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 per year.
On being notified of an accident or incident, our normal approach is to obtain sufficient further detail to decide how to respond. Our response will be influenced by:
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
For accidents or incidents that are in scope and where there is perishable evidence or evidence that needs to be recorded or secured before releasing the site back to the industry, inspectors are deployed to the site to conduct a preliminary examination.
We employ inspectors and principal inspectors with either a professional railway or investigation background, and who have been given extensive and bespoke training concerning railway operations, railway engineering and investigation skills.
All inspectors carry a RAIB warrant card, which identifies their powers at the scene of an investigation.
Our inspectors have the power to:
enter railway property, land or vehicles
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
We have operational centres in Derby and Farnborough. Having two operational centres provides for quicker responses to accidents occurring in any part of the UK. There can be occasions when we require assistance to ensure a rapid initial presence at the more remote locations. For this purpose, we can ask the railway industry to assign personnel 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 pre-selected, trained, assessed and approved by us. Their role is to provide us with early information from the site and to ensure that important perishable evidence is recorded and other evidence that needs to be protected is identified.
The purpose of a preliminary examination is to gather sufficient details and evidence to enable us to make an informed decision about the accident or incident and whether or not to conduct a full investigation. Evidence about the cause of the accident may come from a number of different sources including witnesses, the trains, the track, the signalling system and other infrastructure management, operations and procedures or maintenance, design and training documents. It may also be in different forms, including damaged equipment, data from monitoring equipment on trains and in the signalling system or records.
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 death, or serious injury to five or more people, or damage costing more than €2m to repair.
Very few events come into this category. The law gives us discretion about whether or not to investigate less serious accidents and incidents. When we decide whether to investigate these, we take into consideration various factors. This can include the safety learning that may come out of an investigation, the severity of the outcome, the level of public interest in the event, safety trends, or areas of particular safety concern. At times 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 incidents which, if circumstances had been only slightly different, could have had a serious outcome.
If we find a number of 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 apparent that the safety learning 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.
Some events that result in death or serious injury will not be investigated by RAIB (and are not required to be notified to us). This is because, from the information available at the time, it appears that the person concerned has deliberately trespassed or otherwise put themselves in harm’s way, and there are no safety lessons to be learned.
While all of our investigations are conducted completely independently of any investigations by other parties, we can share with industry stakeholders, and will share with other statutory investigatory bodies, technical evidence and factual data arising from tests and examinations that we carry out. We will not share witness statements or identification, nor medical records relating to persons 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 industry stakeholders involved with the accident or incident. We aim to keep involved parties informed of emerging findings throughout the investigation and may elect to inform the broader industry of progress and findings during the investigation by way of an interim report.
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.
The investigation report
On completion of the investigation we produce a draft report for consultation, as required by the Regulations, with the industry stakeholders, safety authority, individuals and anyone involved in the investigation, and those to whom a recommendation may be directed. We consider representations and will revise the report if we consider that the changes are appropriate.
On completion, the Chief Inspector sends the report to the Secretary of State for Transport and it is published on our website.
The recommendation process
Where appropriate, our investigation reports will include recommendations to improve safety. We can direct recommendations to any organisation or person it thinks is best placed to implement the changes required (the ‘end implementer’). This includes railway and non-railway, private and public sector organisations. Those persons or organisations will be informed of the recommendations through involvement in the investigation and/or our consultation and being formally sent a copy of the final report.
The recommendations are also addressed to the relevant safety authorities, or to other public bodies where appropriate, who are required to ensure that recommendations are duly considered and where appropriate acted upon. 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 implementation measures are being taken. We have no role or statutory powers to follow up on the implementation of recommendations, other than if it becomes relevant as part of a subsequent investigation, so this feedback is important in providing information and transparency on the safety improvements and changing environment resulting from our investigations. We publish full details of the status of our recommendations Index of RAIB recommendations which we will update from time to time.
We may also identify learning points in our full investigation reports if we believe that an investigation has identified good practice that might be adopted by others, or where we believe that a reminder to the industry to reinforce compliance with existing procedures or standards might be appropriate. These are often applied where there is no direct evidence to indicate that noncompliance is broad spread or systemic.
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. Consequently, the opportunities for learning and improvement from our investigations is not just restricted to the parties involved in the investigations, as the reports are readily available to all parts of the industry.
*For most of our investigations on the mainland UK 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 safety authority (for accidents occurring that were not concerned with railway operations. For the Channel Tunnel, the safety authority is the Inter Governmental Commission, and for Northern Ireland it is the Department for Infrastructure.
**Guidance on the ALARP process can be found on the Health and Safety Executive website.
Published: 19 December 2014