JAPAN TRANSPORT SAFETY BOARD ANNUAL REPORT 2013 JTSB Mission We 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. JTSB Principles 1. Conduct of appropriate accident investigations We conduct scientific and objective accident investigations separated from apportioning blame and liability, while deeply exploring into the background of the accidents, including the organizational factors, and produce reports with speed. At the same time, we ensure that the reports are clear and easy to understand and we make efforts to deliver information for better understanding. 2. Timely and appropriate feedback In order to contribute to the prevention of accidents and mitigation of the damage caused by them, we send messages timely and proactively in the forms of recommendations, opinions or factual information notices nationally and internationally. At the same time, we make efforts towards disclosing information in view of ensuring the transparency of accident investigations. 3. Consideration for victims We think of the feelings of victims and their families, or the bereaved appropriately, and provide them with information regarding the accident investigations in a timely and appropriate manner, and respond to their voices sincerely as well. 4. Strengthening the foundation of our organization We take every opportunity to develop the skills of our staff, including their comprehensive understanding of investigation methods, and create an environment where we can exchange opinions freely and work as a team to invigorate our organization as a whole. On the Fifth Anniversary of the JTSB This October marks the fifth anniversary of the establishment of the Japan Transport Safety Board (JTSB) since it was inaugurated through the merger and reorganization of the Aircraft and Railway Accidents Investigation Commission and the cause finding part of the Japan Marine Accident Inquiry Agency on October 1, 2008. Just after the establishment of the JTSB, the overall number of investigations substantially increased because marine accidents and incidents were included in its field. Therefore, we had to devise ideas to conduct investigations and deliberations efficiently. However, while maintaining our position as a specialized accident investigation agency, we endeavored to thoroughly clarify the causes of aircraft, railway and marine accidents and incidents and to make and publish investigation reports as quickly as possible. Based on the results of the investigations, we also made recommendations or stated opinions, as the occasion demanded, for administrative organizations and the parties relevant to the cause of the accidents and incidents, thus calling for efforts to prevent a recurrence of similar accidents and incidents in the future. In carrying out our day-to-day investigation activities, we made efforts to enhance the knowledge and expertise necessary for accident investigations while exchanging views with foreign accident investigation organizations in order to improve our accident investigators’ knowledge while keeping in step with the continuous development of new technologies and at the same time, actively taking part in seminars and other meetings involving experts. In these circumstances, the alleged disclosure of information in the course of the investigation of the Train Derailment Accident between Tsukaguchi and Amagasaki Stations on the Fukuchiyama Line of the West Japan Railway Company came to light in 2009. Consequently, public confidence in the investigation report and our investigations was undermined. After one and a half years of verification efforts by victims of the accident and their families, bereaved families and experts, it was confirmed that the information leakage had no influence on the investigation report. However, in order to deal with the problems revealed in the verification process, we launched the Advisory Meeting for Duty Improvement in July 2011 and, in line with recommendations from these experts, we also came up with the Duty Improvement Action Plan in March 2012 which specified the missions we must pursue as an organization and four action principles. In this way, we endeavored to improve our duties by combining all of our resources. In March 2013, we reviewed the contents of the Action Plan in light of the progress of efforts made under the initiative. At present, we are making further efforts to improve our activities. In order to release information in an appropriate and timely manner, we established a regular press conference featuring the chairman starting in August 2011. Through this press conference, we provide a broad range of information mainly about the progress of accident and incident investigations, and the achievements of our duty improvement efforts. From the point of view of better dealing with the voices of accident victims and other related parties, we established the Victims and their Families Liaison Office in April 2012 in order to ensure effective two-way communication by providing victims and their families with information mainly about accident investigations whenever necessary. We have also made efforts to issue more detailed information about our investigation activities to help prevent the recurrence of accidents and incidents. For example, we started providing JTSB Digests and launched a web-based marine accident map on which users can easily search for investigation reports. We are also striving to make our website easier to read and use. Now, after the first five years of the JTSB, the range of accidents and incidents we are required to investigate is expanding and at the same time, we have noted an increase in requests to and expectations of the JTSB. In response to these expectations, while keeping in mind the social responsibilities we shall fulfill from now on, we intend to strengthen our activities even more actively for the purpose of enhancing transport safety. The JTSB Annual Report 2013 is designed to introduce our activities as broadly as possible and it includes summaries of our accident and incident investigation reports published in 2012 on each of the transport modes of aircraft, railway and marine, as well as summaries of accidents and incidents which occurred in 2012, with related statistics and materials and columns by our investigators. We hope that this Annual Report will enable you, the readers, to have a better understanding of what the JTSB is and that it will also contribute to improving the safety of international transport. Your understanding of, and cooperation with, our activities is deeply appreciated. Norihiro Goto Chairman July 2013 A Message on the Fifth Anniversary of the JTSB Seiji Abe Chairman, Advisory Meeting for Duty Improvement of the JTSB Professor, Kansai University Herbert A. Simon, a political scientist and the winner of the 1978 Nobel Prize in Economics, came up with the “Bounded Rationality” concept to explain that there are boundaries in the rationality of the human being. According to Simon, because there are boundaries in the intelligent ability of the human being, he or she cannot foresee all unexpected situations in the future. (A. Simon, Administrative Behavior, Fourth Edition, S & S International, 1997.) Learning from problems and accidents which have actually occurred in the past in order to broaden the outlook and scope of understanding is useful in compensating for these human boundaries. In other words, we must learn from our failures. Herein lies the importance of accident investigation activities for the purpose of preventing a recurrence of similar accidents and incidents. In modern society, the role of transport is decisively important. It may be considered to be a fundamental condition for the existence of modern society. Paul Virilio, a French cultural theorist, pinpointed two characteristics which decisively differentiate modern civilization from past civilizations. The first is “speed” and the second is “accidents” resulting from speed. (Paul Virilio, L' accident originel, Editions Galilée, 2005.) Speed and accidents are accompaniments to transport in today’s society, and it is the Japan Transport Safety Board that endeavors to reduce the number of accidents, which are a negative side of the convenience the speed, through accident investigations. Incidentally, so that accident investigation by a third-party organization is fruitful and that its investigation results may be broadly accepted by society, conditions such as those mentioned below must be fulfilled. First of all, investigations must be carried out in a fair and impartial manner. Secondly, a professional high-level investigation must be conducted. Thirdly, even if an investigation report has a high level of technical content, its form and descriptive style must be easy to read and understand for those affected by the accident and the general public. Finally, the parties relevant to the cause of the accident and the investigative organization should not have the relationship of questioner and the questioned, but rather, they should have a relationship which, while being strained, enables both sides to work together