ORIGINAL ARTICLE

A proposal for a new accident analysis methodand its application to a catastrophic railway accidentin Japan

Yuji Niwa

Received: 23 July 2007 / Accepted: 18 March 2008 / Published online: 16 April 2008

� Springer-Verlag London Limited 2008

Abstract In a society of highly advanced technology, a

new type of compound accident takes place. In an accident

analysis, recent research concerns three aspects: human (M),

technology (T) and organisation (O). However, technologies

are developing day by day and it is becoming difficult to find

causes of the recent compound accidents even with M, T and

O analyses. This paper suggests further analyses considering

the recent change of Western and Japanese societies quoting

the recent catastrophic railway accident in Japan.

Keywords Accident analysis � Railway accident �Phenotype � Genotype � PG-diagram � MTO �Human reliability analysis � Risk

1 Introduction

Culture is changing drastically and new types of accidents

that were once believed to have never occurred are taking

place recently—Japanese are now confused, not knowing

what is going on in Japan. On 25 April 2005, a catastrophic

accident in a railway system took place making the Japanese

belief in the safety of their railway 28system suffer. On 28

June 2008, the final report of the Japan Nishinihon Passenger

Railway Company (Formally Japan National Railway, pri-

vatised at 1987, divided into seven companies, called JR-

West hereafter, depicted Fig. 1) accident was delivered. This

accident is called the ‘‘JR-accident’’ hereafter in this paper.

According to the final report, a serious defect in human

management, especially a penalty to human errors, has been

found and it also recommended improvement of the human

management system. However, many Japanese seem not to

accept it. The public still wonder what the real cause of this

disaster was and why it had occurred.

In this paper, the author considers the JR-accident as a

sort of compound accident and tried to seek several sig-

nificant causes with a proposal for a new approach of

accident analysis. All information about this accident was

documented and opened to the public as ‘‘Drought of report

concerning factual survey -the accident of the Japan Nishi-

Nihon Passenger Railway Company.’’ (Japanese Ministry

of Land 2006) The analysis was made according to this

interim drought. This paper also concerns how safety

management should be made to avoid such compound

accidents in the proposed framework.

Advanced accident analyses have not been done in this

country. However, the most remarkable primary accident

analysis method that takes into account human factors is

the ‘‘E-shell’’ model (Kawano 1999) application (Ma-

sayoshi et al. 2004, which is an extended model of SHELL

by Edwards (1988). In fact, the E-shell model application

has been applied to the JR-accident in a technical report,

where the problems were derived from five aspects, i.e.,

‘‘Liveware-person concerned’’, ‘‘Liveware-other person-

nel’’, ‘‘Hardware’’, ‘‘Software’’ and ‘‘Work place’’, and it

concluded that problems in each aspect were tightly cou-

pled (Ueno 2005). The analyses of railway accidents have

been treated in the framework of human and machine

problems. Thus, accident analysis in Japan seems to remain

at the traditional level.

Compared with Japanese railway analyses, Western

analyses are more advanced and systematic. As introduced

in the later section, Hollnagel showed that bus–railway

collision accident occurring in the USA could be analysed

in more detail than the analysis by National Transportation

Y. Niwa (&)

Centre for Risk Management and Safety Sciences,

Yokohama National University, 79-5, Tokiwa-dai,

Hodogaya-ku, Yokohama 240-8501, Japan

e-mail: niwa@ynu.ac.jp

123

Cogn Tech Work (2009) 11:187–204

DOI 10.1007/s10111-008-0112-5

Safety Board by a recursive approach (Hollnagel 2006a).

Concerning railway crossing collision problems, Transport

Canada tried to make ‘‘contributor’’ taxonomy from the

past accidents literature. They concluded unsafe acts,

individual differences, train visibility, passive signs (sym-

bolic barrier) and markings, active warning systems, and

physical constraints form the primary categories of acci-

dent contributors. Based on this taxonomy, they analysed

each contributor and issued some recommendations. The

interesting point is they quantified countermeasure type,

effectiveness, and cost referring to several literatures

(Caird et al. 2002).

Wilson and Norris pointed out the necessity of intro-

duction of human factors in railway system. For the reasons

connected to the organisation of the industry, technical

developments, and major safety concerns in recent years,

rail human factors have grown in importance at an inter-

national level. Despite its importance, however, supporting

literature has been largely restricted to specialist journal

publications and technical reports. From this viewpoint,

excellent works have been edited. (Wilson and Norris

2005b) Innovative railway safety researches were also

published in this journal’s special issue. Wilson and Norris

introduced a plethora of research for railway safety, com-

fort and so on since the issues of railway are relevant

domain for the application of cognitive ergonomics. Sim-

ilar studies were applied to signal systems, train control

systems, human machine interface and other hardware for

safety improvements, and others to railway human factor

principles, human error and reliability, timetabling and

planning, maintenance planning and work, safety climate

and safety culture, and passenger comfort and behaviour

(Wilson and Norris 2005a).

Among these, the studies focused on how the principles

of human error in human–machine system should be con-

sidered in railway accident analysis. Especially,

Vanderhaegen et al. focused on ‘‘violation’’, which was one

of human error mode according to the error taxonomy of

Reason (1990) and had been treated less important than

three other modes (i.e., slip, lapse and mistake) as domi-

nant factors in railway accident. They concluded many

violations in railway system occurred by barrier removal

(BR). They also successfully introduced a cognitive model

of violation and the more interesting work was a quantifi-

cation of human error rate due to violation in railway

systems. (Polet et al. 2002; Chang et al. 2002; Chaali-

Djelassi et al. 2007) Applying the error rate to the THERP

(Swain et al. 1983) method, primitive risk assessment of

Japanese railway might be possible if the qualitative

accident analysis is well done and it provides a significant

feedback and ‘‘risk awareness’’ of the railway system—the

most popular transport way in Japan.

It should be noted that human error in railway system

has to be analysed more widely, viewing the JR-accident. It

might be insufficient if a railway accident is taken as

merely a deficiency of human–machine system. In this

sense, Cacciabue (2005) made innovative approach; he

examined the use of various human error risk management

techniques and methods within rail organisation safety

audit. Applying the SHELL model, interesting and essen-

tial outcomes of the work in this paper were the

identification of a model for representing the socio-tech-

nical interactions and the workflows and procedures

applied within the organisation, which covered the ethno-

graphic level. It provides a more extensive, concrete and

realistic analysis than that of 2005)Japanese (Ueno 2005).

In this paper, the detailed description of the JR-accident

is summarised in Sect. 2. Inspired by the aforementioned

innovative researches, especially Cacciabue’s network

representation of train driver, a new methodology that

covers wide area is proposed. Although it is a sort of top-

down approach, it is definitely different from fault tree

analysis (McCormick 1986). According to the proposed

method, the JR-accident is analysed concretely in the later

sections and suggested recommendations for safety man-

agement are also referred.

2 Summary: known facts in the accident of the Japan

Nishinihon Passenger Railway Company (Japanese

Ministry of Land 2006)

2.1 Outline of the railway accident

The most serious railway accident in Japan occurred

involving the JR-West Company. On 25 April25 2005, the

train (code 5418 M) bound for Doshisha-mae departed

from Takarazuka station. After departure from Itami station

with a delay of 1 min and 20 s from the scheduled time, the

train passed through Tsukaguchi station with 1 min and

17 s delay. In the Itami Station (the station just before

JR-Hokkaido

JR-Higashi-Nihon(JR-East)

JR-Tokai

JR-Nishi-Nihon(JR-West)

JR-Sikoku

JR-Kyushu

Tokyo

Osaka

Kyoto

Kobe

Fig. 1 The JR feature and cities in relation with this paper

188 Cogn Tech Work (2009) 11:187–204

123

where the accident took place,) after the passenger had

been taken on and off, the train started immediately. The

train delayed around at1.5 or 2 min at the most when it left

Itami Station. Afterwards, the train derailed at the curve

around 1.9 km far from Tsukaguchi station. The first coach

of the train fell left while running in a right curve of 304 m

in radius in the south of the Meishin Highway and subse-

quently the second to fifth coaches derailed around

09:18:54, and continuously, the seventh coach in part in the

end stopped around 09:19:04. Neither the sixth nor the

seventh coach derailed. At this curve, the speed limit

should be strictly less than 70 km/h. However, in this case,

the train speed was recorded to be 116 km/h. This speeding

operation at the curve is believed to be the direct cause of

this accident.

To make the matter worse, the derailed train crashed

into an apartment house sliding in inertia from the railway

track sideward, which led to a more serious accident. The

first coach turned sideways to the left, whose front-side

collided with the wall in the parking station interior of the

first floor in the apartment, and its lower side of the back

collided with the pillar on the northwest side of the

apartment house. Moreover, the left side body of the sec-

ond coach collided with the pillar on the northeast side,

crushed the left side back of the first coach and the

northwest side pillar of the apartment house.

This accident killed 107 people (106 passengers and an

operator) and injured 555 people.

The real cause of this tragic accident is not correctly

identified since the truck of the first coach, which is the key

component, had been dismantled for the rescue of injured

people from the crushed train in the apartment house.

However, it is undoubtedly a typical compound accident

including organisational factors.

2.2 The operator’s behaviours before accident

2.2.1 The facts

As mentioned above, the accident cannot be analysed as

being caused only by hardware failure since it was a

compound accident. Although the phenotype was train

crash and derailing, how the operator of the accident train

behaved should also be considered. According to JR-

West, this operator had rather a higher performance score

in the company domestic training and examination.

However, he had made a couple of errors previously and

had received re-training, called ‘‘Nikkin-Kyoiku’’. As

mentioned below, on the day of the accident, some

strange behaviours were observed. The location of the JR-

Fukuchiyama-lines and the main stations are depicted in

Fig. 2. This train operated between Takarazuka station

and Doshisha-mae station on the joint lines of JR-

Fukuchiyama (called JR-Takarazuka line,) JR-Tozai line

that is underground line, and JR-Gakken-toshi line. The

event sequence mentioned below is more comprehensive

with referring to the later Fig. 7.

(1) Due to speeding, the interlock system called ATS-P

(illustrated later) was activated. However, it is not

certain if this was a violation, since it depends upon

the company’s culture. Some companies prefer care-

ful manual operation without activation of interlock

system ‘‘soft operation’’ and others do not mind even

if interlock systems activate to accomplish the

mission safely.

(2) From the guard’s testimony: he thought that operator

was adjusting time because it sometimes cruised at

around 10 km/h toward Takarazuka Station.

(3) At an inlet turnout in Takarazuka station at 8:54

(40 km/h limitation) it entered the turnout point at

65 km/h, and it stopped near the platform with

emergency brake by automatic train stop device

(ATS, illustrated later) interlock. There is a possi-

bility of misunderstanding the platform to be entered.

Once an annuciator is activated, the operator has to

push confirmation button. The omission leads to the

activation of the interlock, i.e., automated emergency

brake activation. The operator omitted this confirma-

tion-required action. However, why this error took

place is not known.

(4) To continue the scheduled mission (the electric coach

can make reciprocating operation, i.e., two directions,

therefore operating panels are provided at the front

and at the end of a train) an operator had to move to

another end of the train and prepare for the operation

Fig. 2 The features of the JR-Fukuchiyama lines

Cogn Tech Work (2009) 11:187–204 189

123

of subsequent reverse direction as soon as possible.

However strangely, the operator stayed in the position

without moving to other side of the train for over

1 min. Why he stayed for such a long time is not yet

identified.

(5) After the train operated at around 120 km/h, it

continued to coast and the speed decreased to around

113 km/h. Then the artificial warning voice of a

woman ‘‘Stop, stop’’ was announced from the control

system. Subsequently, a voice of the man ‘‘Stop and

stop’’ by the prevention alarm of station passing

activated and maximum brake was used immediately

after that. The emergency brake was operated due to

interlock system ATC in the seventh coach when the

train passed through the prescribed stop position

about 44 m. Resultant stop position was over the

prescribed stop position by about 72 m.

2.2.2 The operator and the guard communications/

interactions just before the accident

After the train departed from Itami station, there was a

notifying signal that indicated to answer the train staff

telephone from the operator just before announcing that

‘‘The next station is Amagasaki’’ to passengers. The guard

responded because there was a request from the operator

asking if the guard can allow the overrun at the Itami

station though the guard forgot concrete words; he assumed

it was a request to report a shorter overrun than actuality.

He reported cautiously that the operator made a consider-

able overrun. Just as the guard was answering it, a

passenger knocked on the guard door and claimed that he

should apologise. When the guard was broadcasting the

apology, the accident took place. In that case, the guard

reported that overrun was around 8 m and delay time was

1.5 min because it seemed to be too short to report a 5 m-

overrun though he estimated the passed distance was from

around 30 to 40 m. He also heard that the penalty of the

JR-West to the operator was not so severe if the passed

distance was about 5 m.

2.2.3 The status of the operator known after the accident

investigation

The operator had taken out the special red pencil that was

able to be used for writing on the vinyl case of train por-

table diagram that was normally set on operation console

after removing the right glove. It was discovered in the

operation area after the accident. A special wireless oper-

ation was done. Moreover, the operator is supposed to try

to eavesdrop on the communication between the guard and

train control centre, and to attempt to think out a plausible

story why he made a false short distance overrun at Itami

station using this red pencil. More specifically, the operator

was presumed to have tried to take notes of the content of

the telephone call so that he should not contradict the

report of the guard. As a result, surprisingly the operator

had made no train operation and no communication to the

guard and operation centre for about 40 s before

approaching the curve of the accident point. For this, it was

concluded that the brake operation had not been done at all,

though it approached the Meishin highway viaduct of the

point where the speeding train had required to apply the

brakes. This serious fact had not been reported correctly

and clearly by any Japanese media.

3 Accident analysis methodology

3.1 Previous studies

Despite several barriers, these defences have never worked

efficiently for the compound accidents as ‘‘Swiss Cheese

Model’’ proposed by Reason (1997). It had been very hard

to analyse why these barriers had not worked as specified.

As it is obviously seen that the number of compound

accidents in the world is increasing. Recent studies of

Hollnagel (1998, 2004) give an excellent hint to analyse

the compound, especially the JR accident. Hollnagel con-

cluded this accident is a typical outcome of efficiency–

thoroughness-trade-off (ETTO) (Hollnagel 2006b). The

heuristics of ETTO have been surely observed in the JR-

West Company. Moreover, cognitive reliability and error

analysis method (CREAM) approaches from human (M),

technology (T) and organisation (O) and the accident’s root

cause can be discovered by ‘‘recursive’’ analyses (Hollna-

gel 1998). As the background of the CREAM, the sharp

and blunt ends accident model is very convenient to ana-

lyse and/or illustrate why and how an accident occurs or

occurred.

An accident or unsafe action takes place at the sharp end

what is called phenotype or manifestation. Traditionally,

investigation on an accident tended to focus on the sharp

end. However, Hollnagel concluded that the accident and

unsafe action are essentially caused by a management of

organisation, company strategy, government administra-

tion, social norm of each country, culture and so on, that

should be really investigated as a root cause.

3.2 The proposed accident analyses on the present

accident

The Hollnagel’s the sharp and blunt ends models are

depicted in Fig. 3 (Hollnagel 2004). This model suggests

190 Cogn Tech Work (2009) 11:187–204

123

the wider aspects than M, T, O have to be considered in the

analysis of compound and present accident. Figure 3 gives

the inspiration of further analysis how to analyse com-

pound accidents whose causes spread widely. The analysis

of organisational factors may be a main concern to this sort

of accidents. However, no authorized analyses of organi-

sational factors have been conducted. Hence in this paper,

an extended method to analyse organisational factors, or

more even widely, genotype analyses are proposed and

applied to the JR-West accident.

The basic principle of the proposed accident analysis is

as follows:

(1) besides, M, T and O, Social (S), and Environmental/

Cultural (E/C) shall be introduced;

(2) at each aspect, abstraction levels shall be set. The

analysis shall be made from high to low abstraction.

Thus, this forward propagation will mitigate omission

falls;

(3) analyses on each level, the cause shall be investigated

or predicted. The analysis may be terminated at any

level if distinct causality is detected;

(4) if each cause element is carefully considered, links, or

more specifically, causality, between each cause will

be created;

(5) based on these causalities, elements which are located

near sharp- or blunt-end shall be evaluated;

(6) all causalities shall be illustrated and root cause is

likely to be found at the blunt end.

The proposed method is illustrated in Fig. 4. It is natural

for an interaction to exist between M, T, O, S and E/C. This

interaction has to be analysed. A typical interaction, M and

T, is human–machine interface and/or human–machine

interaction. The interaction of M and O may be position,

salary and so on. Although this interaction has not been

analysed explicitly, it also plays quite an important role to

make links from the blunt to sharp end. The diagram in

Fig. 4 may be mapped to the diagram depicted in Fig. 5.

The analyst will be aware that the set of these causali-

ties, i.e., link and node are spread out from sharp- to blunt

end as depicted in Fig. 6. To find the causality and architect

nodes and links that spread widely to blunt end (hereafter

called PG-diagram; P, G denotes phenotype, genotype,

respectively), brief findings and prediction have to be

described based on keen investigation regarding M, T, O, S

and E/C, respectively. Integrating these outcomes, PG-

diagram can describe what was really wrong in the

accident.

3.3 Safety management from PG-diagram

Especially in Japan, the same kind of accidents and un-safe

company activities can be observed. Once an accident

takes place, the presidential executives apologise formally

and managers are substituted. However, successors have

been educated in the company and have same company

ethics. As a natural result, same kind of scandal, accident,

injury and unsafe action are committed repeatedly. It is not

a characteristic phenomenon of Japan. The repetition of

scandals is widely observed in the world, especially in big

organisations.

If such countermeasures toward scandal, accident, and

so on are assigned to PG-diagram, company people make

efforts to change or remove unwanted nodes at the blunt-

Clim

ate

and

soci

alno

rm

Gov

ernm

ent

Aut

hori

ty

Org

aniz

atio

n

Man

agem

ent

Wor

kpl

ace

Work

The failure of Blunt end - it has happened

somewhere before.

Manifestationat Sharp end - what happens now.

GenotypePhenotype

Fig. 3 The sharp and blunt ends accident model

Cogn Tech Work (2009) 11:187–204 191

123

end. However, they, especially the president, must be

aware that the nodes at blunt end are virtually impossible

and too hard to be removed or changed. The possible and

wise way to restore safety is to think out how the links

from/into unwanted nodes can be cut off. This is much

easier than removal and change of unwanted nodes. Thus,

some approach for safety management can be considered

by isolating unwanted nodes.

4 The JR-accident analysis

Based on the principle proposed in Sect. 3, the JR-accident

was analysed and the PG-diagram was formed. Observing

in the diagram how the links can be cut off and restore

safety in railway company are analysed.

4.1 Human—M

4.1.1 Generic

Violation has not been scientifically treated. Human reli-

ability analysis has focused on the distinct errors excluding

violation. From now on, the study on violation has to be

made. Why the operator violated the JR regulation is the

key issue in this accident. On a closer look at the fact that

the operator made no operation just before derail, it must

Accident/DisasterUnsafe action

Function

System

Component

Element

Generic

Specific

HCI(Automation Level)

National

Regional

Social

Singularity

Perspicuity

Demand

Links will be created

Personality

CultureEnvironmentEtc.

InterfaceDesign-detail

Human machineinteraction

Human Reliability Analysis

Fig. 4 Schematic diagram of M–T–O–S–E/C analysis

HMI

Environment Culture

Human affairsWorking conditions etc.

System design policyEtc.

Systemcustomisation

Etc.Human healthcareetc

Fig. 5 Interaction between M,

T, O, S and E/C

SocialEnvironmentalCultural

Oraganisational

HumanTechnical

AccidentOrUnsafe action

node

node

node

node

node

node

node

node

node

node

node

node

node

node

node

Link

Fig. 6 From phenotype to genotype—causality sets

192 Cogn Tech Work (2009) 11:187–204

123

be considered as ‘‘duty (mission) abandonment’’ rather

than violation. An escape from duty or mission is more

serious than human errors. It may be added to an unsafe

action of human and keen studies will have to be made.

Therefore, why the operator abandoned duty has to be

investigated very carefully.

4.1.2 Specific

It was reported that the operator was diagnosed as a slight

Asperger’s syndrome or AD/HD attention deficit / hyper-

activity disorder (AD/HD), which was an exaggerated or

incorrect report by several medias (Japanese Ministry of

Land 2006). According to the official facts report, he has

no serious mental/physical problems. He once was got out

of train operation duty due to some failure and instructed to

have re-training called ‘‘Nikkin-Kyoiku’’ discussed later.

Although JR-West had examined if he was suffered from a

sleep disorder, an apnea syndrome or narcolepsy, no

symptoms were observed. Here is the oversight that may

frequently take place. Many analysts forget he was doing

shift work. Shift work requires the change of sleep time

frequently. It is safe to say that all shift work operators

experience unconscious drowsiness on duty time. They are

bound by drowsiness even if they pay special attention to

the duty they are given. It cannot be detected by medical

testing. Therefore, the organisation with 24 h duty must

design the safety system taking human dosing into account.

An interesting example is Toyota’s attempt. The car sensor

system always monitors a driver’s eye movement. If the

system detects the driver’s unconscious drowsiness, the

system alerts the driver and a chilly wind is sprayed on

the face. Volvo also makes the same attempt (http://

techon.nikkeibp.co.jp/premium/AT/ATEVENT/20041104/4/,

March, 2008). This sort of system must be introduced also

in railway, especially highly automated high-speed train

such as the Shinkansen, TGV and so on.

Operation skills according to the official facts report, it

was concluded his skills were average. The examination of

operation is assumed to be made in ‘‘Nikkin-Kyoiku’’ since

such operation examination is imposed on all operators in

JR-West. The result of his skills is shown in Table 1

(Japanese Ministry of Land 2006).

As shown in Table 1, he had average skills and found no

problem as an operator. He may be short of smooth oper-

ation and may have excellent skill of emergent operation,

which may lead to this accident ironically.

4.1.3 Personality

He was ambitious and expected to become a Shinkansen

operator. Therefore, he may have thought he had to commit

no errors/failures in duty time. His colleague testifies he

had no problem in mental aspects and his dream was to

become the operator of Shinkansen train. Maybe he wor-

ried about any trifle matters easily. The remarkable change

can be observed, although no expert pointed out. In JR-

West, operators are instructed to turn off the power of

private mobile phones during duty time. The operator made

a slight violation at this point. He never turned off the

power during duty time. A schematic diagram of the

operator on the accident day is depicted in Fig. 7.

As shown in the Fig. 7, initial anomaly state takes place

at 1 in the Fig. 7. An interlock system ATS-P (explained

later) activated. However, it does not follow that the

operator made a violation. Concerning speed control,

whether the human makes a careful and calm operation or

relies upon a hardware interlock system is decided by each

company. A remarkable point worth mentioning is this

operator’s behaviour changed to strange or his attention

become scattered after he received the mobile phone mail.

Sadly, what mail he did receive will never be opened since

it concerns a private matter of the sender. If the author’s

reasoning is allowed, he might have felt ill because of

receiving the mail. Many will experience their performance

degrading if they feel ill due to unexpected, unacceptable

or malicious mail. The author suspects that getting the mail

is the real initiating event.

4.2 Technology—T

4.2.1 Function level

It was broadcasted in Japan that the train had some mal-

function and so it was stopped. It is not still clear if the

train derailed at the curve or before curve, since some of

passenger testified considerable vibration before the

accident, i.e., when the train was running at straight line. It

Table 1 Operation skill of the operator in this accident

Examination item Score of the operator Means

Speed eye measurement 100 98

Speed adjustment 85 97

Distance eye measurement 90 91

Stop position 100 97

Stop temptation 100 97

Braking operation 75 78

Check before service 97 89

Adaptive operation 96 93

Driving time 92 94

Equipment handling 100 100

Smooth operation 90 97

Emergency operation 95 88

Amount 1,120 1,118

Cogn Tech Work (2009) 11:187–204 193

123

was said that meander movement was observed before

derailing, although it was not sure. Medias concluded an

indirect hardware cause of overrun at previous station

might have been a partial loss of control (stop function) in

2006.

4.2.2 System level

The malfunction of the brake system has not been iden-

tified since trucks of the first coach have been dismantled

for the rescue of injured people. Moreover, the serious

problem is JR-West applied narrow gauge system

(1,067 mm gauge) whereas the competitors normally

employ world standard gauge, 1,435 mm gauge. Con-

cerning JRs, this standard gauge is applied to only high-

speed Shinkansen trains. As mentioned earlier, JR-West

had been a national railway and railway system had been

introduced from the UK, since the UK’s old locomotives

had been normally small and fitted for a mountainous

country, Japan. Since it was necessary to use spiked rails

at mountains and valleys, so a narrow gauge system was

introduced (Hayashi 1986). As explained later, in Kyoto–

Osaka–Kobe area, a keen competition, i.e., how they

obtain as many as passengers, is unfolded historically.

The advantage of JR-West is its speed 29 min from Kyoto

to Osaka, while it is 35–45 min by other competitors.

This means JR trains are essentially unstable due to the

relative high gravity centre.

It was also broadcasted that JR-West operators com-

plains the slight weak working of train brake of the train

used (called 207 series electric coach) in JR-Fukuchiyama

lines and it might be one of cause of the accident. The

accident train is a mixed train of 207-0 series and 207-1000

series. The only fact is the stroke of the brake control bar,

‘‘maximum brake position’’ (notch-8) between emergency

brake position is slight different. The 207-1000 series

coach is said slight longer. Therefore, when an operator

intends to activate emergency brake and he thinks bar is in

emergency brake position, the bar tended to be in notch-8

position. This is the real reason of operators’ complaints.

The serious problem is mixture of different property of the

coach. Operator has to be always aware of what type of

coach he operates. It is very hard to identify the type in

control area. Considering the improper design policy, it is

deeply related to the human–machine interface issue.

4.3 Human–machine interaction

As depicted in Fig. 5, interactions are generated amongst

M, T, O, S, E/C. The interaction between M and T, i.e.,

human–machine interaction is only treated in this paper,

since quite a lot of interactions can be considered. If all

interactions are analysed, vast amount of space is required

regarding this paper. It is appropriate to feature human–

machine interaction considering the topic that should be

treated in this journal.

Hanaten

1’’ 20”late

Kyo-bashi1’’ late

Amagasaki

No delay

Takarazuka

Duty start

Overrun 72mKita-itami

1

2

3

1 ATS-P Annuciator2 Excessive Low Speed Operation3 Emergency Brake activates due

to omit confirmation4 Unidentified long stay in operation seat5 Anuuciator, Subsequent annuciator

MobilePhone

4

5

1’’ 30”lateInitial Violation

Matsui-yamate

Station name

Out-service218S 5769M

4469M

Out-service4469M 5418M

: Train code name

Fig. 7 The operator’s

behaviour on the accident day

194 Cogn Tech Work (2009) 11:187–204

123

4.3.1 Automation level

The automation has introduced for efficiency improve-

ment. However, the feature of automation is changing to

the principle that the common goal is achieved as human–

machine collaboration. Recently, the automated systems

are highly advanced in many industries. Once an aero-

plane pilot changes to ‘‘AUTO-PILOT’’ after taking off,

then his concern should be how he should prevent himself

from dozing off. Many process chemical plants have also

been highly automated. Main work of a crew in a nuclear

power plant is to monitor whether the plant state is stable

and normal rather than operation/manipulation. In JR

Shinkansen trains, drowses have been reported since the

only work left for human is to stop the train at the

specified position exactly. In this sense, advanced auto-

mation makes machine plays a role of main function

whilst human owes sub-function. In this environment,

human tunes himself so that machine works so well. In

fact, human can make tuning and matches machine to the

convenience of the machine. Human must study hard and

try to understand machine property to collaborate with

highly automated systems. This tuning by human might

impose stress to human. Bainbridge (1987) pointed out

the accompanying problem of automation as ‘‘irony of

automation’’. In highly automated environment, machine,

if a new problem occurs it must be resolved, taking this

problem as irony of automation 2 in the sense that high

automation deprives human’s essential work and spoils

him excessively. Few tedious and boring works are

addressed to human.

In recent highly advanced technology, humans must

always take machine’s convenience (service) into account.

A good example can be seen in the mobile phone. Recent

mobile phones have plenty of functions. It is essential to

carry a telephone. However, recent devices have small

liquid crystal display (LCD) for service of viewing TV,

accessing web, playing video games, monitoring camera

view and so on. LCD requires considerable huge power.

Users are always cautious not to discharge battery. If dis-

charged, users must look for a convenient store and must

purchase battery-charging device at an expensive price.

Thus, some of recent highly advanced technology requires

human to adjust to the machine’s convenience, since the

back up of machine by human is impossible. It also

imposes latent stress to human and may cause several

accidents. It might be taken as irony of automation 3.

In the JR-West urban line, the automation level is near

‘‘management by exception’’ (Sheridan 1992). In the

Shinkansen train, the French TGV and other leading high-

speed trains equip automatic train control (ATC). However

in JR-West lines, automatic train stop (ATS) device, sim-

ilar system is called automatic warning system (AWS) in

the UK, is employed (Japanese Industrial Standards 1995;

‘‘Wikipedia’’ Japan, http://ja.wikipedia.org/wiki/, March

2008).

Simply speaking, the difference between ATC and ATS

is whether sensor is inside or outside of the train. The

simplified schematic diagram of ATC and ATS are

depicted in Fig. 8.

As obviously seen, the ATS requires great number of

ground sensors. Since it is not realistic to set ground

Sensor

Processing

Control

(Speed, Brake)Feedback

Sensors

Processing

Control

(Speed, Brake)Feedback

Simplified schematic diagram of the ATC

Simplified schematic diagram of the ATS

Signal

Receiver

Fig. 8 The simplified diagram of the ATS and ATC

Cogn Tech Work (2009) 11:187–204 195

123

sensors on all area due to economical constraints, it

normally set specified areas that demands operators’

attention, for example, main lines (with many passen-

gers), and point before sharp curvature, turnout and inlet

of station. ATS requires a plenty of ground sensors. The

interval distance of sensors is designed from the maxi-

mum specified velocity of the train on that point. The

accident occurred at the point where there was no ATS

sensors, since JR-Fukuchiyama lines is a branch line and

to make the matter worse, the train is operated with

greater speed than specified. Thus, JR-West had decided

the ATS ground sensors had not been necessary at the

accident point.

The ATS has several variations. Amongst JR-Fuku-

chiyama lines, Takarazuka and Gakken-toshi lines

adopted the ATC-S type whilst Tozai line adopts the

ATC-P type. The ATS-S is an old type control (interlock)

systems. The ATS alerts when speed of the train exceeds

the specified value. If an operator ignores the alert and

keeps on increasing the speed, then interlock system

specifically activates the emergency brake. To avoid the

activation of emergency brake, operator has to push

‘‘confirmation’’ button. Then the activation of interlock is

blocked. The ATS-P is advanced one, the position of stop

signal, the information on time limitation, the inclination,

and the distance, etc. are transmitted from the ground

sensor to the train. The upper limit of speed is checked

sequentially from the breaking performance and the

mileage of the train. This exchange of information and

activation of interlock is the essence of the ATC-P, whose

purpose is ‘‘soft’’ decrease of excessive speed for pas-

sengers’ security and easiness. It, however, should be

noticed that both the ATS-S and P have same interaction

with human. Some media-commentary pointed out, it was

a big problem that the application of the older ATS-S led

to the accident. It is not obviously correct. The problem is

mixture of the ATS-S and P and no train control system

was equipped in some areas in this line. The ATS system

is NOT comprehend due to the complex activation con-

ditions and it seems that quite a few operators can

understand them. Different control systems are employed

like a patch-work, which makes difficult to operate the

train without any problem in this line. It is really stressful

for operators.

4.3.2 Perspicuity

Further analysis may be made from different view of

automation level by Sheridan. It is system perspicuity that

means the level how machine concerns with ‘‘Meddle-

someness’’ to human. Perhaps the users of Windows

Personal Computer will recognise it. Some may suffer from

sudden change of indentation by auto-format function;

others feel an avatar ‘‘dolphin’’ is nothing but something to

bother the users. The possible perspicuity levels are as

follows:

Level-0: the machine is not concerned with humans;

Level-1: the machine warns humans after violation;

Level-2: the machine acts as a limitation to humans after

violation (weak interlock);

Level-3: the machine warns man beforehand;

Level-4: the machine acts as a limitation to man before

violation (strong interlock).

The aforementioned levels are improved ones from Gofuku

et al. (2004).

Perspicuity is necessary to be designed according to the

environment, context and users’ voice. However, in many

cases, the system designer tends to only focus on function,

not to decide the perspicuity forgetting especially users’

opinion and real convenience. The user absence design is

also seen in a general chemical process plants, especially

interface design, etc. Vendors devote themselves to intro-

duce highly advanced device, which might have created a

new type of stress to human.

If the JR-accident is considered, the perspicuity of the

train control at the derailed point is evaluated as Level-0,

although almost the area is Level-2 by the ATS-P or

ATS-S. Unfortunately, the very point of the accident was

not recognised as a critical curvature. As mentioned

earlier, the sensors of ATS-S or P is set only at specific

area.

However, the number of the passenger was/is increasing

since many young people have been moving to sub-

urbs (e.g., http://www.stat.go.jp/data/chiri/map/c_koku/pdf/

map3-09.pdf, March 2008). Considering the convenience

of the passengers whose working place is Kobe or Osaka,

more strong interlock, i.e., the higher perspicuity might be

necessary, since

(1) JR-Fukuchiyama line is also operated considerably at

high speed due to the increase of passengers.

(2) Level-4 is necessary and should be introduced in train

control systems if train service is made in a densely

populated region and high safety is required.

4.3.3 Interface design detail

No information is provided. It is only known that the

introduction of CRT is more advanced than that by other

competitors. However, it should be discussed whether

hardwired or CRT is more proper for train control and has

to be studied further.

After the analyses of M and T, the summarised PG-

diagram is shown in Fig. 9. Broken lines denote the indi-

rect causality of the each node.

196 Cogn Tech Work (2009) 11:187–204

123

5 O—Organisation

Plausible quantification methodology has not been estab-

lished in quantitative risk assessment (QRA). It may be

impossible to treat explicitly the basic second generation

HRA such as CREAM, MERMOS (Le Bot 2004) and

ATHEANA (U.S. Nuclear Regulatory Commission 1999).

However, a lot of recent disaster and/or accident (also in

Japan) originate from the organisational factor. For

example, False accident with data falsification report of

Tokyo Electric Power Company, maintenance crews’ death

of The Kansai Electric Power, JR-West Japan (the accident

concerned in this paper), a child death by escaped tyre by

Mitsubishi Motors, the operators’ death of JCO, Chelnobyl,

fire by defected battery by Sony, and disaster of water

heater defects and subsequent concealment by Paroma and

so on. Whenever such disasters take place, both govern-

ment and companies concluded that introduction of safety

culture was required and thereafter they would always keep

safety culture in mind. The companies have promised

safety is the highest priority in their activities. However,

such companies will make same scandal. It is easily rea-

lised that they are too ambitious, since company’s

management always owes risk to obtain benefit. Strangely

Japanese, especially the public, cannot understand this

natural principle. In this Japanese situation, safety culture

seems to be merely rhetoric in this country.

Japanese industries have greatly changed since they

accepted globalisation that really means American Stan-

dards. Specifically Japanese industries made abolition of

seniority order and the life-employment. They also intro-

duce performance-based evaluation (Jo 2006). The essence

of the American (or Western) organisation is the compe-

tition in employee management. As a result, the American

standard led to change of organisation structure. Tradi-

tionally Japanese companies have valued harmony rather

than competition amongst employee (Jo 2006). In fact, it

had been a unified view amongst industrial commentator

that the excellent organisation should have a network

structure rather than hierarchical one, which means even

executives are a node in the network (Wakabayashi 1999).

The diagram of each structure is depicted in Fig. 10.

Out of track,Disaster

Appearancebrake function

DefectPersonalityAmbitious

-fear of failure

Awake sleep disorder

Upset &Violation

PerspicuityInadequate

HI/HCIConsideration is

insufficient.

StructuralThe vehicle is

unstable.

Dutyabandonment

Mobileinterfere

Lowperformance

Trivialerrors

Narrow gauge

Mixed sameType oftrains Trivial

Overrunfailure

Initial violation?

Fig. 9 Interim PG-diagram

A

B

K

C

I J

L

F E

DG

H

N

M

Excellent organizationInterconnected organization structure

Average organization structure (30 years ago). Pyramidtype (hierarchical) constitution

Fig. 10 Network and

hierarchical structure of an

organization

Cogn Tech Work (2009) 11:187–204 197

123

After the introduction of the American standard, Japa-

nese companies have altered to typical Western style

company. As is well known, the US laboratories clearly

distinguish a technician from a researcher and the techni-

cian never engages in research. NASA’s organisational

defect is reported. The manufacturer’s warning of O-ring

defect had never reached executives ears (Hall 2003). It is

virtually impossible for workers to transfer executives.

Thus, the organisation is separated completely and two

different societies are generated. The language used, the

culture, and the way of thinking are differential in each

society, which means communication/information gap is

created in the organisation. Accompanying easy resigna-

tion of workers, loss of motivation, morale hazard and a

decrease of company-centred person are likely to occur

(Takahashi 2006). The change of the organisational struc-

ture is depicted in Fig. 11 (Yamada 1992).

5.1 National

It is argued whether Japanese life is comfortable after

introduction of ‘‘globalisation’’ (the American standard),

since Japanese have singular or unique characteristics in

the world. Japanese people pay attention to negotiation

before action and prefer conference rather than competition

(Ikeda 1983). Therefore, some sorts of grating are gener-

ated everywhere in Japan. Whilst this informal intimation,

the Japanese are rarely unite into one. It is believed in the

Japanese intellects that the Japanese interfere (pull of foot

each other or obstruction) is remarkably active in the

world. (Ryo et al. 2007). Therefore, in Japanese organisa-

tion, organisational consensus is hard to form and

frequently important decision-making is postponed. For

this reason, important management decisions tend to fall

behind. Japanese presses criticise some national failures are

due to this reason, e.g., early stage of refueling problem in

the Indian Ocean in war with ‘‘terrorism’’ (whether it is

true international contributions or not).

Recently, Japan manufacturers a different DVDs; they

are DVD - R, DVD + R and they are now imposing

further different memory medias; Blue Ray Disc and High

Dense DVD in this country forgetting users’ convenience

and national marketing strategy. In the earlier analogue

technology, Japanese made double standard in video

media, VHS and Beta-video tapes.1

The empty words (called ‘‘Tatemae’’ in Japanese) and

actual intention (called ‘‘Honnne’’ in Japanese) have been

an unbridgeable gulf due to compulsory US education after

WW2. It becomes a polite fiction society and the crime is

made malicious like in USA. It may be comprehensive for

Western people that Japanese principle and practice are

different, if they see the Japanese (Kato 1999). For this

reason, Japanese organisations and their customs are rather

opaque and incomprehensive for Westerns’ eyes.

Considering these situations, organisational analysis is

extremely hard also in accident analysis. An analyst has to

think about unique Japanese culture into account.

Besides these incomprehensive characteristics, recent

degradation of Japanese organisation has to be taken into

account. After the lost battle of WW2, giving birth to a

child had been strongly recommended by the Japanese

government. This generation is now retiring from several

companies. They are called ‘‘nodule’’—the bloom genera-

tion or baby-boomer (after WW2) (Sakaiya 1980) and

recently birth rate is drastically decreasing. The imbalance

of the population has made Japan similar to a Western

advanced country. In USA, same phenomena took place

and this bloom generation is called ‘‘the baby boomer.’’

The frequent criticism to the bloom generation is rather

selfish since they had to face severe competition to survive

(Okumura 2006). Now the bloom generation governs

Japan. It is frequently pointed out Japanese companies are

degrading even in Japan (Fujita 1994). It is also pointed out

that other properties of the bloom generation, ‘‘irrespon-

sible’’, ‘‘inconstant’’, ‘‘stingy’’ and negative ones were

observed (Fujita 1994).

The people whose birth year range from 1947 to 1949

comprise the broom generation (Sakaiya 1980). Hence

some of them are now executives of government and

companies recently. As mentioned earlier, Japanese or-

ganisations are changing its structure. The properties of the

bloom generation are all against safety. Since Japanese

Hierarchicalorganization

ExecutiveSociety

Workers’Society

Organisation has been dividedInto 2 societies Gap

Fig. 11 The change of the

organisational structure

1 Toshiba and NEC gave up marketing High Dense DVD since the

leading US cinema company, the Warner Brothers decided to employ

Blue Lay Disc as a video media for next generation in February 2008.

198 Cogn Tech Work (2009) 11:187–204

123

organization is separated into two societies, an excellent

‘‘large-boned’’ mediator is strongly required. Unfortu-

nately, executives of companies of the bloom generation

are rather indifferent to promotion of the younger genera-

tion since their main concern is how they can enjoy a happy

life. As a result, a lot of degraded mediators can be

observed in Japanese organisations. The middle-ranking

managers have actually received the criminal prosecution

in the JR accident (Nakajima 2005). The civil suit is also

worn, and the instruction toward middle-ranking manager’s

compensation is issued (Shimura 1992). Thus, some sort of

punishment to employee named ‘‘Nikkin-Kyoiku’’ is

committed by the mediators and it is considered that

company management by the bloom generation easily

creates the degraded mediator.

As mentioned, if an operator made violation, he is out of

the train operation duty and is sent to re-training centre or

other work place as the ‘‘Nikkin-Kyoiku’’. Table 2 shows

the number of re-training due to violation, etc. from 2004

fiscal year to 2005 fiscal year and the days required for re-

training (Japanese Ministry of Land 2006).

Above three items are the violations/failures specified in

JR inner regulation. The top item is the serious violations/

failures that may have led to the accident accompanying

human death or injury. (might have accompanied death or

injury). The serious problem lies in the many number of

items under ‘‘Others’’. It means many crews had re-trained

as the ‘‘Nikkin-Kyoiku’’, since they never violated the

regulation and re-trained by the obscure judge of inter-

mediate manager/mediator. Although, the JR-West

announces the slight violation is assumed to be classified

under others. However, the standard regard the extent of

‘‘slight’’ violation cannot be observed. The requirement of

re-training was decided by the subjective sense of the

intermediate managers. In the ‘‘other’’ case, days of train-

ing are short. It is too short to understand why the crew

made failures or violation, interlock systems and shortage

of skill. According to the story of the ward chief of

Kyobashi station, weeding of yard as a penalty was never

imposed to re-trainee. However, some crews said some job

was imposed that is nothing to do with the train operation

and it was really stressful. Of course, salary is cut off

during the re-training and real stress was imposed to the

trainees. JR-West insisted they developed a guideline of re-

training. However, concerning the judgment, it was left to

the site. Therefore, the executives never knew how re-

training is made (Japanese Ministry of Land 2006).

Therefore, it may give some idea to evaluate organisa-

tional level in human reliability analysis. The suggested

level is shown in Fig. 12.

5.2 Regional

Observing the companies or organisation in Kansai area,

almost all of them had delay of organisational moderniza-

tion. For, Kyoto, in Kansai area, the capital had been located

around 1,100 years. Therefore many old stores, more than

1,000 years old, still remains especially in Kyoto. In this

kind of the old stores, clerk and apprentice diathesis are

observed. In this work environment, business culture that

creates degraded mediator is easily raised. As same sort of

characteristics of the organisation in Kansai are:

– Director heredity system that may lead to the study

shortage in executives.

– Excessive council system that may lead to slow

decision making and action. (Japanese learned club

2005).

Recently, many Kansai companies are loosing their

competitiveness. The reason seems to be an excessive

outsourcing and as a result, manufacturing or operating

technology is degrading. The contractors are also located in

Kansai area where the small- and medium-sized companies

are dominant. It is also the disadvantage of the excessive

outsourcing that makes the basic technology of the mother

company black-box and an original, technological promo-

tion difficult. Thus, the highly skilled workmen tend to

retire or change companies. When the electric utility is

looked, recent employees do not know the basic technology

for managements of the company (Takase et al. 2007). In

fact, it is suspicious if all operators and guards know and

understand the ATS system perfectly.

As mentioned above, railway companies have been

excessively competitive in Kansai area. It is a famous

gossip amongst railway researcher that Shin-Keihan

(Non-governmental, now Hankyu railway) train and JNR

Table 2 The number of re-training and course days (2004FY-2005FY)

Number Training total (day) Median Maximum Minimum

Serious violation 17 15.4 14 31 1

Specified violation 1 19 13.4 11 32 3

Specified violation 2 86 9.5 7 44 1

Other 241 4.6 2 41 1

Amount 363 6.7 4 44 1

Cogn Tech Work (2009) 11:187–204 199

123

(Japan National Railway, antecedent of JR-West and other

JRs) had made irregular speed competition at a paralleled

point. It is still byword that Hankyu train overtook the

JNR’s limited express that had been the fastest train in JNR

(Yamaguchi 2001). In this sense, this kind of violation had

been popular in Kansai railway companies. Such violated

competition is now never made after beginning service of

Shinkansen train. However, severe competition continues

in several fields. The JR-West virtue is its speed and

modern vehicle design. Other railway companies oppose

with frequent service and the lower charge.

Conclusively, JR-West has focused on speed tradition-

ally, which might be the latent background of the accident.

6 Social

The companies that concern social infrastructure always

suffer from the inconsistent demand of the public (Mi-

yamoto 2002).

6.1 Demand

As mentioned earlier, Japanese lack the sense of risk-

benefit. They frequently insist that risk should be zero in

every industry. The Japanese media’s interesting term

concerning safety is ‘‘safety myth has been fallen’’ when an

accident takes place, nevertheless no industries guarantee

the relevant risk is zero (Concerning JR-press release,

Miyamoto 2002). The public demand that it is cheap, high

speed and comfort. However, the public tend to be

unpleasant to owe the risk. Therefore, they are unpleasant

to pay money for safety. The public in Japan never accept a

fact that disaster or accident can take place at anytime

and anywhere to everyone. These voices—free from

accidents—are frequently created by mass-media (http://

www2.asahi.com/special/050425/TKY200504250185.html,

March 2008). The mass-media also seek for profit and

report an incident drastically without keen research once an

accident occurs. It is natural that the public opinion formed

is inconsistent and the compliance of this demand is

Level-4

REAL Interpreter

and Arbitrator

Level-5

Now, never

exist,

Imaginary

A

B

K

C

I J

L

F E

DG

H

N

M

CEO

Level-3

Hierarchical

Level-2

Hierarchical

Separated

Level-1

Hierarchical

Separated

degraded mediator exists

Safety of organisation

Level high

Fig. 12 Suggested

organisational level

200 Cogn Tech Work (2009) 11:187–204

123

impossible. However, if rejected, mass-media attacks the

executive of the company. In many countries, companies

suffer from broadcasting by mass-media that is not always

correct. It gives the great pressure to the executives of the

companies. Then the executives are frequently obliged to

promise the safety goal that cannot be attained.

7 Culture and environment

7.1 Kansai regional culture

Concerning this aspect, the singularity of Kansai area is

concerned. As pointed out, singularity of Japan is becom-

ing hard to describe apparently due to globalisation.

Compared with Kanto area (Tokyo and Yokohama are

included), people in Kansai area is quite easy to irritate

(PHP Institute learned club 2001). Especially, they are very

severe to the diagram of train operation and never permit

the delay. It may be the famous report by the New York

Times in USA. They tried to give a questionnaire, ‘‘How

late is late?’’ The interesting answer is:

(1) in JR West Japan, 1 min;

(2) in former Japan National Railways and in Britain,

5 min;

(3) in the subway in New York, 6 min (http://www.

nytimes.com/imagepages/2005/04/26/international/

20050427_JAPA_GRAPHIC.html, March 2008).

Kansai passengers are likely to complain if the train is

delayed even a few seconds compared with their watch.

This irritation imposes the railway company strong stress.

In relation with the Sect. 5.2, this strictness becomes the

excessive demand to the site crews via the aforementioned

mediator. No delay is prohibited and if failed, ‘‘Nikkin-

Kyoiku’’ awaited for this crew.

The railway companies in Kansai imposed continuous

pressure of punctual operation than that in Kanto area and

punctual operation has sometimes the higher priority than

safety in Kansai area. Shinkansen train becomes out-of-

service very frequently since JRs stop all relevant Shinkan-

sen trains only if they find small failure to avoid accident.

In the comparison to automation of railway service

facility in Kansai and Kanto, automated ticket machine and

automated ticked gate was introduced more than 10 years

ago in Kansai. The fare IC card had been introduced in

Kansai before railway companies in Kanto did. Kansai

people tend to prefer new technology whilst Kanto people

are rather conservative to it (PHP Institute learned club,

2001). When relevant facilities are automated, people

prefer the more speedy service. Kansai peoples’ hasty/

impatient to railway service might have promoted by this

automation.

From historical view, significant and singular culture is

observed in Kansai area. In Japan, Kyoto in Kansai area

had been capital from 8AD to 19AD. After that capital had

been moved to Tokyo in Kanto area. In this sense, Tokyo is

as accepted as the capital in the recent past, in Kansai.

Especially Kyoto and Osaka had been treated as special

prefecture by the Tokugawa shogunate. Osaka had been

governed by the shogunate directly and Kyoto had been

inspected by the shogunate since the emperor had been in

Kyoto to avoid the rebellion by the emperor. This historical

background led to the anti-Tokyo sense. Till now, some

Kansai old people call Kanto people as ‘‘Bando-mono’’

(means eastern people from some ancient boundary) with

some sort of mockery. Kansai people, especially people in

Kyoto tend to think Tokyo people are rough, careless and

rash. This had been pointed out in the ancient essay

‘‘Tsurezure-Gusa’’, written in 14AD and still now Kansai

people seem to have same sense (Kenko 1330). Current

Japanese capital and Japanese government are in Tokyo.

Therefore, it might be believed some people are unpleasant

to comply with Japanese (central and Kanto’s) regulations.

In fact, the number of crime and regulation violation in

Kansai is very high compared with other areas. (http://

juki.nomaki.jp/keiko.htm, March 2008). Thus, JR-West

accident might have been likely to occur in Kansai from a

cultural aspect.

7.2 Japanese national environment

As known well, Japan is mountainous country and have

narrow plains. Approximately 75% is occupied by moun-

tainous district. The reason, the past JNR introduced

1,067 mm gauge was the lack of plains, since railway track

has been laid along with ridge line of mountains. The lack

of plains is disadvantage for modern high-speed train. For

example, the TGV can have sufficient distance from track

to residences around. In case of Japan, distance from track

to residences is definitely small. Wide room between track

and residences will give the defence in depth as in nuclear

industries, i.e.,

(1) Prevention of accidents: quality control, design

margin, fail sage, fool proof, railway signs, deep

flange of tyre, cant, etc.;

(2) Expansion prevention of accidents (early detection of

accidents, minimise consequence): brake system

governed by ATC/ATS, train central control system;

(3) Mitigation of consequence of post-accidents, wide

room between track and residents.

Considering O, S, E/C, the summarised PD-diagram can

be shown in Fig. 13. It should be noted that it is a

summarised example and all aforementioned findings are

not included.

Cogn Tech Work (2009) 11:187–204 201

123

8 JR-West feedbacks for safety management

Conclusively M, T and O are concerned, the following

findings and countermeasures can be mentioned:

(1) The failure of T (Technology)

– Hardware failure of truck cannot be identified still

in the final report

– Control systems must be re-designed or how

ground sensors are set is carefully re-considered

– The operation of the mixed train should be

avoided.

– A narrow-gauge system should be reconsidered if

competition is demanded.

(2) It can be said that the JR-West accident is the

typical organisational accident of ‘‘separated orga-

nisation (executives and workmen)’’ like as the

NASA Challenger accident. Executives did not

know the problem of workspace that is facing.

(Organisation)

– The improved traditional organisation properties,

which are life employment and seniority order,

may be re-evaluated. Western organisational style

might not fit for Japanese due to racial singularity.

More exactly, imitation or rapid introduction of

Western organisational style will lead to the

accident that affects society. In fact, some leading

companies in Japan gave up performance-based

evaluation since these companies failed to obtain

the higher commercial performance. Workmen

lost motivation to their own work.

– All executives must make continuous efforts to

learn relevant technology of own company/orga-

nisation. Some improved promotion system must

be introduced so that qualified person can take an

active part in company/organisation. It is said by

Japanese that Japan is a technological founding

country that raw-materials are a little. Neverthe-

less most of executives are graduated from the

faculty of cultural science. It was reported that the

Out of track,Disaster

Appearancebrake function

DefectPersonalityAmbitious

-fear of failure

Awake sleep disorder

Upset &Violation

PerspicuityInadequate

StructuralThe vehicle is

unstable.

Dutyabandonment

Mobileinterfere

Lowperformance

Trivialerrors

Mixed sameType oftrains Trivial

Overrunfailure

Initial violation?

SeverePenalty

HI/HCIConsideration is

insufficient.

GenerationOf

Evil mediator

KansaiOrganizational

climate

Excessive of society

demand

KansaiCulture and

climate Pressure toManager of organization

ExcessiveCompetition:

Fast and comfortably

Narrow gauge

JapaneseGeographical

features

Globalisation

False SafetyCulture

Coexistence of“Tatemae” &

“Hnnne”

Fig. 13 The summarised PG-diagram of the JR-West accident

202 Cogn Tech Work (2009) 11:187–204

123

liberal arts course and the science course become

in halves when sitting on the board though when

graduated person join a company, 80% of new

comers were graduated from science course

(Mainichi Shimbun science environment division

2006). It is very serious problem in Japan that the

high school students tend to be reluctant to go on

to faculty of engineering. Japanese companies

must make preferential treatment for engineer or

the person from faculty of natural science.

(3) Shortage of mental caring to M (Human)-person

– Now a worker is rejected by neurological disorder

as a member of company. Such disorder easily

takes place in present stressful company. A

mental care system where the employee can rely

upon freely must be constructed.

As mentioned in the Sect. 3.3, the nodes near blunt ends

cannot be changed or removed easily. The linkages might

be cut-off and the occurrence of the accident may be

mitigated. Considering this idea, some countermeasure can

be thought out (mentioned quite a few, since a lot of

countermeasure to cut off the linkages can be thought out).

(1) Prevent generation of the degraded mediator

Reconsideration of performance-based evaluation of pro-

motion program, personnel system with transparency and

promotion of interpreter are strongly recommended. (The

manager who should not essentially evaluate the employee

is evaluating in a present Japanese performance-based

evaluation. Therefore, current evaluating system has to be

improved or traditional seniority with improvement may be

introduced. Life employment might be re-considered).

(2) Promotion of the researches of perspicuity is strongly

recommended.

(3) The executives in Kansai area must have wider view.

They must not manage the company with anti-Tokyo

sense. For this purpose, the executives have to decide

management policy based upon risk-benefit principle.

They must visit the site frequently and collaborate

with the site crew. They must bare in mind that they

will fail sooner or later if they think it trifle.

The public must also have the sense of risk in current

socio-technical systems.

9 Concluding remarks

The wider and advanced, however, simple analysis was

proposed in this paper. By this simple causality, the root

cause and how the present compound accidents can be

avoided may be found. As shown in this paper, the

JR-West accident was analysed as a case study and more

detailed analysis than governmental final report (JR

Fukuchiyama line derailment tune final report 2007), where

pressure of Nikkin-Kyoiku was concluded to cause the

operator’s unsafe action and only recommended improve-

ment of management to employee, can be made and some

counter measures were delivered with cut of the links of the

accident nodes. Whilst the government report is somehow

sceptical, the analysis by PG-diagram is expected to seek

for the more essential cause and to be a strong tool for

accident feedback.

Ideally the PG-diagram should be analysed by an

organisation. Every level of employee including worker

and executives should participate in the analysis. The

essence of PG-diagram is based on free conception. The

problem how consensus is obtained naturally arises. Con-

cerning this problem accompanying human factors, further

discussion should be made. Perhaps the Japanese KJ

method (Kawakida 1967) might be applicable to this

problem. The KJ method is a stepped analysis. First a lot of

fragmentary data is integrated, second a creative idea is

invented, and thirdly it searches for the beginning of the

problem solution.

Although only human–machine interface is concerned in

this paper. Interaction between M, T, O, S and E/C is very

important in this analysis. For example,

O–M interaction: human affairs, salary, power harass-

ment, etc.,

T–O interaction: whether there is an equipment intro-

duced by the conference and other irregular ways,

introduced technology and mission of organisation, etc.,

O–E/C interaction: whether characteristics of an organi-

sation accept the culture of the nation, etc.

In this way, if the interactions are considered, the analysis

would be more essential and precise.

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