| Case Name |
By the signal error, the train was stopped. |
| Pictograph |
|
| Date |
September 8, 2003 |
| Place |
The Yachimata City, Chiba Prefecture |
| Location |
The JR Sobu Line E station premise. |
| Overview |
Roof folded plate with the shed new construction of the station was tightened.
The train lookout man signaled to a manager to leave from the field after confirming the approach of a train over 800m away, then lookout-man confirmed workers had left and signaled train operator to leave, and at that time he didn't raise a yellow flag but a red flag, so the train stopped. |
| Incident |
While working at neighboring business line, a construction manager and a train lookout man were stationed and carried out the work at pause, but when a train approached the field, work had to be suspended and lookout man was meant to signal to the train operator whether the train can approach safety, ( the yellow means proceed and the red is stops ) .
Since the train lookout man made a mistake, the train under business operation had been stopped, when the signal of the shunt completion is issued by accident on at day.
By this, the concerned train was delay 2 minutes. |
| Sequence |
The work on that day was the construction on the roof and it was done by a construction manager, two sheet metal workers and a train lookout man.
At 9:00 a.m., the construction manager announced for work to start and that it should be carried out.
At 9:02 a.m., the train lookout man stand in a fixed position.
At 9:15 a.m., since the train lookout man confirmed a train was approaching about 800m in front, he raised the red flag to the construction manager.
After 9:16 a.m., the train lookout man confirmed the signal and raised the red flag to the train driver.
The train was passed in front of the lookout man, while the train driver put his face out of the window, and the train stopped in the station building.
The abnormality was sensed, since the train driver was putting the face out of the driver's seat towards the train lookout man, and when nominating flag was watched the flag was red.
The confirmation telephone of "whether train lookout man is staffed the station" entered the E station from 9:20 a.m..
The E station employee confirmed "that the red flag was raised in error," to the train lookout man, and train resumed operation. |
| Cause |
The train lookout man signaled completion of evacuate without confirming the color of signal flag.
The train lookout man thought the yellow and red flags were the same, and had put both flags in his hip pocket.
The signal was not confirmed, when before and during be used the signal flag.
Construction manager didn't instruct the train lookout man about how to carry the red flag in morning gathering and in the inspection.
There was no role about prior confirmation and acquirement way for carry ingredient of the train lookout man. |
| Countermeasures |
Make the checklist of personal effects.
Teach about confirmation and acquirement way modeled on the checklist of personal effects.
Show a signboard which specified the mission the of train lookout man and the construction manager, and it is confirmed every day.
Check experience of the train lookout man and employ a person who has rich experience. |
| Knowledge Comment |
The human error ( anyone makes mistakes ).
No experience causes make the same mistakes ( sometimes once sometimes twice ). |
| Background |
According to the train driver, when he passed the side of the train lookout man, he didn't only put his face out of a window in driver's seat but also as head "if you made a mistakes", but there no response from the train lookout man.
It stopped at 20m of the fixed stopping place, because the train driver saw a stop signal of the red flag, he intended to ask the circumstance, but the train lookout man didn't any explain. |
| Sequel |
The train lookout man had stood guard for train at night four times but had no experience on signal using flag. |
| Reason for Adding to DB |
A single mistake could result in a large transport disaster. |
| Scenario |
| Primary Scenario
|
Poor Value Perception, Poor Safety Awareness, Carelessness, Insufficient Precaution, Poor Response to Change in Environment, Change in Environment, Regular Movement, Careless Movement, Regular Movement, Wrong Movement, Damage to Society, Social Systems Failure
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| Number of Deaths |
0 |
| Number of Injuries |
0 |
| Consequences |
The train was delayed by two minutes. |
| Field |
Civil Engineering
|
| Author |
KITAJIMA, Munekazu (TEKKEN CORPORATION)
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