At about 9:15 on the morning of April 25, 2005, a seven-car rapid train on JR West’s Fukuchiyama Line came into Itami station too fast. The conductor, in the rear cab, hit the emergency brake switch. The train stopped about 72 meters past its mark, backed up, and left at about 9:16:10, roughly 1 minute 20 seconds late.
The conductor had just announced the next stop when the intercom from the driver’s cab rang. The conductor couldn’t recall the exact words; it was something like “makete kurehen ka,” Kansai dialect for “can you knock it down a bit?” The conductor took it as a request to report a shorter overrun, said the train had gone quite a way, and hung up. A passenger was rapping on the glass, demanding an apology announcement.
Then the conductor radioed the control center. The overrun had felt like 30 or 40 meters. But the conductor had heard that around 5 meters meant no harsh punishment for a driver, and 5 seemed too few. So the conductor said 8. The dispatcher repeated the figure back.
Somewhere in the five seconds after that read-back, the train passed the point where braking for the next curve should have begun. Radius 304 meters, limit 70 km/h. By the investigators’ estimate the brakes came about 16 seconds late, and the train entered the curve at about 116 km/h. At 9:18:54 the first car tipped onto its left side and slammed into an apartment building. It killed 107 people, 106 passengers and the driver, and injured 562.
He was 23 and had been driving trains for less than a year. In June 2004 he had overrun a station by 100 meters and was pulled off duty for 13 days of what was known as nikkin kyoiku, “day-shift education”: incident accounts, reflective essays, reports. A colleague who sat through it with him said essays came back until they had the words supervisors wanted; you wrote things you didn’t believe, or you didn’t drive. His pay for the period fell by 43,471 yen. An acquaintance told investigators he had said one more mistake could cost him his job as a driver.
The Aircraft and Railway Accidents Investigation Commission reported in June 2007. Thinking his call had been cut off, it found, the driver was listening closely to the conductor’s radio exchange and, worried about being sent to nikkin kyoiku, was likely working out excuses to match “8 meters.” A red pencil on the cab floor suggested he may also have been trying to note it down. The commission said JR West’s way of managing drivers, with retraining or discipline that could feel like a penalty and harsher treatment for anyone who failed to report an incident or lied about it, may have played a part.
Investigators found his essay topics were mostly exhortation, with nothing on braking. Yet on some cars of his train’s type, the brake handle could stall between the two strongest positions and apply neither. He had overrun a station that way in July 2004.
Less than an hour before the crash, driving the same train on another line, he had come up on a curve too fast, and the ATS-P safety system sounded a warning and applied the brakes itself. On this stretch of the Fukuchiyama Line, ATS-P was not yet in use; a decision taken in 2003 had pushed its start to April 2005 or later.
The first item in the commission’s recommendations to the transport minister was about reporting: railways should encourage crews to report incidents, including by setting up non-punitive reporting systems.