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 The Japan Transport Safety Board (JTSB) is a government organization tasked with investigating the causes of accidents and serious incidents in the transport sector. The sector is closely connected to all of our lives in the modes of aviation, railways and marine. Based on the outcome of these investigations, our goal is to improve transport safety and protect people’s lives by safety recommendations to prevent accidents or to reduce damage when an accident occurs. In 2016, many accidents and serious incidents still occurred throughout Japan. For example, there were the “Serious incident involving an aircraft of Korean Air at Haneda airport” in May in aviation mode, the “Kyusyu Shinkansen derailment due to the Kumamoto earthquake” in April in railways mode and the “Capsizing accident of a fishing vessel, Daifuku Maru” in December in marine mode. We are proceeding with these investigations. In addition, the JTSB is striving to enhance and upgrade its system of investigation to ensure accurate and prompt investigation of accidents and serious incidents. We are also working hard to prevent a recurrence of such accidents or serious incidents by releasing information on the findings obtained in our investigations. As well as the above, we publish investigation reports at the end of investigations. The 938 investigation reports published in 2016 included: the report in November on the “Accident involving an aircraft of Asiana Airlines (collision with ground facilities) at Hiroshima airport” in April 2015 in aviation mode; the report in July on the “Serious incident (fall of a utility pole on tracks) on JR Tohoku Line (Yamanote Line)” in April 2015 in railways mode; and the report in July on the “Capsizing accident of a fishing vessel, Genpuku Maru No.1” in December 2014 in marine mode. Among these, safety recommendations to take measures to enhance safety were issued in the investigation report of the Asiana Airlines accident based on the Chicago convention. “JTSB Annual Report 2017” gives brief descriptions of accidents that occurred and became subject to investigation in 2016, and an outline of investigation reports published in 2016, with additional statistics and other data. I expect the Annual Report will provide useful lessons for improving safety in your various activities. I hope I can count on your continued understanding and support in connection with JTSB activities in future. Kazuhiro Nakahashi Chairman Japan Transport Safety Board June 2017 Japan Transport Safety Board Annual Report 2017 Contents JTSB Mission / JTSB Principles A Message from the Chairman Chapter 1 Summary of Recommendations and Opinions Issued in 2016 ································· 1 1. Recommendations ···························································································· 2 2. Safety Recommendations ················································································· 4 Chapter 2 Summary of major investigation activities in 2016 ·············································· 8 1. Statistics of accident investigation activities ···························································· 8 Chapter 3 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 investigations launched in 2016 ·························································· 14 5. Summaries of aircraft accidents and serious incidents which occurred in 2016 ···················· 15 6. Publication of investigation reports ····································································· 19 7. Actions taken in response to recommendations in 2016 ············································· 20 8. Provision of factual information in 2016 ······························································· 27 9. Summaries of major aircraft accident and serious incident investigation reports (case studies) ··· 29 Chapter 4 Railway accident and serious incident investigations ········································· 35 1. Railway accidents and serious incidents to be investigated ············································ 35 2. Procedure of railway accident/incident investigation ················································ 41 3. Statistics for the investigations of railway accidents and serious incidents ······················ 42 4. Statistics of investigations launched in 2016 ············································· 42 5. Summaries of railway accidents and serious incidents that occurred in 2016 ··················· 43 6. Publication of investigation reports ····································································· 48 7. Actions taken in response to recommendations in 2016 ············································· 48 8. Provision of factual information in 2016 ······························································· 57 9. Summaries of major railway accident and serious incident investigation reports (case studies) ·· 59 Chapter 5 Marine accident and incident investigations ···················································· 65 1. Marine accidents and incidents to be investigated ···················································· 65 2. Procedure of marine accident/incident investigation ················································· 67 3. Jurisdiction of the Offices over marine accidents and incidents ······································· 68 4. Role of the Offices and Committees according to category of accident and incident ················ 69 5. Statistics of investigations of marine accidents and incidents (As of end of February 2017) ······· 70 6. Statistics of investigations launched in 2016 (As of end of February 2017) ·························· 70 7. Summaries of serious marine accidents and incidents which occurred in 2016 ······················ 73 8. Publication of investigation reports ······································································ 75 9. Actions taken in response to recommendations in 2016 ··········································· 76 10. Provision of factual information in 2016 ····························································· 76 11. Summaries of major marine accident investigation reports (case studies) ······················ 78 Chapter 6 Efforts toward accident prevention ······························································· 83 1. Publications ································································································ 83 2. Issuance of the JTSB Digest ················································································ 83 3. Issuance of the Analysis Digest Local Office Edition ··················································· 85 4. Issuance of the JTSB Annual Report ······································································· 87 5. J-MARISIS – Now even easier to use ······································································· 88 6. Outreach lectures (dispatch of lecturers to seminars, etc.) ·············································· 90 7. Activities of the Accident Victim Information Liaison Office ····································· 91 Chapter 7 International efforts for accident prevention ·················································· 93 1. Objectives