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EFGHIPQRS TUVW X Y ` a b c d e f g h i p q r st e ABBCAD u v w X Y 1234156789@ ` a b c d !"#!$%&'$()#!0 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. A Message from the Chairman The Japan Transport Safety Board (JTSB) has the duty that 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. In order to undertake accident investigations that are truly useful tocitizens, we have made concerted efforts to tackle the following issues: “Conducting of appropriate accident investigations,” “Timely and appropriate feedback,” “Consideration for victims” and “Strengthening the foundation of our organization.” We also ensure that we take into consideration the fact that there have been some accidents in recent years that have attracted a lot of attention. With this in mind, we are trying to develop and sophisticate our investigations of accidents and serious incidents. We also make better use of investigation results, as well as develop international cooperation. For instance, since April 2014, we have engaged our investigation field for railway. In addition, in order to improve transport safety for society as a whole, we have published the “Japan-Marine Accident Risk and Safety Information System” (in Japanese and English). We have also issued “JTSB Digests” and the “Analysis Digests Local Office Edition.” Among these, we have released a global version of the first “Japan-Marine Accident Risk and Safety Information System” in April 2014. We have established this information system in the hope of making more detailed information available to other countries that can be used to prevent accidents. We will continue to actively improve transport safety so that we at JTSB can meet our social responsibilities. The “Japan Transport Safety Board Annual Report 2014” presents a summary of our investigation reports published in 2013, which deal with each of the transport modes of aircraft, railway, and marine. This publication also includes summaries of the accidents and incidents that occurred in 2013, and contains related statistical materials. Furthermore, it includes some feature articles for the “Utilization of Accident Investigation Results to Improve Transport Safety” and columns by the accident investigator. We sincerely hope that this Annual Report will enable you, the readers, to have a better understanding of what the JTSB is contributing to. Your understanding of, and cooperation with, our activities is deeply appreciated. Norihiro Goto Chairman Japan Transport Safety Board June 2014 Japan Transport Safety Board Annual Report 2014 Contents JTSB Mission / JTSB Principles A Message from the Chairman Special Article Improving transport safety by utilizing accident investigation result 1. Various proposals (recommendations, opinions, safety recommendations), information provision ··········································3 2. JTSB Digests ································································································3 3. Analysis Digests Local Office Edition ··································································4 4. Information dissemination to other countries ···························································4 5. Japan-Marine Accident Risk and Safety Information System ········································5 Chapter 1 Summary of major investigation activities in 2013··············································8 1. Statistics of accident investigation activities ····························································8 Chapter 2 Aircraft accident and serious incident investigations ········································· 11 1. Aircraft accidents and serious incidents to be investigated ········································· 11 2. Procedure of aircraft accident/incident investigation ················································ 13 3. Statistics of investigations of aircraft accidents and serious incidents ···························· 14 4. Statistics of aircraft accident and serious incident investigations launched in 2013 ················································· 14 5. Summaries of aircraft accidents and serious incidents which occurred in 2013················· 15 6. Statistics of published aircraft accident and serious incident investigation reports······························································· 19 7. Summaries of recommendations and opinions ························································ 25 8. Actions taken in response to recommendations in 2013 ··········································· 35 9. Information dissemination in the process of investigations in 2013······························· 42 10. Summaries of major aircraft accident and serious incident investigation reports (case studies) ············································ 45 Chapter 3 Railway accident and serious incident investigation ·········································· 50 1. Railway accidents and serious incidents to be investigated········································· 50 2. Procedure of railway accident/incident investigation ················································ 56 3. Statistics for the investigations of railway accidents and serious incidents······················ 57 4. Statistics for investigations launched in 2013 ························································· 57 5. Summaries of railway accidents and serious incidents that occurred in 2013 ··················· 58 6. Publication of investigation reports ····································································· 61 7. Summary of recommendations and opinions ·························································· 67 8. Actions taken in response to recommendations in 2013 ············································· 71 9. Information dissemination in the process of investigations in 2013······························· 79 10. Summaries of major railway accident and serious incident investigation reports ···················· 80 Chapter 4 Marine accident and incident investigations ···················································· 85 1. Marine accidents and incidents to be investigated···················································· 85 2. Procedure of marine accident/incident investigation················································· 87 3. Jurisdiction of the Offices over marine accidents and incidents ··································· 88 4. Role of the Offices and Committees according to category of accident and incident ··················· 89 5. Statistics of investigations of marine accidents and incidents (As of end of February 2014) · 89 6. Statistics of investigations launched in 2013 (As of end of February 2014) ····················· 90 7. Summaries of serious marine accidents and incidents which occurred in 2013 ················· 93 8. Publication of investigation reports ····································································· 98 9. Summaries of recommendations and opinions ·······················································105 10. Actions taken in response to recommendations in 2013 ··········································111 11. Information dissemination in the process of investigations in 2013······························128

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