. At the private opening survivors, victims’ families, and JR West
President Kijima Tatsuo laid flowers at the foot of the sculpture
created to commemorate the disaster
ii. Pres. Kijima also apologised for JR West’s role in the accident
and vowed to create a safety culture within the company so
that this kind of accident would never happen again
c. The 14 anniversary ceremony was held at Inori no Mori on 25 Apr.
th

2019 and was attended by over 500 survivors and families of the
deceased, as well as Pres. Kijima
i. Pres. Kijima: "It is our most important mission not to forget
the accident, to keep in mind the regrets and lessons learned
and to continue to be a safe railway operator in the future.”
(Kyodo News, 25 Apr. 2019)
d. A stone memorial stands in the middle of a copse of trees, a few yards
away from part of the damaged apartment building which is also
memorialised
i. Remained standing at its full nine stories but completely empty until
some point between July 2015 and Apr. 2017 (according to Google
Maps street view history), when everything above the building’s 4 th

floor was torn down to make it easier to fit inside the semi-translucent
glass memorial awning
ii. The stone memorial put up by the company bears the names
of the deceased
e. Later in 2019 JR West floated the idea of adding the damaged railway
cars to the memorial
 i. The cars had been given to JR West after the investigations concluded
and the company was already expanding its employee training facility
to include the cars
1. At least half of JR West’s employees had joined after
the 2005 derailment
2. “A majority of the victims agreed on using the cars
for safety training, saying they want JR West
employees to ‘feel’ the tragedy of the accident and
to use that experience for future operations.” (The
Asahi Shimbun, 11 Nov. 2019)
ii. Some survivors and victims’ families wanted the cars displayed at Inori
no Mori, but others rejected the idea because having the carriages as
part of the memorial would bring back trauma and they didn’t want
the carriages shown to the public
iii. However, most of those affected by the tragedy supported
preserving all seven cars as well as separate pieces of the cars
1. “Many urged the preservation of all seven cars, with
some saying they will serve as evidence that the
victims had existed in this world.” (The Asahi
Shimbun, 11 Nov. 2019)
f. 15 anniversary memorial event in 2020 was cancelled, as was the
th

memorial event in 2021, because of the COVID-19 pandemic.

i. However, JR West President Hasegawa Kazuaki did lay a bouquet of
flowers down by the memorial and give a speech to reporters
1. “‘We will continue to make improvements in our
efforts to ensure safe operations as we deeply
reflect on the accident and keep the important
lessons from it in mind,’ Hasegawa told reporters.”
(Kyodo News, 25 Apr. 2020)
ii. The cancellation in 2020 came just as a survey by the
Mainichi showed that some family members feared people
were forgetting about the tragedy
1. “Meanwhile, 33 respondents, or about 91.6%, said
they feel that the incident is fading from people's
memories. Asked why they feel that way, with
multiple answers permitted, 18 answered that there
are now more people who don't know about the
crash, 16 said it has not been a topic of
conversations lately, 14 said they have not seen
news reports about it, and 13 responded that they
are having less interaction with other bereaved
families. Asked about their mental and physical
state, 18 respondents said they have ups and downs
but believe that they are moving on. Meanwhile,
seven people answered that their condition ‘has
worsened’ or ‘has not improved’. Five disclosed that
they are getting counseling, revealing the reality that
some bereaved families are still struggling
emotionally 15 years after the incident.” (The
Mainichi, 24 Apr. 2020)
g. 25 Apr. 2022: A memorial service was held for the first time in two years,
where attendees including bereaved families and JR West President Hasegawa
observed a moment of silence
h. Memorial flyer (in English):
https://www.westjr.co.jp/fukuchiyama/inorinomori/pdf/e_inorinomori.pdf
i. Images of Inori no Mori
iii. Names of some of the victims
1. Kuki Tetsuji, son of Kuki Hiroko (Hiroko: "I wish it were only a nightmare. I only
saw him the night before ... I wish he were alive somewhere.") (9 News, 2005)
2. Saito Mitsuru, son of Saito Yuriko ("The monument we had been waiting for is
completed," said Yuriko Saito, 76, who lost her 37-year-old son Mitsuru in the
accident […]. "I suppose you've felt lonely for these 14 long years," she
continued, addressing her late son. "Please watch over the safety (of train
operations) and rest in peace.") (Kyodo News, 25 Apr. 2019)
3. Kobata Sachiko, wife of Kobata Hirokazu (“’I am furious at JR West,’ Hirokazu
Kobata, 57, said after seeing the body of his wife, Sachiko, 53. ‘Please bring her
back,’ Kobata said full of emotion […].”) (Al Jazeera, 26 Apr. 2005)
4. Nishino Setsuka, wife of Nishino Michiharu ("’If it did not speed, my wife could
not have died, it was a human-error disaster,’ 65-year-old Michiharu Nishino
said, who lost his 63-year-old wife, Setsuka, newspaper Yomiuri Shimbun
reports.”) (ABC News, 27 Apr. 2005)
5. Heguri Kyosuke, college freshman (“Eri Kusuhara, 19, came to the local morgue
after hearing that her freshman college classmate, Kyosuke Heguri, had died.
‘Even after hearing many times that he died, I still can’t believe it, so I had to
come here to see if it’s true,’ she said, her eyes brimming with tears. ‘It’s such a
shame that he died, now that we’ve passed our entrance exams and can finally
enjoy ourselves.’” (East Bay Times, 27 Apr. 2005)
iii. Notable survivors
6. Okazawa Aiko, 19, college sophomore
a. Born 10 Jan. 1986
b. Before the accident was very into physical activity and exercise
i. Competed in dog frisbee tournaments
c. Sophomore at Doshisha University and was riding in the first carriage
of the train on the day of the accident
i. When the train derailed she was tossed into the air, breaking her neck and
injuring her spinal cord
ii. She was hospitalised for 377 days, the longest out of any of
the injured people
 1. “She experienced great difficulty breathing, making
her feel like she was drowning all day. She thought
she would die.” (The Asahi Shimbun, 2 Sept. 2021)
2. Paralysed from the waist down because of the
derailment
3. Difficulty regulating her blood flow makes her
susceptible to anaemia
4. Needed a lot of assistance
d. However, she didn’t let any of that get her down
i. After she left the hospital she returned to Doshisha University, got her own
apartment, and did her best to live as independently as possible
ii. Got a job with Sony Corp. in Tokyo in 2008 and worked there for 6 years
iii. Took up archery in 2013 after Tokyo won the privilege of
hosting the 2020 Olympics, due to encouragement from her
mother
1. At first she couldn’t even pull back the bowstring,
but she learned to compensate
a. “Since Okazaki has limited use of the muscles in her abdomen
and back, she needs to employ her arm and shoulder strength
to support the nearly 3-kilogram bow used for competitions.
So in addition to archery range practice, Okazaki goes to a
gym once a week for strength training.” (Kyodo News, 27 July
2019)
b. Uses bows with mechanical pulleys that assist archers with a
weak grip
c. Practises even on rainy and windy days
d. Wraps a release aid around her wrist to help with her grip
e. Adjusts her wheelchair so that she has more stability
f. Her boyfriend Hori Yuta helps her notch her
arrows
i. “‘At first, she was shooting for a
12-meter target, but now she can
hit through the center of a 50-
meter target. I feel happy when
she hits the center of the target,’
said Hori, who himself has had to
deal with a physical handicap since
having one of his legs amputated
due to cancer.” (Kyodo News, 27
July 2019)
g. It took her three years to be able to shoot a target from 10 m
away and another year and a half to increase the shooting
distance to 50 m
h. Okazawa: “When I face a challenge, I always try to find a way
to overcome it.” (The Asahi Shimbun, 2 Sept. 2021)
2. Became a Paralympian in the archery section
a. 1 Sept. 2021: Got to the quarter-finals in
the women’s individual archery event in the
W-1 class (for people who have limited use
of their entire body) but lost by 3 points to
her Chinese opponent, who went on to win
the gold medal for the event
iv. Wrote a book about the derailment and her experiences in 2015
 1. “In the book, she describes how, after being on the
verge of death, she overcame her painful
experiences and developed a positive attitude
toward life with the support of family, friends and
hospital staff. She also talks about the passion she
had for physical exercise and competitive sport
before the accident, when she regularly toured
Japan to compete in dog frisbee competitions. The
experiences she has gone through as a result of the
accident, while not good, have given Okazaki a new
perspective on things she would have never noticed
if she had not been there on that fateful day, she
says. But the memory of the derailment itself now
has little influence on her.” (Kyodo News, 27 July
2019)
v. Has held lecture sessions
vi. Okazawa: “I don’t want to be pitied just because I was injured
in the accident […] I want to enjoy my life.” (The Asahi
Shimbun, 2 Sept. 2021)
7. Suzuki Junko, 30, art student, daughter of Suzuki Momoko
a. Junko and her father usually took Rapid train 5418M to work and to
school
i. When Momoko heard about the accident from TV she called her husband’s
workplace
1. “I called his office and they told me he was in. I was
relieved, but then I thought, maybe Junko was on
that train.” (Trapped, S 1 Ep 3)
2. She called Junko’s phone but there was no answer
ii. “I called many hospitals, but I couldn’t get information about Junko from any of
them, so I realized there is a possibility that Junko is already dead and at the
morgue. We were not allowed to go into the actual morgue to see the bodies.
We had to wait in a room, and if there was a positive identification then we
could go into the morgue. There were polaroid photos of the dead people that I
had to go through to check if Junko was among them.” (Trapped, S 1 Ep 3)
iii. 5 hours after crash rescuers find a young woman in the second carriage who
matches Junko’s description
1. They carried her out and Dr Akitomi checked for
signs of life
2. When he opened her mouth he found small glass
shards everywhere
3. Severe injury to her torso and a blow to her head
that could leave permanent brain damage
4. Dr. Akitomi was able to discern that she was in a
coma given the very low level of response to stimuli
5. Dr. Akitomi, about the ambulance ride with Junko:
“Her consciousness level dropped dramatically. It
was a bad situation. Dr. Hase quickly gave her
mouth-to-mouth resuscitation, and I went to get a
breather [breathing pump].” (Trapped, S 1 Ep 3)
6. She had to be airlifted to hospital
iv. Junko’s mother Momoko was notified and quickly rushed to the hospital
1. “The doctor told me that Junko was brought here by
helicopter and that there was an emergency
 operation in her stomach area that they had to do
without permission in order to save her life.”
(Trapped, S 1 Ep 3)
v. Junko was in a coma for 6 months before finally waking up
1. She suffered some brain damage but she’s back
home with her family now
2. Junko: “I was really relieved that I was alive.”
(Trapped, S 1, Ep 3)
vi. She still works as an artist
8. Yoshida Kyoichi, 35
a. Was inside the first carriage, which was buried deep in the apartment
building’s underground parking garage
i. Usually he’d be in the back of the train but on 25 Apr. 2005
he decided to sit in the first carriage.
b. “When I woke up, the world in front of my eyes was foggy. It could be because I wasn’t
fully conscious.” (Trapped, S 1 Ep 3)
c. When he woke up he had his laptop crushed up against his chest, leaving a space
between his chest and the carriage wall, which he believes is what saved his life
d. “I was holding somebody’s hand for quite some time. My mental state was not normal;
it took me a long time to realise that the person whose hand I was holding had already
passed away.” (Trapped, S 1 Ep 3)
e. Was eventually found by the doctor and his team, who Yoshida describes as very
professional and quick
f. They injected him with an intravenous drip to help stop the onset of crush syndrome,
which drastically increased his chances of survival
g. Yoshida was trapped with a bunch of dead bodies so they didn’t know
which foot was his and had to tap on them all to find out.
i. “They asked me many times, ‘Is this it? Is this it?’ while they
were tapping shoes, but I couldn’t feel anything. I actually
thought that my shoe was being tapped, but that my foot
might be partially dead.” (Trapped, S 1 Ep 3)
h. They finally found his foot and released it from the rubble and then
bundled him into an ambulance
i. While in the ambulance he started to go into shock
ii. Doctors still watching to make sure there were no signs of
crush syndrome
i. Stayed in the hospital for two months due to the severity of his injuries
j. Eventually wrote a book about his near-death experience aboard Rapid Train 5418M
9. Hayashi Hiroki, 19, college student
a. Last person pulled from the rubble alive
b. Was standing at the front of the first car and was thrown into the driver’s compartment
with Takami’s body
c. Pinned by twisted metal and corpses of other victims
d. Found by Dr. Nagata Hiroiki after Nagata had made his way through
multiple dead bodies to the front of the first carriage
i. Dr. Nagata: “He actually sometimes said ‘I might just give up’. When he said
that I told him […] that the rescuers are trying to get to him, so until they reach
you, until they save you, you can’t give up. That’s what I told him.” (Trapped, S
1 Ep 3)
ii. Hayashi was hanging upside down in the wreckage so that
was an awkward position in which to attach the IV drip
e. Pulled from the damaged car 22 hours after crash after surviving the night with bottled
water passed to him and through an intravenous drip
 f. Injured in the legs but conscious and in stable condition
g. Extremely panicked between crash and rescue (“‘I'm in pain, I can't take it anymore,’ he
told his mother by cell phone after the crash, according to his 18-year-old brother
Takamichi Hayashi.”) (9 News, 26 Apr. 2005)
h. Rescuers were afraid to use an electric drill because of the potential of sparks igniting
fuel; the fire department had to bring in hydraulic equipment to pry the wreckage apart
to get Hayashi free
i. Had to eventually have both legs amputated
6. Urban legends surrounding the Amagasaki derailment (Toshiden, S3 Ep 3)
a. 24 Apr. 2005: The ghostly figure of a person was allegedly spotted walking on the train tracks by
a train conductor exactly where the crash site would be a day later. The area was actually
searched but no one was found. The search delayed nearly 40 trains. There is no proof to back
the driver’s claims up, but his story could stem from rumours of ghosts in the area because of
many deaths caused by the 1995 Great Hanshin Earthquake (aka Kobe Earthquake), which
affected the same area where the derailment took place (Hyogo Prefecture).

b. 25 Apr. 2005: A woman was forced off the train at Itami Station by an old lady screaming about
how she shouldn’t be on the train. She found out it had crashed a few minutes later through an
announcement on the platform. When she turned to look, the old woman wasn’t there anymore.
This is unverified; it was most likely spread after the incident to add a bit of mysticism to the
tragedy.