JR西日本脱線事故の「組織事故」的考察 (聖学院大学チャペル完成記念論文集)

概要

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The JR West derailment which occurred in April 2005 was analyzed according to the `organizational accident theory'. The `unsafe act' as an immediate cause of the accident was drastic excess of the speed limit at the curve of the Hukuchiyama Line. It was supposed that the excess in speed was caused by human error, that is, not braking and speeding to make up lost time, a common practice in the company not disclosed to the public in order to make up the delay in time, which vioalted the principle of safety first. The excess of speed was caused by a `local workplace factor', i.e. the pressure on the train driver to make up ate time in a congested area. This `local workplace factor' is also considered to be the result of the `organizational factor', i.e. the emphasis on productivity, rather than safety, by the management, due to severe competition with other railway companies. On the Hukuchiyama Line, safety depended on the margin of difference between the speed limit and the normal traveling speed, without resorting to equipment of the advanced ATS (ATS-P). This margin of safety was usually lost que to speeding up to make up for lost time. Therefore, precautions against derailment were utterly unsatisfactory from the point of view of `defence-in-depth'.
2006-03-27