Building the safety culture of JR East Japan TOMOAKI KURIHARA
HIDEAKI KIMURATransport Safety Department
East Japan Railway Company
International Railway Safety Conference in VancouverOctober 8, 2013
1. Introduction of JR East Group.
2. Safety efforts in the JR East Group
3.“Soft” measures for Safety in the
JR East Group
4.Raising up a Culture of Safety
Contents Contents
2
1. Introduction of JR East Group.
2. Safety efforts in the JR East Group
3.“Soft” measures for Safety in the
JR East Group
4.Raising up a Culture of Safety
Contents Contents
3
JR Group Map JR Group Map
JR East
JR Central
JR West
JR Shikoku
Tokyo Osaka JR Kyushu
JR Freight
JR Hokkaido
4
5
Nagano
Niigata
Tokyo
AkitaHachinohe
Shinjo
Shinkansen 1134.7 km Conventional lines 6377.9 km New direct lines (see above) 275.9 km
*The figures are as of April 1, 2011
Number of employees 59,130 Working kilometers 7,512.6 km Number of stations 1,689 Number of in-service trains 12,757 Number of trains 13,157 Income JPY 1,705.7 billion Number of station escalators 1,751 Number of station elevators 1,109
Overview of JR East ( 1 ) Overview of JR East ( 1 )
Extension work underway (Shinkansen)
Shin-Aomori
6
Passengers: 16.50 millionTrain-kilometers: 700,000 KM
Door openings: approximately 6 million times
Signal validations: approximately 1.2 million times
Crossing openings: approximately 700,000 times
Per day:
Overview of JR East ( 2 ) Overview of JR East ( 2 )
1. Introduction of JR East Group.
2. Safety efforts in the JR East Group.
3.“Soft” measures for Safety in the
JR East Group.
4.Raising up a Culture of Safety.
Contents Contents
7
Safety Basic Plan 1994-1998Integrated plan covering both
tangible and intangible aspects
Safety Basic Plan 1994-1998Integrated plan covering both
tangible and intangible aspects
Safety Priority Investiment Plan 1989-1993Formulation of a safety-related
investment plan
Safety Priority Investiment Plan 1989-1993Formulation of a safety-related
investment plan
Safety Plan 21 1999-2003Prevention of major accidents and
improvement of transportation quality
Safety Plan 21 1999-2003Prevention of major accidents and
improvement of transportation quality
Safety Vision 2013 2009-2013Approach safety through
independent thinking and acting
Safety Plan 2008 2004-2008Going back to basics and
re-approaching safety
Safety Plan 2008 2004-2008Going back to basics and
re-approaching safety
Midterm Plans for SafetyMidterm Plans for Safety
8
Creating a culture of safety
Rebuilding a safety
management system
Safety-related human resource development
and system improvement
New perspective II
Taking sure steps
to reduce risks
Promoting active installation
of safety facilities
Prevention of accidents by evaluating risks in advance
New perspective I
Safety Vision 2013 Approach safety through independent thinking and acting
Safety Vision 2013 Approach safety through independent thinking and acting
9
Train accident (all JNR and All JR) Train accident (all JNR and All JR)
All JNR
0
20
40
60
80
100
120
140
160
1962 1967 1972 1977 1982 1987 1992 1997 2002 2007 2012
(件)
年度
列車衝突 列車脱線 列車火災
All JR
Collisions
Derailments
Fires
Fiscal year
(No. of accidents)
10
11
5 8142 3 7 1 3 3 4 3 1 2 3 1 3 2 6 4 2 2 2 1 2 1 4
247
176156123116958673727571695184 564046 577432424343363634
124
130116115128
10812292908486668965
646847575657 699290106107108
11
1
11 2
1
1
376
315287
240247210209
168165164160136142152
12111196
121136
92113
134144144147
- 0.5
0.0
0.5
1.0
1.5
2.0
0
100
200
300
400
500
600
87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10 11 12
件
年度
鉄道運転事故の推移
鉄道物損事故鉄道人身障害事故踏切障害事故列車事故列車走行100万㌔あたりの件数
100万㌔あたり
Number of Railway Operation Accidents
[Fiscal year]
Reduced by approximately one-third since JR established
[Number of accidents]
0.48
Accidents causing personal injury Crossing obstacle accidents Train accidentsAccidents per million operating km
Railway damage accidents
Number of accidentsper million kilometers
Trend of railway operation accidents
Major past accidents (1) Major past accidents (1)
1951 Sakuragicho train fire 106 deaths
1962 Mikawashima train collision 159 deaths
1963 Tsurumi train collision 161 deaths 12
Major past accidents (2) Major past accidents (2)
2005 Fukuchiyama Line derailment
107 deaths
1988 Higashinakano Station train collision 2 deaths
2005 Uetsu Line derailment 5 deaths13
One misstep...One misstep...
Operator related(Train collision at Otsuki Station on the Chuo Line)
Passengers: approximately 550 (78 injuries)
Train car related(Fire on the Arcadia on the Joetsu Line)
Passengers: 80 (no deaths or injuries)
Work related(Track upheaval near Takadanobaba Station on the Yamanote Line)
Passengers: approximately 2,000 (3 injuries)
Disasters (earthquakes)(Derailment accident on the Joetsu Shinkansen Line between Urasa and Nagaoka)
Passengers: 151(no deaths or injuries)
Signal related(Derailment accident at Sendai Railyard)
Passengers: 159(no deaths or injuries)
Track maintenance related(Backhoe collision near Oimachi Station on the Keihin Tohoku Line)
Passengers: approximately 150 (no deaths or injuries)
14
○1951 Sakuragicho train fire → Improvements to train body structure, window structure and connecting doors; train announcements; safety manifesto
○1962 Mikawashima train collision → ATS improvement, radio alarms for train protection, regulation revisions, establishment of railway labor science institute
●1987 Japanese National Railways privatized and divided, and JR established○1988 Higashinakano train collision → ATS-P improvement, safety research institute, training center, Midterm Plans for Safety
○1988 Rokuhara derailment → disaster prevention information system○1991 Shigaraki Kogen Railway collision → substitute blocking on single tracks prohibited as general rule
○1992 Osuga crossing accident → obstacle detection equipment, OH warning device○1995 Great Hanshin Earthquake → anti-seismic reinforcement measures on elevated bridges○1997 Accident at Katahama on the Tokaido Line→blocking instructions operations○2004 Shinkansen derailment caused by the Chuetsu Earthquake → train breakaway prevention measures, early earthquake detection system, power outage detection equipment
○2005 Fukuchiyama Line derailment → ATS equipment for curved tracks○2005 Uetsu Line derailment → expansion of anemometers, gale warning systems, disaster prevention research center, operating regulations and Doppler radar research using weather information
〇 2011 Great East Japan Earthquake → anti-seismic reinforcement measures expanded, behavioral guidelines for tsunami occurence
History of railway accidentsHistory of railway accidents
15
276550
813 885 892 892 895 886 979 970 889 872 944 1,023 1,017
1,679
1,3491,638
2,130
2,773
2,189
2,459
2,753
3,153
3,234
3,6373,544
3,074
4,044
4,450
1,6761,5191,560
1,818
1,1771,1121,0801,063
3,211
2,3552,414
2,2702,2232,2362,146
2,2382,2342,262
2,0962,038
1,961
1,749
1,301
829
0
500
1,000
1,500
2,000
2,500
3,000
3,500
4,000
4,500
5,000
87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10 11 12 13(年度)
(億円)
16
Investment results
(Hundred millions of yen)
Safety Priority Investment PlanSafety Priority
Investment PlanSafety Basic
PlanSafety Basic
Plan Safety Plan 21Safety Plan 21Safety Plan
2008Safety Plan
2008
Fiscal Year
Safety Vision 2013Safety Vision 2013
Approximately JPY 845 billion
(Five years)Trend in safety investmentsTrend in safety investments
Total of over \2.8 trillion in safety investment
Inve
stme
nt in
Sa
fety
Oth
er In
vestm
en
ts
17
Occurred: Friday, March 11, 2011 at around 14:46
Epicenter: Sanriku Oki (approximately 130 km east-
southeast of Oshika Peninsula (N38.0, E142.9))
Earthquake magnitude: M 9.0
(maximum magnitude of 7 = Kurihara City, Miyagi
Prefecture)
Number of aftershocks
Magnitude of approximately upper/lower 6: 1 time
Magnitude of approximately upper/lower 5: 14 times
(as of 15:00, 3/31)
Observed Si value: 85.4 kine at Shin-Sanbongi
(Shinkansen)
98.5 kine at Yabuki (conventional line)
44.0 kine at Shin-Urayasu (conventional line)
[Reference] Shinkansen operations suspended at 18
kine or aboveMap of estimated distribution of seismic intensity
Source: Japan Meteorological Agency (March 11, 2011 16:00)
Tokyo
Niigata
Morioka
Sendai
Fukushima
Omiya
TakasakiNagan
o
Epicenter
Overview of the Great East Japan Earthquake Overview of the Great East Japan Earthquake
18
仙台
青森
盛岡秋田
郡山
福島
山形
新潟
川部
大館
東能代
八戸
好摩
花巻
北上
一ノ関
小牛田前谷地
石巻
岩沼
米沢
会津若松
いわき
新庄余目
坂町
大曲
横手
茂市
宮古
野辺地
大湊
久慈
岩泉
盛
女川左沢
仙石線
気仙沼線
釜石線
常磐線
山田線
岩泉
八戸線
東北本線
奥羽本線
陸羽東線
仙山線
磐越東線
Damage caused by the Great East Japan Earthquake (trains and train cars)
Sendai Station on the Tohoku Shinkansen Line: Derailment
Shinchi Station on the Joban Line: Overturning
Tsugaruishi Station on the Yamada Line: Derailment
Between Matsuiwa and Saichi on the Kesennuma Line:
Overturning
Onagawa Station on the Ishinomaki Line: Overturning
Nagacho Station on the Tohoku Line: Derailment
Hamayoshida Station on the Joban Line:
Flooding and overturning
Sendai Shinko: Derailment and flooding
Between Tomei and Nobiru on the Senseki Line: Derailment
Ishinomaki Station on the Senseki Line: Flooding
19
長岡
仙台
青森
盛岡秋田
郡山
福島
山形
松本
長野
高崎
新潟
千葉東京
大宮
八王子
水戸
宇都宮
川部
大館
東能代
八戸
好摩
花巻
北上
一ノ関
小牛田前谷地
石巻
岩沼
米沢
会津若松
いわき
小山
小淵沢
渋川
新庄余目
坂町
大曲
横手
茂市
30km
20km
宮古
野辺地
大湊
久慈
岩泉
盛
女川左沢
日光 烏山
仙石線
気仙沼線
釜石線
常磐線
山田線
岩泉線
八戸線
東北本線
奥羽本線
陸羽東線
仙山線
磐越東線
水郡線
Damage caused by the Great East Japan Earthquake (ground equipment)
Between Sakunami and Yatsumori on the Senzan Line: Embankment runoff
Slippage
Between Fukushima and Higashifukushima on the Tohoku Line:
Bridge girder angle portion damage
Between Nagacho and Miyagino on the Tohoku Freight Line: Retaining wall landslide and embankment runoff
Between Shin-Hanamaki and Morioka on the Tohoku Shinkansen Line: Elevated bridge pillar damage (reinforcements
exposed)
Hitachitaga Station on the Joban Line: Platform retaining wall collapsed
Between Sendai and Shinkansen General Railyard Center on the Tohoku Shinkansen Line: Electric pole breakage
Between Niwasaka and Akaiwa on the Ou Line: Retaining wall
tilting and track bed runoff
Between Nobukata and Kashimajingu on the Kashima Line:
Bridge girder slippage
Between Yabuki and Izumisawa on the Tohoku Line: Embankment sinking
19
20
(1) Structural reinforcements
Seismic reinforcement of elevated bridges
(2) Emergency train stops
Improvements in the Shinkansen early earthquake detection system
Installation of train stop detection equipment in train cars
(3) Measures to keep train close to track in case of derailment
L-shaped car guide
Countermeasures against rail rollover
Existing countermeasures against earthquakesExisting countermeasures against earthquakes
Anti-seismic reinforcement measures in preparation for earthquakes directly under the Tokyo metropolitan area, and anti-seismic reinforcement measures in other regions
Anti-seismic reinforcement of bridges, electric poles, station and platform ceilings and walls, etc. Anti-seismic reinforcement of embankments, slopes, iron girders, brick arch bridges, etc.
21
Further strengthening through anti-seismic reinforcement measures
Speedy search and rescue after the occurrence of an earthquake and measures to ensure the maintenance of the functions of the Countermeasures Headquarters
Strengthening communication functions, enhancing capacity of batteries at communications offices ,etc.
Reinforcement of anti-stress after occurrence of an earthquake
Establishment of guidelines on operating regulations and evacuation guidance during tsunami warnings
Improvement of facilities aiding evacuation guidance such as ladders for train cars and signs displaying evacuation routes
Operating regulations and evacuation guidance during tsunami warnings
Expanding countermeasures against earthquakeExpanding countermeasures against earthquake
10s
15s
20s
25s
Early detection and early stopping
地震発生
地震発生緊急停止
迅速な検知
自動でブレーキ
Countermeasures for large earthquake in Tokyo metropolitan area
Countermeasures for large earthquake in Tokyo metropolitan area
Times indicated on circles indicate time until seismic shock reaches city center(An earthquake in the north of Tokyo Bay used as calculation example)
Jr201r.icoJr201r.icoJr205y.ico
Chuo Line (Ochanomizu to Suidobashi)
Embankment (retaining walls, etc.)
Reinforcement example (ground anchor)
Reinforcement of particularly weak sections
Expanding anti-seismic reinforcements
15s25s
Earthquakeoccurs Prompt detection
Emergency stop
whenearthquake occurs
Automatic braking
22
1. Introduction of JR East Group.
2. Safety efforts in the JR East Group
3.“Soft” measures for Safety in the
JR East Group
4.Raising up a Culture of Safety
Contents Contents
23
・ “ Hard” measures: Installation of equipment or facilities for safety purposes.
・ “ Soft” measures: Other non-structural measures.
・ Tazan-no-ishi: Utilization of the experience of another department or workplace.
・ Events requiring attention: Serious events which can cause train operation accidents.
Notation Notation
24
“Soft” measures for Safety“Soft” measures for Safety
We invest in safety, but ・・・We cannot measure unexpected situations!
・ We are sure that front-line employees can act according to situations.
“Hard” measures
・ Cooperation between system (“hard” measures) and man (“soft” measures) is very important.
And, management resources are limited.
In the Great East Japan Earthquake, there were no injuries or fatalities along lines which were affected by the tsunami.
25
The activation of Challenge Safety CampaignThe activation of Challenge Safety Campaign
・ To move “maintaining the present level of safety” to “rising to a higher level of safety.”・” each employee thinks and acts for themselves”
In each operating organization, expand the discussion of safety
26
The Safety Action for setting “Sangen shugi”The Safety Action for setting “Sangen shugi”
See with one’s own eyes, listen with one’s own ears. Feel and think.
The actual location : We should go to the actual location to understand what happened and how it happened.
The actual object : We should examine the actual objects, such as rolling stock, equipment, machines and tools to understand the circumstances.
The actual people : We should meet face to face with the people actually involved, to understand their circumstances.
The actual location : We should go to the actual location to understand what happened and how it happened.
The actual object : We should examine the actual objects, such as rolling stock, equipment, machines and tools to understand the circumstances.
The actual people : We should meet face to face with the people actually involved, to understand their circumstances.
・ Safety issues are on-site issues.
Is it unnecessary to go on-site?
・ The answers to the issues are also on-site.
JR East Group’s standards for action in safety
27
Safety-related human resource developmentSafety-related human resource development
Key Safety Leaders
Cooperating to utilize results from training centers for education at operating organizations.
Mutual cooperation in training program
Training
Safety Professionals
Enhanced training
programs to suit real
situations.
General Training Center
しっかりと連携
Sharing information and consulting
Strong cooperation
28
Building the safety culture of JR East Group Building the safety culture of JR East Group
Correct and quick reporting is very important and the starting point for the prevention of accidents.Correct and quick reporting is very important and the starting point for the prevention of accidents.
If we are aware of the hidden signs leading to accidents and share this information, we can prevent accidents.If we are aware of the hidden signs leading to accidents and share this information, we can prevent accidents.
By coming over the fear of discussing what people don’t want to discuss, we can all be aware of the background of incidents or events and can take proper countermeasures against them by discussing them thoroughly.
By coming over the fear of discussing what people don’t want to discuss, we can all be aware of the background of incidents or events and can take proper countermeasures against them by discussing them thoroughly.
Learning from accidents continually through the Challenge Safety Campaign or from the data book of past accidents will help us prevent them.
Learning from accidents continually through the Challenge Safety Campaign or from the data book of past accidents will help us prevent them.
Safety is guaranteed only if we relate reporting, awareness, discussing and learning to safety action. Standard behavior and pointing for confirmation are safety actions. “Thinking and acting for ourselves” is the source of support for safety.
Safety is guaranteed only if we relate reporting, awareness, discussing and learning to safety action. Standard behavior and pointing for confirmation are safety actions. “Thinking and acting for ourselves” is the source of support for safety.
Culture of Correct reporting
Culture of Awareness
Culture of Discussion
Culture of Learning
Culture of Action
29
1. Introduction of JR East Group.
2. Safety efforts in the JR East Group
3.“Soft” measures for Safety in the
JR East Group
4.Raising up a Culture of Safety
Contents Contents
30
Mai hyatto
Train accidentsCollisions, derailments, firesAccidents at level crossings(Collisions or contact with trains at crossings)Accidents resulting in injuries or fatalities(Accidents causing deaths or injuries to people [excluding suicides])Accidents causing damage to property(Accidents causing JPY 5 million or more in property damage)
Train accidentsCollisions, derailments, firesAccidents at level crossings(Collisions or contact with trains at crossings)Accidents resulting in injuries or fatalities(Accidents causing deaths or injuries to people [excluding suicides])Accidents causing damage to property(Accidents causing JPY 5 million or more in property damage)
Events causing an impact or delay in train operations
Events causing an impact or delay in train operations
Events that could lead to a railway operation accident, events causing a major impact on passengers, and events caused by human error
Events that could lead to a railway operation accident, events causing a major impact on passengers, and events caused by human error
Events that were caught in advance, and for which the stipulated handling was conducted as a resultEvents causing concern on a regular basis
Events that were caught in advance, and for which the stipulated handling was conducted as a resultEvents causing concern on a regular basis
Transportation disruption
Events requiring attention
Events requiring reporting
Events with high possibility of passenger or employee death or injuryEvents with high possibility of passenger or employee death or injury
* Defined in Train Accident Report Regulations
Kind of railway accidents occur Kind of railway accidents occur
Train operation accidentsTrain operation accidents
31
そのうち、繰り返し発生しているもの(過去の同種発生を含む)
0
2
4
6
8
10
10月 12月 2月 4月 6月 8月 10月 12月 2月 4月 6月 8月 10月 12月 2月 4月 6月 8月 10月 12月 2月 4月 6月 8月 10月 12月 2月
Understanding of the current situation Understanding of the current situation F
requ
ency
of
occu
rren
ce
Month of occurrence
Events requiring attentionwhich were similar to past events
40% of events requiring attention were similar to past events. 32
Accident
Forgetting
Tim
e
Distance
33
Time of accident
Awareness of accidents decreases exponentially with both time and distance
Awareness of accidents decreases exponentially with both time and distance
Party directly related to accident
Accident
Forgetting
Tim
e
34
Look back toserious accident
of the past
Make the best use of “tazan-no-ishi”
Action to prevent forgetting
Awareness of accidents decreases exponentially with both time and distance
Awareness of accidents decreases exponentially with both time and distance
Party directly related to accident
Time of accident
Distance
Symposium on Safety Symposium on Safety
Theme
Important views gained from 21st symposium
Each employee utilizes and understandsex. ) Each employee will be encouraged to think independently and express their thoughtsex. ) By using a support tool of “tazan-no-ishi,” each employee utilizes and understands experience from other departments or workplaces.
Engrave in the heart by “Sangen shugi” and experiencesex. ) We make reconnaissance surveys at sites of accidents.
ex. ) Use a “Serious Accident Encyclopedia,” recording serious accidents of past based on senior employees’ experiences.
ex. ) We propose to single out only events that are likely to occur in related workplace.ex. ) We provide the opportunity to discuss what the fatal problem of accidents or events are, and now to keep them in mind so as not to repeat them. ex. ) We make use of reference materials made in each department or workplace for review, selected from accidents or events in the past.
「 We learn from these serious events or accidents to prevent accidents which could lead to train accidents involving fatalities or injuries of passengers or employees 」~ Each employee utilizes and understands experience from other departments or workplaces, and takes action. ~
Regarding incidents which could lead to fatalities or injuries of passengers or employeesSingle out accident cases
35
Caravan in Safety Caravan in Safety
Our company Employees ofour company
Assistant directorsof our company
Group companies Partners, etc.
18 organizations 121 people 110 people 20 places 76 people 26 companies 46 people
36
【 Single out important events】◇Head office and branch office handle a large amount of information, so cannot provide customized information due to time constraints.◇When we researching events to study from, materials are often unavailable, leading to resignation.【 Understand events which are singled out】◇Even if we have the information through “ tazan-no-ishi,” we cannot comprehend it sufficiently without understanding differences of operation or background. Information is often wordy and difficult to understand.【 Utilize experience and think thoroughly】◇We want to decide the theme of our workplace, but it is difficult to make the materials. It would be helpful to customize common materials based in our company.
【 Theme】“Why ‘tazan-no-ishi’ style thinking is not sufficiently utilized on site.” ~ To prevent “events requiring attention” that tend to be repeated. ~Problems and issues in operating organizations
○It is difficult to make the best use of others’ experience to prevent accidents involving passenger’s fatality or injury.○Operating organizations have trouble, singling out understanding the singled-out experience, or utilizing the experience.
Found from visits and discussions
Participants of discussion
36
Summary• Recently, in JR East, the frequency of major accidents has
greatly decreased.• On the other hand, events have occurred which could lead to
serious train accidents involving passengers or employees, including fatality.
• These events are often caused by human error, i.e., operative failure, or by blind spots within the system.
• We need to learn from these serious events to prevent accidents. It is thus important to cultivate a culture of safety.
37