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Using HFACS to Investigate Rail Accidents: Case Study: Amagasaki Rail Crash (2005)


HFACS stands for Human Factors Analysis and Classification System.

Developed by the US Navy to analyze aviation accidents; now widely used in rail, healthcare, and more. Focuses on understanding human and organizational errors. Organizes causal factors into four tiers:


1. Unsafe Acts

2. Preconditions for Unsafe Acts

3. Unsafe Supervision

4. Organizational Influences


Case Study – Amagasaki Rail Crash (2005)


Date: April 25, 2005 | Location: Amagasaki, Japan

Casualties: 107 fatalities, over 500 injuries.

Cause: Train derailed due to over speeding on a curve.

The operator was under pressure due to previous errors and tight schedules.

Investigation revealed deeper organizational and supervisory issues.