Answer all questions. (Total 100 marks)
The aim of this assignment is to assess your ability to gather testable data, to analyse this data using structured methodology, draw conclusions on the root cause(s) that created this incident, and to detail recommendations on how to prevent such an incident from happening again.
Derailment Accident on the West Japan Railway’s Fukuchiyama Line on 25 April 2005
On 25 April 2005 a West Japan Railway (JR-West) rapid passenger train No. 5418M was travelling on the Fukuchiyama Line from the Takarazuka Station westbound to the Doshishamae Station as scheduled. At approximately 0918 hours while travelling between the Tsukaguchi Station and the Amagasaki Station, Train No. 5418M crashed in Amagasaki City, Hyogo Prefecture.
The derailment occurred at approximately 1.8 kilometres before the Amagasaki Station and five of the seven train cars collided into an apartment building. The first carriage or train car of Train No. 5418M slid into the first-floor carpark of the building.
Train No. 5418M entered a rightward curve with a radius of about 300 metres at 116 km/h which significantly exceeded the speed limit of 70 km/h for the corner. The train driven by a 23-year old driver was carrying an estimated 700 passengers. The driver and 106 passengers died from the accident and another 562 passengers were injured. Of the fatalities, majority were in the first two cars – at least 42 passengers and the driver in the first car and at least 45 passengers in the second car.
The section where the derailment took place remained closed until 19 June 2005 when it reopened for operation. JR-West purchased part of the land surrounding the building and built a memorial site to remember the victims.
You are tasked to conduct an Incident Investigation on what caused these losses using evidence that has already been established. You are not expected to uncover new evidence, but should use sources already in existence and discoverable to the public.
Question 1 – Evidence and Timeline
(a) Examine the collected evidence for this incident and present this using the structure of the Quadrant Model.
(b) You should present each Quadrant independently and highlight your reasons for placing each item within the Quadrant. You should also state where there are shortcomings in the evidence, the reasons why these shortcomings are so, and how they might be overcome (if possible).
(c) For all evidence that you use, you should present actual and/or potential scientific verification, and you should formally cite the source(s).
(d) From this evidence, create a timeline of events that led up to the derailment and the subsequent crash. Each element of the timeline should identify contributory factors and from which sector of the Quadrant Model these come from.
(e) You are free to use other additional tools to support your analysis, but if so, you should state your reason(s) for doing so.
Question 2 – Root Cause Analysis
(a) From the evidence gathered and your timeline, construct a Root Cause Analysis using the Quadrant Model created in Question 1.
(b) Identify the Root Cause(s) of the incident using a Causal Tree.
(c) From this Causal Tree and using the Hierarchy of Controls, compose your conclusion and recommendations to ensure that this incident does not happen again.
(d) Analyse the likelihood of success for each recommendation, presenting reasoning for this.
You are free to choose the format of the recommendations. However, the format chosen should support the earlier assessment methodologies that you employed. (40 marks)
Question 3 – Incident Report
(a) Write a detailed report of this incident using the structure studied in this course, i.e.
(i) What happened?
(ii) What caused it to happen?
(iii) What do you recommend should happen next?
(b) Your report should be in a form suitable for submission to the Board of a company as shown below:
1. Table of Contents
2. Executive Summary – with Recommendations
3. Details of Investigation Team
4. Details of Incident
a. Summary of the Incident
b. Summary of evidence and data
i. Direct evidence
ii. Supporting documentation
iii. Interview evidence
5. Details of Analysis
a. Methods Used
b. Output from RCA – presented in Quadrants
c. Unknowns, Uncertainties, and Controversy
d. Conclusions drawn
a. To prevent recurrence of this type of incident
i. Management System
iii. Other jobs
iv. Other Companies
v. Other Industries
7. Appendices – as needed
c. People involved