RAIB’s response to accident and incident notification
The Regulations place a duty on railway industry bodies (railway infrastructure managers, railway operators, or maintainers), involved in an accident or incident, to notify us
RAIB’s response to notifications
RAIB has a duty co-ordinator and a team of inspectors on call 24 hours a day, 365 days a year.
When we are notified of an accident or incident, we make contact with the railway to obtain sufficient further detail to decide how to respond. Our response will be influenced by:
- whether the event is within the RAIB’s scope
- whether the investigation is mandated by law
- whether there is important evidence at the scene
- whether it is part of a trend
- the safety issues at stake.
In the case of an accident or incident where there is perishable evidence or evidence that needs to be recorded or secured before releasing the site back to the industry, we will deploy inspectors to the site to conduct a preliminary examination.
When we have been notified of an accident or incident, we may decide to carry out a preliminary examination of the circumstances. This may mean that we deploy inspectors to the scene, or to another location (such as a depot), either immediately or by arrangement at a suitable later time. It can also involve further office-based enquiries, often involving review of electronic data.
Sometimes we require assistance with a rapid initial presence at more remote locations. For this purpose, we have arranged for the railway industry to assign selected people from its own staff, known as ‘Accredited Agents’, to carry out limited activities on our behalf until our inspectors arrive on site.
Accredited Agents have all been trained, assessed and approved by RAIB. Their role is to provide us with early information from the site, to ensure that important perishable evidence is recorded, and that other evidence that needs to be protected is identified.
The purpose of a preliminary examination is to gather sufficient information and evidence to enable us to make an informed decision on whether or not to conduct a full investigation of the accident or incident.
Powers of RAIB inspectors
All inspectors carry a RAIB warrant card, which identifies the powers which the law gives them to carry out their work.
Our inspectors have the power to:
- enter property, land or vehicles, on the railway or close to it
- seize anything relating to the accident and make records
- require access to and disclosure of records and information
- require people to answer questions and provide information about anything relevant to the investigation.
When they are acting on our behalf, RAIB’s Accredited Agents also exercise some of these powers.
How RAIB selects accidents to investigate
The railway industry notifies us of many accidents, incidents and near misses each year. We do not investigate all of them. We use various criteria to help us decide which ones we will look into.
The law under which we operate requires us to investigate some types of accidents. These include train collisions and derailments which result in the death of a person, or serious injury to five or more people, or damage costing more than €2m to repair.
Since we could never hope to investigate every accident that is notified to us, the law gives us discretion about whether or not to investigate less serious accidents. When we decide whether to investigate these, we take into consideration various factors. These include:
- the severity of the outcome
- the potential for the consequences to have been more severe
- the potential for new safety learning, and how widely it could be applied
- safety trends
- areas of particular safety concern.
At times the level of public interest in the event and the resources available to us may also influence our decision. We will normally only investigate accidents which involve moving trains although, on occasions, we do investigate other types of accident closely associated with the operation of trains.
Sometimes we are notified of events in which serious consequences have been narrowly avoided. We consider very carefully whether to investigate such incidents which, if circumstances had been only slightly different, could have had a serious outcome.
If we find a number of similar minor events are happening repeatedly, we may launch an investigation into this class of event. This is because such repeated incidents may indicate a weakness in safety management, or deep rooted problems in railway systems or organisations. In such cases, we may monitor the incidents for some time to build up data before beginning an investigation.
When it is clear that the safety learning from an event has been identified by a previous investigation, relates to compliance with existing rules, or is local in nature, we may choose to publish a safety digest, rather than carry out a full investigation.
How we investigate
Every one of our investigations is different, but each follows our established processes. Gathering of evidence begins immediately. Having made the decision to investigate, we publish details of the investigation on this website. We prepare a remit for the investigation, which defines the scope of the investigation work. We tell the companies involved in the event about the investigation remit, and let them know what we will expect from them during the investigation.
Evidence about the cause of the accident may come from a number of different sources such as witnesses, CCTV, audio, data and written records, as well as the trains and the track itself.
The investigation process may involve interviews with witnesses, tests, analysis of data, reconstructions, computer simulations, and discussions with managers, trade unions, regulators and organisations who represent passengers and other rail users.
It is a thorough and painstaking process that takes time, but we aim to complete a full investigation and publish a report as soon as possible, usually between nine and twelve months after the event. When we have decided to publish a safety digest rather than carry out a full investigation, it should appear in two to three months.
During each investigation, we carry out regular reviews, to check that the investigation is following the remit and that the right evidence is being gathered and analysed. Later reviews cover the causal analysis, which determines the factors that contributed to the event and the severity of its consequences.
Recommendations for safety improvements arise from the results of the causal analysis, so we usually know what we are likely to recommend before the drafting of the investigation report begins.
The investigation report
We produce a report on every investigation we carry out. The draft report is reviewed internally at several levels, and is finally approved by the Chief Inspector. We then begin the process of consulting interested parties on the report and the recommendations.
We try to meet organisations who are likely to be affected by our recommendations, to explain why we have reached our conclusions and why we believe that a recommendation is needed, After this, we send copies of the draft report to the companies whose trains, equipment or staff were involved, to individuals whose reputations might be affected by the findings of the report, to regulatory bodies, to organisations representing staff and passengers, and to other parties affected by the accident. The law requires us to do this, and to give people fourteen days to comment on the draft report.
The consultation process adds to the time taken to publish our reports, but it is an important part of the process, and the time that it takes is included in the publication timescales that we aim to achieve, as described above. The purpose of consultation is to allow people to make comments on errors of fact or analysis, or recommendations that may affect them. After the end of the consultation period, we consider the comments and provide a written response to the consultees that explains how we have dealt with each one. If necessary we make changes to the report, and if these are significant or extensive, or if we have changed or added to the recommendations, we will re-consult with affected parties.
Once the whole process is complete, the report is submitted to the Secretary of State and published on this website. Before publication, we send advance copies of the report to the people and organisations who were consulted on it.
We also consult on our safety digests, although the process is simpler because a safety digest does not include recommendations.
While all of our investigations are conducted completely independently of any investigations by other parties, we can share with the railway industry, and will share with other statutory investigatory bodies, technical evidence and factual information arising from tests and examinations that we carry out. We have agreed a Memorandum of Understanding with enforcing authorities to clarify our respective roles.
We will not share the identity of witnesses, their statements, or medical records relating to people involved in the accident or incident. More information about how the RAIB protects the identity of witnesses and their statements can be found in Leaflet 02 - Your witness statement.
During investigations we maintain contact with the various parties involved in the accident or incident. We aim to keep the industry and other people who are involved informed of emerging findings throughout the investigation. We may decide to update the public about progress and findings during the investigation by publishing an interim report or by updating our website.
If at any time during the investigation we become aware of any safety matter we believe requires urgent consideration, we will formally alert the industry and safety authority by issuing an Urgent Safety Advice notice.
The recommendation process
Almost always, our investigation reports will include recommendations to improve safety. We can direct recommendations to any organisation or person that we think is best placed to implement the changes required. This includes railway and non-railway, private and public sector bodies.
The recommendations are also addressed to the relevant safety authorities, or to other public bodies where appropriate, because the law requires them to ensure that recommendations are duly considered and where appropriate acted upon.
For most of our investigations in Great Britain the safety authority, which has the legal responsibility for supervising the safety of the railways, is the Office of Rail and Road (ORR); although there are some recommendations made by us where the Health and Safety Executive (HSE) has been the appropriate public authority (for aspects of accidents and their consequences that were not related to railway operations). For the Channel Tunnel, the safety authority is the Intergovernmental Commission, and for Northern Ireland it is the Department for Infrastructure.
The safety authorities will want to ensure that the recommendations have been considered in accordance with the Health and Safety at Work etc Act 1974 (HSWA), which requires duty holders to reduce the risk of their activities to as low as reasonably practicable (ALARP) taking into account levels of risk, costs of mitigation and good practice. They are also required to report back to us details of any implementation measures, or the reasons why no action is being taken.
We have no role or statutory power to follow up on the implementation of recommendations, unless it becomes relevant as part of a subsequent investigation. As such, feedback from the safety authority provides RAIB with important information on the safety improvements and changing environment that result from our investigations. We publish full details of the status of our recommendations in our Index of RAIB recommendations which we update from time to time.
We identify learning points in our investigation reports and safety digests if we believe that we have identified good practice that might be adopted by others, or where a reminder to the industry to reinforce compliance with existing procedures or standards might be appropriate.
One of the requirements of the Railways and Other Guided Transport Systems (Safety) Regulations 2006 is that railway operators and infrastructure managers must have processes in place, as part of their safety management systems, for learning from accidents or incidents. The opportunities for learning and improvement from our investigations are not just restricted to the parties involved in the investigations, as the reports are readily available to all parts of the industry.
Published: 19 December 2014