Building the safety culture of JR East Japan TOMOAKI KURIHARA HIDEAKI KIMURA

1. Building the safety culture of JR East Japan TOMOAKI KURIHARA HIDEAKI KIMURA Transport Safety Department East Japan Railway Company International Railway Safety Conference in Vancouver October 8, 2013

2. Contents Introduction of JR East Group. Safety efforts in the JR East Group “Soft” measures for Safety in the JR East Group Raising up a Culture of Safety 2

3. Contents Introduction of JR East Group. Safety efforts in the JR East Group “Soft” measures for Safety in the JR East Group Raising up a Culture of Safety 3

4. JR Group Map JR Hokkaido JR East JR West Tokyo JR Kyushu Osaka JR Central JR Freight JR Shikoku 4

5. Overview of JR East （1） *The figures are as of April 1, 2011 Number of employees 59,130 Working kilometers 7,512.6 km Number of stations 1,689 Number of in-service trains12,757 Number of trains13,157 Income JPY 1,705.7 billion Number of station escalators1,751 Number of station elevators1,109 Shin-Aomori Hachinohe Akita Shinjo Niigata Nagano Shinkansen1134.7 km Conventional lines6377.9 km Tokyo New direct lines (see above) 275.9 km 5 Extension work underway(Shinkansen)

6. Overview of JR East （2） Per day: Train-kilometers: 700,000 KM Passengers: 16.50 million Crossing openings: approximately 700,000 times Signal validations: approximately 1.2 million times Door openings: approximately 6 milliontimes 6

7. Contents Introduction of JR East Group. Safety efforts in the JR East Group. “Soft” measures for Safety in the JR East Group. Raising up a Culture of Safety. 7

8. Midterm Plans for Safety Safety Priority Investiment Plan 1989-1993Formulation of a safety-related investment plan Safety Basic Plan 1994-1998 Integrated plan covering both tangible and intangible aspects Safety Plan 21 1999-2003 Prevention of major accidents and improvement of transportation quality Safety Plan 2008 2004-2008 Going back to basics and re-approaching safety Safety Vision 2013 2009-2013 Approach safety through independent thinking and acting 8

9. Safety Vision 2013 Approach safety through independent thinking and acting Taking sure steps to reduce risks Prevention of accidents by evaluating risks in advance New perspective I Promoting active installation of safety facilities Creating a culture of safety Safety-related human resource development and system improvement New perspective II Rebuilding a safety management system 9

10. Train accident (all JNR and All JR) All JR All JNR (No. of accidents) 10

11. Number of Railway Operation Accidents [Number ofaccidents] 0.48 [Fiscal year] Reduced by approximately one-third since JR established 11

12. Major past accidents（１） 1951Sakuragicho train fire106 deaths 1962Mikawashima train collision159 deaths 1963Tsurumi train collision161 deaths 12

13. Major past accidents（２） 1988Higashinakano Station train collision2 deaths 2005Fukuchiyama Line derailment 107 deaths 2005Uetsu Line derailment5 deaths 13

14. Operator related (Train collision at Otsuki Station on the Chuo Line) Signal related (Derailment accident at Sendai Railyard) Disasters (earthquakes) (Derailment accident on the Joetsu Shinkansen Line between Urasa and Nagaoka) Passengers: 159 (no deaths or injuries) Passengers: 151 (no deaths or injuries) Passengers: approximately 550 (78 injuries) Train car related (Fire on the Arcadia on the Joetsu Line) Work related (Track upheaval near Takadanobaba Station on the Yamanote Line) Track maintenance related (Backhoe collision near Oimachi Station on the Keihin Tohoku Line) Passengers: 80 (no deaths or injuries) Passengers: approximately 2,000 (3 injuries) Passengers: approximately 150 (no deaths or injuries) One misstep... 14

15. History of railway accidents ○1951 Sakuragicho train fire → Improvements to train body structure, window structure and connecting doors; train announcements; safety manifesto ○1962 Mikawashima train collision → ATS improvement, radio alarms for train protection, regulation revisions, establishment of railway labor science institute ●1987 Japanese National Railways privatized and divided, and JR established ○1988 Higashinakano train collision → ATS-P improvement, safety research institute, training center, Midterm Plans for Safety ○1988 Rokuhara derailment → disaster prevention information system ○1991Shigaraki Kogen Railway collision → substitute blocking on single tracks prohibited as general rule ○1992 Osuga crossing accident → obstacle detection equipment, OH warning device ○1995Great Hanshin Earthquake → anti-seismic reinforcement measures on elevated bridges ○1997Accident at Katahama on the Tokaido Line→blocking instructions operations ○2004Shinkansen derailment caused by the Chuetsu Earthquake → train breakaway prevention measures, early earthquake detection system, power outage detection equipment ○2005Fukuchiyama Line derailment → ATS equipment for curved tracks ○2005 Uetsu Line derailment → expansion of anemometers, gale warning systems, disaster prevention research center, operating regulations and Doppler radar research using weather information 〇2011 Great East Japan Earthquake→ anti-seismic reinforcement measures expanded, behavioral guidelines for tsunami occurence 15

16. Trend in safety investments Approximately JPY 845 billion (Five years) Safety Basic Plan Safety Priority Investment Plan Safety Vision 2013 Safety Plan 2008 Investment results (Hundred millions of yen) Safety Plan 21 Other Investments Investment in Safety Total of over \2.8 trillion in safety investment Fiscal Year 16

17. Overview of the Great East Japan Earthquake Occurred: Friday, March 11, 2011 at around 14:46Epicenter: Sanriku Oki (approximately 130 km east-southeast of Oshika Peninsula (N38.0, E142.9))Earthquake magnitude:M 9.0(maximum magnitude of 7 =Kurihara City, Miyagi Prefecture) Number of aftershocks Magnitude of approximately upper/lower 6: 1 timeMagnitude of approximately upper/lower 5: 14 times(as of 15:00, 3/31) Observed Si value: 85.4 kine at Shin-Sanbongi (Shinkansen) 98.5 kine at Yabuki (conventional line)44.0 kine at Shin-Urayasu (conventional line) [Reference] Shinkansen operations suspended at 18 kine or above Morioka Sendai Niigata Epicenter Fukushima Nagano Takasaki Omiya Tokyo Map of estimated distribution of seismic intensity Source: Japan Meteorological Agency (March 11, 2011 16:00) 17

18. Damage caused by the Great East Japan Earthquake (trains and train cars) Between Matsuiwa and Saichi on the Kesennuma Line: Overturning Ishinomaki Station on the Senseki Line: Flooding Tsugaruishi Station on the Yamada Line: Derailment Between Tomei and Nobiru on the Senseki Line: Derailment Onagawa Station on the Ishinomaki Line: Overturning Sendai Shinko: Derailment and flooding Nagacho Station on the Tohoku Line: Derailment Sendai Station on the Tohoku Shinkansen Line: Derailment Hamayoshida Station on the Joban Line: Flooding and overturning 18 Shinchi Station on the Joban Line: Overturning

19. Damage caused by the Great East Japan Earthquake (ground equipment) Slippage Between Sendai and Shinkansen General Railyard Center on the Tohoku Shinkansen Line: Electric pole breakage Between Sakunami and Yatsumori on the Senzan Line: Embankment runoff Between Shin-Hanamaki and Morioka on the Tohoku Shinkansen Line: Elevated bridge pillar damage (reinforcements exposed) Between Nagacho and Miyagino on the Tohoku Freight Line: Retaining wall landslide and embankment runoff Between Niwasaka and Akaiwa on the Ou Line: Retaining wall tilting and track bed runoff Between Fukushima and Higashifukushima on the Tohoku Line: Bridge girder angle portion damage Hitachitaga Station on the Joban Line: Platform retaining wall collapsed 19 Between Nobukata and Kashimajingu on the Kashima Line: Bridge girder slippage Between Yabuki and Izumisawa on the Tohoku Line:Embankment sinking 19

20. (1) Structural reinforcements Existing countermeasures against earthquakes Seismic reinforcement of elevated bridges (2) Emergency train stops Improvements in the Shinkansen early earthquake detection system Installation of train stop detection equipment in train cars (3) Measures to keep train close to trackin case of derailment L-shaped car guide Countermeasures against rail rollover 20

21. Expanding countermeasures against earthquake Further strengthening through anti-seismic reinforcement measures Anti-seismic reinforcement measures in preparation for earthquakes directly under the Tokyo metropolitan area, and anti-seismic reinforcement measures in other regions Anti-seismic reinforcement of bridges, electric poles, station and platform ceilings and walls, etc. Anti-seismic reinforcement of embankments, slopes, iron girders, brick arch bridges, etc. Reinforcement of anti-stressafter occurrence of an earthquake Speedy search and rescue after the occurrence of an earthquake and measures to ensure the maintenance of the functions of the Countermeasures Headquarters Strengthening communication functions, enhancing capacity of batteries at communications offices ,etc. Operating regulations and evacuation guidance during tsunami warnings Establishment of guidelines on operating regulations and evacuation guidance during tsunami warnings Improvement of facilities aiding evacuation guidance such as ladders for train cars and signs displaying evacuation routes 21

22. Reinforcement of particularly weak sections Embankment (retaining walls, etc.) Chuo Line (Ochanomizu to Suidobashi) Reinforcement example (ground anchor) Countermeasures for large earthquake in Tokyo metropolitan area Times indicated on circles indicate time until seismic shock reaches city center (An earthquake in the north of Tokyo Bay used as calculation example) 25s 15s 10s 15s 20s 25s Early detection and early stopping Expanding anti-seismic reinforcements 22

23. Contents Introduction of JR East Group. Safety efforts in the JR East Group “Soft” measures for Safety in the JR East Group Raising up a Culture of Safety 23

24. Notation ・ “Hard” measures: Installation of equipment or facilities for safety purposes. ・ “Soft” measures: Other non-structural measures. ・ Tazan-no-ishi: Utilization of the experience of another department or workplace. ・ Events requiring attention: Serious events which can cause train operation accidents. 24

25. “Soft” measures for Safety We invest in safety, but・・・ We cannot measure unexpected situations! “Hard” measures And, management resources are limited. In the Great East Japan Earthquake, there were no injuries or fatalities along lines which were affected by the tsunami. ・We are sure that front-line employees can act according to situations. ・Cooperation between system (“hard” measures) and man (“soft” measures) is very important. 25

26. The activation of Challenge Safety Campaign ・To move “maintaining the present level of safety” to “rising to a higher level of safety.” ・”each employee thinks and acts for themselves” In each operating organization, expand the discussion of safety 26

27. The Safety Action for setting “Sangen shugi” The actual location: We should go to the actual location to understand what happened and how it happened. The actual object: We should examine the actual objects, such as rolling stock, equipment, machines and tools to understand the circumstances. The actual people: We should meet face to face with the people actually involved, to understand their circumstances. ・Safety issues are on-site issues. ・The answers to the issues are also on-site. • Is it unnecessary to go on-site? See with one’s own eyes, listen with one’s own ears. Feel and think. • JR East Group’s standards for action in safety 27

28. Safety-related human resource development Key Safety Leaders Cooperating to utilize results from training centers for education at operating organizations. Sharing information and consulting Strong cooperation General Training Center Enhanced training programs to suit real situations. Training Mutual cooperation in training program Safety Professionals 28

29. Building the safety culture of JR East Group Culture of Correct reporting Correct and quick reporting is very important and the starting point for the prevention of accidents. Culture of Awareness If we are aware of the hidden signs leading to accidents and share this information, we can prevent accidents. Culture of Discussion By comingover the fear of discussing what people don’t want to discuss, we can all be aware of the background of incidents or events and can take proper countermeasures against them by discussing them thoroughly. Culture of Learning Learning from accidents continually through the Challenge Safety Campaign or from the data book of past accidents will help us prevent them. Culture of Action Safety is guaranteed only if we relate reporting, awareness, discussing and learning to safety action. Standard behavior and pointing for confirmation are safety actions. “Thinking and acting for ourselves” is the source of support for safety. 29

30. Contents Introduction of JR East Group. Safety efforts in the JR East Group “Soft” measures for Safety in the JR East Group Raising up a Culture of Safety 30

31. Kind of railway accidents occur * Defined in Train Accident Report Regulations Train accidentsCollisions, derailments, fires Accidents at level crossings (Collisions or contact with trains at crossings) Accidents resulting in injuries or fatalities(Accidents causing deaths or injuries to people [excluding suicides]) Accidents causing damage to property (Accidents causing JPY 5 million or more in property damage) Train operation accidents Events requiring attention Events with high possibility of passenger or employee death or injury Transportation disruption Events requiring reporting Events that could lead to a railway operation accident, events causing a major impact on passengers, and events caused by human error Maihyatto Events that were caught in advance, and for which the stipulated handling was conducted as a result Events causing concern on a regular basis Events causing an impact or delay in train operations 31

32. Understanding of the current situation Frequency of occurrence 　　　そのうち、繰り返し発生しているもの（過去の同種発生を含む） Events requiring attention which were similar to past events Month of occurrence 40% of events requiring attention were similar to past events. 32

33. Awareness of accidents decreases exponentially with both time and distance Party directly related to accident Distance Accident Time of accident Time Forgetting

34. Awareness of accidents decreases exponentially with both time and distance Party directly related to accident Distance Accident Time of accident Make the best use of “tazan-no-ishi” Action to prevent forgetting Look back to serious accident of the past Time Forgetting

35. Symposium on Safety Theme 「We learn from these serious events or accidents to prevent accidents which could lead to train accidents involving fatalities or injuries of passengers or employees」～Each employee utilizes and understands experience from other departments or workplaces, and takes action.～ Important views gained from 21st symposium Regarding incidents which could lead to fatalities or injuries of passengers or employees Single out accident cases ex.） We propose to single out only events that are likely to occur in related workplace.ex.） We provide the opportunity to discuss what the fatal problem of accidents or events are, and now to keep them in mind so as not to repeat them.ex.）We make use of reference materials made in each department or workplace for review, selected from accidents or events in the past. ex.） Each employee will be encouraged to think independently and express their thoughtsex.）By using a support tool of “tazan-no-ishi,” each employee utilizes and understands experience from other departments or workplaces. Each employee utilizes and understands Engrave in the heart by “Sangenshugi” and experiences ex.）We make reconnaissance surveys at sites of accidents.ex.）Use a “Serious Accident Encyclopedia,” recording serious accidents of past based on senior employees’ experiences. 35

36. Caravan in Safety 【Theme】“Why ‘tazan-no-ishi’ style thinking is not sufficiently utilized on site.”～To prevent “events requiring attention” that tend to be repeated.～ Problems and issues in operating organizations 【Single out important events】 ◇Head office and branch office handle a large amount of information, so cannot provide customized information due to time constraints. ◇When we researching events to study from, materials are often unavailable, leading to resignation. 【Understand events which are singled out】 ◇Even if we have the information through “ tazan-no-ishi,” we cannot comprehend it sufficiently without understanding differences of operation or background. Information is often wordy and difficult to understand. 【Utilize experience and think thoroughly】 ◇We want to decide the theme of our workplace, but it is difficult to make the materials. It would be helpful to customize common materials based in our company. Found from visits and discussions ○It is difficult to make the best use of others’ experience to prevent accidents involving passenger’s fatality or injury.○Operating organizations have trouble, singling out understanding the singled-out experience, or utilizing the experience. Participants of discussion 36

37. Summary • Recently, in JR East, the frequency of major accidents has greatly decreased. • On the other hand, events have occurred which could lead to serious train accidents involving passengers or employees, including fatality. • These events are often caused by human error, i.e., operative failure, or by blind spots within the system. • We need to learn from these serious events to prevent accidents. It is thus important to cultivate a culture of safety. 37