Beyond human error or organizational culture: Systemic skill management in organizations and the Fukuchiyama-line derailment accident

Tsukuba, Japan—The derailment accident on the Fukuchiyama-Line of the West Japan Railway Company occurred on April 25, 2005, in Amagasaki City, Hyogo Prefecture. An upbound rapid-service train entered a curved section of track between Tsukaguchi Station and Amagasaki Station at approximately 116 km/h, well above the speed limit. Five cars derailed, and the first two struck a residential apartment building beside the tracks. In total, 106 passengers and the train driver were killed.

The accident challenged a basic assumption of railway system design: train drivers operate according to established rules.

Conducted around the twentieth anniversary, this study addressed two key questions: What were the underlying system-level causes of this accident? What kinds of measures are needed to prevent accidents caused by the same mechanism?

It re-examined explanations focused on human error or organizational culture and instead identified failures in organizational management as the root cause. The analysis focused on skill development, how an organization supports and guides the development of drivers' operational knowledge/skills, examining which approaches best prevent unsafe behaviors such as excessive speed on curved tracks. Multi-agent-based simulations assumed that train drivers rely on layered knowledge structures, or Shared Mental Models (SMMs), when operating trains.

Results indicated that skill development systems based on two-way communication among drivers are the most effective measure for preventing isomorphic accidents, including the Fukuchiyama Line derailment. In contrast, top-down approaches relying on one-way managerial instructions are less effective. These findings suggest that the company's reliance on a top-down skill development system was a contributing factor in the accident.

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This work was supported by JST SPRING, Grant Number JPMJSP2124.

_{Original Paper}

Title of original paper:
An Alt-Study of the Fukuchiyama-Line Derailment Accident to Prevent Organizational Accidents via Safety Systems Science Approach

Journal:
Journal of Japan Society for Safety Engineering

DOI:
10.18943/safety.65.1_35

_{Correspondence}

YAMAGUCHI, Shuji
Doctoral Program in Risk and Resilience Engineering, Graduate School of Science and Technology, University of Tsukuba

Professor ITOH, Makoto
Institute of Systems and Information Engineering, University of Tsukuba

_{Related Link}

Institute of Systems and Information Engineering