Abstract
Similar crashes or incidents may recur as a result of insufficient communication in uncertain and risky situations that potentially threaten safety. The common root causes of insufficient communication across a series of incidents and crashes must be explored in detail to prevent a vicious circle of similar incidents or crashes from occurring. This study summarizes a series of incidents and crashes (derailment due to excessive train speed) at JR West at the West Japan Railway Company (JR West) that are considered to have arisen from insufficient communication. The incidents included (i) resuming train service without confirming the number of passengers on board and leaving passengers behind the station at Higashi-Hiroshima station, (ii) continuing train service in spite of an apparent risk of a crash detected at Okayama station, and (iii) leaving the crack of the train hood as it was at Kokura station. We discuss the causes of insufficient communication (particularly in relation to the sharing of information) among the three branches of staff—the station staff, the conductor and train driver, and the train operation management center—that led to the incidents or crashes. Two factors contributed to the insufficient communication in the series of incidents and crashes: (a) Asymmetry of authority, which hinders the discussion of issues openly and equally among the branches concerned. (b) An unacceptable level of knowledge or information for all branches concerned.
Highlights
Published: 5 May 2021Careful and accurate communication is critical in a variety of activities and services, such as air traffic, train or medical treatment services
We investigated the issue of insufficient communication underlying a series of incidents and crashes that occurred at JR West
This study addressed the causes of insufficient communication among the relevant staff in a series of incidents and crashes, which potentially pose safety-threatening risks
Summary
Careful and accurate communication is critical in a variety of activities and services, such as air traffic, train or medical treatment services. If one branch with greater authority is not willing to listen to and accept the important information A transmitted by the other branch, the sharing of information and the open communication between branches is hindered Such types of miscommunication as a cause of crashes or incidents are based on symmetry of authority or information and have not been fully explored. This study addressed the causes of insufficient communication (concerning the sharing of information) among the relevant staff in a series of incidents and crashes, which potentially pose safety-threatening risks. We explored why similar insufficient communication repeatedly occurred, from the viewpoints of asymmetry of authority or information and unacceptable levels of knowledge or information, owing to an underdeveloped open safety culture
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