Annual Report 2012
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JAPAN TRANSPORT SAFETY BOARD ANNUAL REPORT 2012 A Message from the Chairman The Japan Transport Safety Board (JTSB) was established in October 2008 as an independent and multi transport-mode accident investigation agency through the merger of the Aircraft and Railway Accidents Investigation Commission (ARAIC) and the Japan Marine Accident Inquiry Agency (JMAIA). It aims to enhance the investigation function which is to determine the causes of aircraft, railway and marine accidents or incidents, and to prevent their recurrence. Our mission is to contribute to preventing the occurrence of accidents and mitigating the damage caused by them, thus improving transport safety while raising public awareness, and thereby protecting the people’s lives by accomplishing appropriate accident investigations which thoroughly unveil the causes of accidents and damages incidental to them, and urging the implementation of necessary policies and measures through the issuance of safety recommendations and opinions or provision of safety information. Since its establishment until 2011, the JTSB has published 72 aircraft investigation reports, 49 railway investigation reports, and 3,831 marine investigation reports, together with its recommendations and opinions where required. This Annual Report is the summary of the JTSB activities in 2011. We are honored to be able to share with people around the world our work and activities in the Report. In 2011, investigation reports on 12 accidents and 8 serious incidents were published regarding aviation, and an opinion on a fatal helicopter accident was issued to the Minister of the Land, Infrastructure, Transport and Tourism. In terms of railway safety, investigation reports on 8 accidents and 6 serious incidents were published, and a recommendation regarding a serious incident involving an electric tramway was issued to the operator. In marine safety, investigation reports on 1,027 accidents and 138 incidents were published with 16 recommendations and opinions issued. 2011 was also an important year in determining how the JTSB should operate in future. Following a problem in connection with a previous investigation conducted by the ARAIC, a series of verification meetings involving victims, their families and experts were convened to carry out a verification of the investigation. After a year and a half of verification, the meeting issued a proposal regarding the ideal future of the JTSB in April 2011. Responding to the proposal, we decided to work together for the improvement of our duties, and in July 2011 a panel of experts for improvement of duties was established. Subsequently, we established the Duty Improvement Action Plan and since then, we have been continuously working on duty improvement together with experts. Some of the specific improvements include a regular press conference conducted by the Chairman, and the establishment of the Victims and their Families Liaison Office so that accident investigation information can be provided to accident victims in a timely and appropriate manner. In this Annual Report, we provide introductions in relation to the JTSB’s activities in general. I hope that the Annual Report will provide people with a better understanding of the JTSB and also contribute to improving the safety of international transport. Norihiro Goto Chairman Japan Transport Safety Board Annual Report 2012 Contents A Message from the Chairman Special Topic Establishment of the JTSB Mission, Principles and Duty Improvement Action Plan 1. Duty improvement review process ···································································· 1 2. Mission and Principles ···················································································· 3 3. Duty Improvement Action Plan ········································································ 4 4. Continuous duty improvement ········································································· 6 Chapter 1 Aircraft accident and serious incident investigation 1. Summary of major investigation report ··························································· 10 2. Summary of recommendations and opinions ····················································· 36 3. Statistics of investigations of aircraft accidents and serious incidents ·················· 38 4. Statistics of investigations launched in 2011 ···················································· 38 5. Publication of investigation reports ································································ 40 Chapter 2 Railway accident and serious incident investigation 1. Summary of major investigation report ··························································· 47 2. Summary of recommendations and opinions ····················································· 71 3. Statistics of investigations of railway accidents and serious incidents ·················· 72 4. Statistics of investigations launched in 2011 ···················································· 72 5. Publication of investigation reports ································································ 73 Chapter 3 Marine accident and incident investigation 1. Summary of major investigation report ··························································· 76 2. Summary of recommendations and opinions ····················································· 97 3. Statistics of investigations of marine accidents and incidents ···························· 105 4. Statistics of investigations launched in 2011 ··················································· 106 5. Publication of investigation reports ······························································· 108 Chapter 4 International efforts in accident prevention 1. Objectives and significance of international cooperation ··································· 116 2. International cooperation in accident investigation ·········································· 116 3. Participation in overseas training ·································································· 118 Chapter 5 Other efforts toward accident prevention 1. Publications ······························································································· 119 2. Dispatch of lecturers to seminars ·································································· 119 3. Explanatory guide on accident investigation report on the crash of JAL flight 123 in Osutakayama ··································· 120 Board Members Appendixes Column Commencement of regular press conference by the Chairman ·································· 7 "Victims and their Families Liaison Office" was established in April 2012 ················· 8 The logo of the Japan Transport Safety Board ······················································· 9 Special Topic Special Topic – Establishment of the JTSB Mission, Principles and Duty Improvement Action Plan The Japan Transport Safety Board (JTSB) was established in October 2008 under Article 3 of the National Government Organization Act. It is an independent professional investigation agency formed by the merger of the Aircraft and Railway Accidents Investigation Commission (ARAIC) and the Japan Marine Accident Inquiry Agency (JMAIA), which investigated marine accidents. The agency’s purpose is to conduct scientific investigation into the causes of aviation, railway, and marine accidents or incidents from impartial and neutral standpoint so as to contribute to prevent the occurrence of accidents and mitigate the damage by them. However, in September 2009, it came to light that a member of the ARAIC leaked information on the investigation of the train derailment accident on the West Japan Railway Company’s Fukuchiyama line in 2005 and that undermined the public’s confidence in our investigation. After verification of this regrettable event, the JTSB established a mission, principles and the Duty Improvement Action Plan in March 2012 to promote its reforms so that the JTSB can achieve truly needed investigation and greater social confidence by improving the issues identified through the verification. 1. Duty improvement review process (1) In order to verify the reliability of the Final Report on the JR Fukuchiyama line accident which was publicized in June 2007, including whether the information leakage had any influence on the report, a verification meeting consisting of the victims, their families and experts (the Verification Members) was formed in November 2009. The verification was subsequently conducted over the next one and a half years. The verification concluded that the Final Report was not influenced by the leakage, but the Verification Members pointed out other issues and challenges the JTSB faced, and compiled a proposal on the future of the JTSB (the Proposal). The Proposal pointed out key areas that require improvement, such as ensuring transparency in accident investigation, enhancing the provision of information to victims, and various other issues. It recommended that the JTSB address the issue of duty improvement by setting up a panel of external advisors to review and improve the Board’s duties where necessary in future. The Proposal on the future of the JTSB (excerpt) 10．JTSB Duty Improvement Policy Taking the regtettable event as a lesson, the JTSB is in the process of reviewing the work processes. It should continue to proactively review its duties so as to achieve truly needed investigation and greater social confidence, exploiting the Board’s great capabilities. To this end, the external advisors should be invited to set up a