Transport Accident Investigation Status and Issues
Faculty of Safety Science, Kansai University, 7-1 Hakubaicho, Takatsuki-city, Osaka 569-1098, Japan
Railroad, aviation, and shipping transport accidents tend to be handled as organizational incidents. The objective of accident investigation is to effectively decrease and prevent accident recurrence, rather than to ascribe blame to any person. Such investigations clarify technological, system-based, and managerial shortcomings. By eliminating factors that cause accidents, we may be able to prevent similar recurrences. In this article, we first review the global status of accident, then, look at current situations and issues as they apply to accident investigation in Japan.
-  In this article, aviation, railroad, road and shipping accidents are collectively called transport accidents.
-  After Kuniko Miyajima lost her son in the 1985 Japan Airlines 123 crash, she published her personal notes 25 years later under the title “Living with Osutakayama – 25 years in the Life of a Japan Airlines 123 Crash Victim’s Family.” In it, she eloquently expresses how victims’ families feel when overtaken by such occurrences.
-  James Reason, “Managing the Risks of Organizational Accidents,” Ashgate, 1997, p. 1.
-  H. W. Heinrich, “Industrial Accident Prevention: A Scientific Approach,” 4th Edition, New York, p. 26, 1959.
-  International Civil Aviation Organization, Annex 13 to the Convention on International Civil Aviation, Chapter 3-1.
-  European Transportation Safety Council, “Transport Accident and Incident Investigation in the European Union,” Brussels, 2001, p. 1.
-  Korea’s state-owned railway was “privatized” in 2004-2005 and the Railroad Administration Bureau became the Korea Railroad Corporation. With privatization, the Korean Railway Safety Act was enacted in October 2004 and the Aircraft and Railway Accidents Investigation Commission was established. For details, refer to Abe Seiji, Chung Byung Hyun, Korean Railway Safety Act (1), “The business review of Kansai University,” Vol.50, No.6, pp. 125-127, 2006.
-  Descriptions of multimodal accident investigation organizations in individual countries is based on information from sources in Table 1.
-  Donald R. Whitnah, “US Department of Transportation: A Reference History,” Greenwood Press, pp. 10-12, 1998.
-  National Transportation Safety Board, “2009 Annual Report to Congress,” January 2010, p. 2; Akita Masashi, NTSB and rail accident investigations in the United States (in Abe Seiji (Ed.), “Searching for Prevention of Rail Accident Recurrence,” Nihon Keizai Hyoronsha, 1998), pp. 73-75.
-  The NTSB is supposed to investigate on all commercial airflight accidents, but for other types of accidents, the NTSB’s investigation authority is limited to major or “unusual” accidents. Not all railroad accidents within the US, for example, are investigated by the NTSB. In 2009, accident investigations were conducted in 3 major and 6 regional accidents. For this reason, the Office of Railroad, Pipeline, and Hazardous Materials Investigations, in charge of railroad, pipeline, and hazardous-materials transport accidents, has a staff of only 35 members ; 24 at headquarters and 11 at regional offices. This is less than 10% of the entire NTSB staff (National Transportation Safety Board, Annual Report to Congress 2009. p. 77).
-  Akita Masashi, cited in , pp. 96-99.
-  National Transportation Safety Board, Safety Recommendations Statistical Information,
-  On March 28, 2007, for example, NTSB Chair Mark V. Rosenker stated in a speech at the board’s 40th anniversary that, “I have often said that the NTSB is one of the best bargains in government. With fewer than 400 employees, the Safety Board is responsible for investigating more than two thousand transportation accidents a year. In our 40 years, our independent investigations have played an important part in improving the safety of every mode of transportation. As a result of the efforts of the Safety Board and other government agencies, manufacturers, operators and stakeholders, the United States enjoys a safe transport system that is the envy of the world.”
(NTSB News, March 28, 2007 SB-07-17, http://www.ntsb.gov/Pressrel/2007/070328.htm)
-  When the Omnibus Transport Safety Act was enacted in March 2006, in an additional resolution, the House of Councilors and the House of Representatives emphasized the dual need to, first, enhance investigative ability in clarifying accident causes and preventing the recurrence of aircraft and railway accidents and, second, to maintain and upgrade the accident investigation system. This was also an important impetus in establishing the JTSB.
-  Japan Transportation Safety Board, “Japan Transportation Safety Board: Identification of the causes of aircraft, railways, and marine accidents/incidents for prevention of their recurrence” (leaflet), March 2010.
-  For details on the JTSB’s strengthened authority due to the shift to an “Article 3 organ,” refer to Uga Katsuya, “Current situations and issues of the Japan Transport Safety Board,” Jurist, No.1399, pp. 12-13, April 15, 2010.
-  In September 2009, an ARAIC board member involved in investigating the JR Fukuchiyama Line accident was found to have been leaking inside information to JR West, which was the company that the ARAIC was investigating. This board member also complied with a request from the then JR West president to speak favorably of the railway company at board meetings where investigational reports on the accident were discussed, and tried to change the content of the report. This scandal seriously damaged trust in the JTSB, the ARAIC’s successor. In December 2009, the JTSB directed a verification team on the scandal that included outside experts, accident victims, and victims’ families. As of November 2010, the team is still conducting verification for preventing the recurrence of such scandals.
-  For aircraft accidents, “a memo concerning the Act for Establishment of the Aircraft Accidents Investigation Commission” was made and agreed upon between the National Police Agency director-general and the administrative vice minister for transportation. In September 2008, just before the JTSB was established, a memo entitled “Concerning application of the Act for Establishment of the Transport Safety Board” was drawn up and agreed upon between the National Police Agency director-general and the viceminister of Land, Infrastructure, Transport, and Tourism. The memo in part agreed to follow the agreement made in the February 1972 memorandum.
-  Regarding the claim that, in view of recurrence prevention, accident investigations by third-party organizations are better than those by the police and prosecutors, refer to Abe Seiji, “Searching for Prevention of Rail Accident Recurrence,” (Abe Seiji, cited in ), pp. 204-206.
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