On the morning of 25 April 2005, at about 09:19, a West Japan Railway Company (JR West) rapid commuter train on the Fukuchiyama Line derailed on a tight left-hand curve at Amagasaki, in Hyōgo Prefecture, just before the morning peak had fully cleared. The seven-car train entered a curve of 304-metre radius — limited to 70 km/h — at about 116 km/h. The leading cars left the rails and slammed into a trackside apartment building; the first car was driven into the ground-floor parking area and the second was crushed against the structure. One hundred and seven people died, including the 23-year-old driver, and 562 were injured. It is one of the deadliest Japanese rail accidents of the postwar era.
The train was a 207-series electric multiple unit running a rapid service. Minutes before the curve, the driver had overrun his stop at Itami station, putting the train roughly 90 seconds behind schedule. Recovering lost time was not a trivial matter at JR West: the railway ran an intensely punctual operation, and a driver who fell behind or made an error faced disciplinary re-education. In the moments before the curve the driver appears to have been preoccupied — his attention drawn to the delay and to a radio exchange about how the overrun would be reported — and he braked late and inadequately, using the service brake rather than the emergency brake until it was too late to slow the train enough for the curve.
The accident was investigated by Japan’s Aircraft and Railway Accidents Investigation Commission (ARAIC), whose functions were later folded into the Japan Transport Safety Board, in report RA2007-3, published in 2007. The Commission did not reduce the disaster to the driver’s overspeed alone. It found the proximate cause was the train entering the curve far too fast because the driver did not brake in time, but it placed that error in a context that made it both more likely and more dangerous: JR West’s punitive retraining regime, known as nikkin kyōiku (“day-shift education”), which subjected erring drivers to humiliating non-driving duties and was found to have created fear that distracted drivers from driving; and the absence of an automatic train stop (ATS) system capable of enforcing the speed limit on that curve. The Finding is therefore Multi-factor.
The legal aftermath turned on whether senior JR West managers could be held criminally responsible for not having installed curve-protecting ATS. Successive prosecutions of former executives ended in acquittals, with courts finding the specific derailment had not been foreseeable in law even as they criticised the railway’s safety management.
At about 4:22 p.m. Pacific time on Friday, 12 September 2008, westbound Metrolink commuter train 111 ran past a red signal at Control Point Topanga, near the Chatsworth district of Los Angeles, and continued onto a single-track section straight into the path of eastbound Union Pacific freight train LOF65-12. The two trains met head-on. Twenty-five people died, including the Metrolink engineer; about 102 passengers were taken to hospitals, with dozens critically hurt. It was the deadliest accident in Metrolink’s history and, at the time, one of the worst US passenger-rail collisions in decades.
The investigation by the National Transportation Safety Board established the cause with unusual directness, because the engineer’s actions in the final minute were recorded in the cellular network. The Metrolink engineer, 46-year-old Robert Sanchez — employed by the contractor that supplied Metrolink’s train crews — had been exchanging text messages throughout his shift with a teenage railfan, and sent his last text at 4:22:01 p.m., roughly twenty-two seconds before impact. He did not observe and respond to the red stop signal at Control Point Topanga, did not slow, and never applied the brakes. The Union Pacific engineer applied emergency braking about two seconds before the collision, far too late to matter.
The NTSB’s probable cause is stated plainly: “the failure of the Metrolink engineer to observe and appropriately respond to the red signal aspect at Control Point Topanga because he was engaged in prohibited use of a wireless device, specifically text messaging, that distracted him from his duties.” Because the determining act was the operator’s distraction and failure at the controls, the finding here is recorded as driver. The Board further found, as a contributing factor, the absence of a positive train control system that would have automatically stopped train 111 short of the red signal and prevented the collision.
The case became the catalyst for a national change in US railway safety law. Within weeks Congress passed the Rail Safety Improvement Act of 2008, mandating the installation of positive train control (PTC) on main lines carrying passengers and on key freight routes. A federal liability cap limited the aggregate recovery for all passenger claims to 200 million dollars, which a court had to apportion among the many victims.
At about 2:39 a.m. on 6 January 2005, Norfolk Southern freight train 192 was running through Graniteville, South Carolina, at roughly 47 mph when it met a mainline switch that had been left lined for an industry siding. The switch diverted the through freight off the main line and into the siding, where it collided head-on with a parked, unoccupied train. Three of train 192’s tank cars carrying chlorine derailed; one was breached, releasing a dense cloud of chlorine gas over the sleeping town. Nine people died, including the engineer of train 192; hundreds were treated for respiratory injury, and about 5,400 residents within a mile of the site were evacuated for days.
The chain of events was not mechanical. The switch at the Avondale Mills industry track was a manually operated, hand-throw switch, and it was the responsibility of a crew to return it to the normal — main line — position after finishing work there. The crew of a local train, train P22, had used the industry track earlier and parked their train clear of the main line. When they secured for the night, the switch was not relined to the main line. It stayed set for the siding. Hours later, train 192, with the right of way and no reason to expect a diverted route, ran into it in the dark.
The National Transportation Safety Board investigated and issued railroad accident report RAR-05/04, adopting it on 29 November 2005. Its probable cause was the failure of the crew of train P22 to return the mainline switch to the normal position after completing their work at the industry track. The Board found a contributing factor in the absence of any feature or mechanism that would have reminded the crew of the switch’s position and prompted them to reline it before leaving — there was nothing in the system to catch the omission. This is an operator/crew finding: a procedural failure in the operation of the railroad, not a defect in a train, a rail, or a tank car’s basic function.
The disaster was, after Lac-Mégantic, among the most consequential American rail-hazmat events of its era. It reshaped how the industry treats the position of hand-thrown switches in dark (unsignaled) territory and intensified scrutiny of how chlorine and other toxic-inhalation-hazard materials are routed and carried by rail.
On the morning of 31 January 2003, a CityRail Tangara interurban train left the rails on a tight curve in a rock cutting near Waterfall, about thirty-seven kilometres south of Sydney, killing seven people — including the driver — and injuring some forty more. The train was travelling at roughly twice the speed the curve was rated for. The reason it was travelling so fast was that the man controlling it was already dead or dying, and every system that should have stopped a train without a functioning driver had failed to do so.
The train was set G7, a four-car Tangara of the State Rail Authority’s CityRail network, running the early service from Sydney’s Central station south toward Port Kembla via the Illawarra line. At about 7:15 a.m., as the train ran through the descending, curving territory near Waterfall, the 53-year-old driver, Herman Zeides, suffered a sudden and fatal cardiac event. He did not brake, did not ease the power, and did not react to the approaching curve. The train accelerated to around 117 kilometres per hour and entered a curve rated for no more than 60. It derailed, the leading cars striking the rock walls of the cutting.
The reason the driver’s collapse did not stop the train was a defeated safety device. The Tangara’s “deadman” control was a foot pedal that the driver must hold within a defined range; releasing it or pressing it fully was meant to cut power and apply the brakes, on the assumption that an incapacitated driver’s foot would slip off. Investigators found that the unconscious driver’s body weight held the pedal within its active range, so the system read a live, attentive driver where there was none. The guard, the train’s second safety-critical crew member, was not monitoring speed and did not intervene with the emergency brake in time; the inquiry found the vigilance and guard-alerting arrangements inadequate to catch a silently incapacitated driver.
A Special Commission of Inquiry was established under the Honourable Peter Aloysius McInerney, who had also led the inquiry into the 1999 Glenbrook accident. McInerney’s final report, delivered in January 2005, located the immediate cause in the driver’s incapacitation and the resulting overspeed, while finding that an underdeveloped safety culture and a reactive approach to risk had left the railway without effective defences against exactly this scenario. The finding for this file is Driver — the proximate cause was the incapacitation of the man at the controls — but the report’s force lay in showing how predictable that single point of failure was, and how poorly the system had guarded against it.