GO/GN3519. Guidance on Accident and Incident Investigation. Rail Industry Guidance Note for GO/RT3119

Transcription

1 GN Published by: Block 2 Angel Square 1 Torrens Street London EC1V 1NY Copyright 2012 Rail Safety and Standards Board Limited GO/GN3519 Issue Three: December 2012 Rail Industry Guidance Note for GO/RT3119

2 Issue record Issue Date Comments One 04 October 2008 Original document Two Three 04 September December 2012 Contains new and reworded SPAD categories and some additional requirements for lead organisations for investigations. Contains revised definition of a SPAD and some additional requirements when reporting local investigations. Amended or additional parts of revised pages have been marked by a vertical black line in the adjacent margin. Superseded documents Uncontrolled When Printed The following Railway Group documents are superseded, either in whole or in part as indicated: Superseded documents GO/GN3519 Guidance on Accident and Incident Investigation, issue two Sections superseded Date when sections are superseded All 02 March 2013 Supply The authoritative version of this document is available at Uncontrolled copies of this document can be obtained from Communications,, Block 2, Angel Square, 1 Torrens Street, London EC1V 1NY, telephone or enquirydesk@rssb.co.uk. Other Standards and associated documents can also be viewed at Page 2 of 42

3 Contents Section Description Page Part 1 Introduction 4 G 1.1 Purpose of this document 4 G 1.2 Background 4 G 1.3 Principles 4 G 1.4 Related requirements in other documents 5 G 1.5 The structure of this document 5 G 1.6 Copyright 5 G 1.7 Approval and authorisation of this document 5 Part 2 Guidance for accident and incident investigation 6 G 2.1 Responsibilities common to infrastructure managers and railway 6 G 2.2 Responsibilities of the lead organisation for formal investigations 12 G 2.3 Responsibilities of the lead organisation for local investigations 18 G 2.4 Responsibilities of infrastructure managers 21 G 2.5 Responsibilities of railway 26 Appendices Appendix A Decision criteria formal investigations 28 Appendix B Decision criteria local investigations 31 Appendix C Requirements for persons responsible for managing the investigation process 33 Appendix D Requirements for persons appointed to lead an investigation 35 Appendix E Explanatory note on progress reporting requirements 39 Definitions 40 References 42 Page 3 of 42

4 Part 1 G 1.1 G G G G 1.2 G Introduction Purpose of this document GO/RT3119 Accident and Incident Investigation mandates requirements for the investigation of accidents and incidents involving more than one infrastructure manager or railway undertaking so that system improvements (including changes to European and national standards, national operating rules and company systems and procedures) necessary to prevent or reduce the likelihood of recurrence, or mitigate the consequences, are identified and implemented. The entitlements and role in the investigation process of railway industry parties and others not directly involved in the event subject to investigation are defined. This guidance document has been published by Rail Safety and Standards Board to give guidance on interpreting the requirements of Railway Group Standard GO/RT3119. It does not constitute a recommended method of meeting any set of mandatory requirements. Background The requirements from GO/RT3119 reproduced in Part 2 of this document define a procedural framework and common processes for the investigation of accidents and incidents to enable: a) Infrastructure managers, railway and other railway industry parties cooperate to investigate immediate and underlying causes, identify measures and make recommendations to eliminate or prevent recurrence and to mitigate consequences of accidents and incidents. b) The results of investigations and recommendations to be reported in a structured way. c) Investigations to be completed and the findings made known in a timely way so that lessons are learned (including the need to review risk controls) at the earliest opportunity. d) An awareness of safety lessons relevant to infrastructure managers' and railway ' operations and the recommended actions to apply them. e) Information necessary to support the development of the industry's safety strategies and safety risk models to be produced and reported. f) Changes to Railway Group or European standards or working instructions to be progressed promptly. G G 1.3 G The requirements from GO/RT3119 reproduced in Part 2 of this document permit infrastructure managers and railway to appoint a person independent of either party involved to lead or participate in a formal investigation if required. Principles The requirements from GO/RT3119 as reproduced in this document are based on the following principles: a) Investigations determine the facts of an accident or incident, its immediate and underlying causes, and make recommendations to eliminate or minimise the risk from such events by addressing the frequency of occurrence and the consequences of the event. b) The investigation processes mandated in this document are not intended as a process for allocating blame or liability. Page 4 of 42

5 c) The information included in a report of an investigation carried out in compliance with this document is not intended to create any presumption of blame or liability. d) No degree of severity or importance is implied either by the use of the provisional collective term or between any of the post-investigation SPAD categories described in GO/RT3119. G 1.4 G Related requirements in other documents The following Railway Group Standards contain requirements that are relevant to the scope of this document: a) GO/RT3118 Incident Response Planning and Management. b) Guidance on SPAD incident categorisation and risk ranking referred to in this document, together with associated Provisional SPAD Data Collection Forms RT/3119/A, B, C and D, can be found on the website G 1.5 G G G G 1.6 G G G G 1.7 G The structure of this document Relevant requirements from Railway Group Standard GO/RT3119 are reproduced with a grey background in this document. Guidance is provided as a series of sequentially numbered clauses prefixed G immediately below the greyed text to which it relates. Specific responsibilities and compliance requirements are laid down in the Railway Group Standard itself. Copyright Copyright in the Railway Group documents is owned by Rail Safety and Standards Board Limited. All rights are hereby reserved. No Railway Group document (in whole or in part) may be reproduced, stored in a retrieval system, or transmitted, in any form or means, without the prior written permission of Rail Safety and Standards Board Limited, or as expressly permitted by law. members are granted copyright licence in accordance with the Constitution Agreement relating to Rail Safety and Standards Board Limited. In circumstances where Rail Safety and Standards Board Limited has granted a particular person or organisation permission to copy extracts from Railway Group documents, Rail Safety and Standards Board Limited accepts no responsibility for, nor any liability in connection with, the use of such extracts, or any claims arising therefrom. This disclaimer applies to all forms of media in which extracts from Railway Group Standards may be reproduced. Approval and authorisation of this document The content of this document was approved by Traffic Operation and Management Standards Committee on 18 September G This document was authorised by on 29 October Page 5 of 42

6 Part 2 G 2.1 G G Guidance for accident and incident investigation Responsibilities common to infrastructure managers and railway Requirement to investigate accidents or incidents 2.1 Responsibilities common to infrastructure managers and railway Requirement to investigate accidents or incidents Infrastructure managers and railway shall investigate accidents or incidents to establish: a) The events leading up to the accident or incident. b) The immediate cause(s). c) The underlying cause(s). 2.1 Responsibilities common to infrastructure managers and railway Requirement to investigate accidents or incidents Infrastructure managers and railway shall identify system improvements necessary to eliminate or minimise the risk from such accidents or incidents by addressing the likelihood of recurrence and the consequences. G Regulation 22 of the Railways and Other Guided Transport (Safety) Regulations 2006 sets a wide-ranging duty of cooperation between transport operators whose activities affect, or are affected by, each other. It also applies to contractors carrying out work on an infrastructure manager's or railway undertaking's premises or plant. G In addition to the basic establishing purposes of an investigation, as listed in requirement , the following general reasons should be considered (non-exhaustive list): a) To establish the role that infrastructure and train borne systems might have played in the events leading up to the incident. This might include such items as (according to the incident concerned) SPAD incident history of a signal or group of signals, operation of signals, management systems, braking distances, transitions between signal types, staff supervision, training and working time patterns of those people involved, vehicle systems and equipment etc. b) To assess human factors issues, including, but not limited to, fitness for work, the working environment, distraction issues, compliance with and fitness for purpose of rules and procedures. c) To examine the process for the input of data into equipment (including train data for in-cab signalling systems). d) To determine the effectiveness and relevance of previously introduced mitigations relating to the incident type concerned and to identify any residual risks. e) To help determine how any lessons learnt from an incident might be communicated to people. f) To provide data for input to SMIS for analysis and use by all organisations that might benefit from it. g) To help assess the potential severity of an incident and the likelihood of reoccurrence. Page 6 of 42

7 h) To help consider the system risks arising from the circumstances of an incident. i) To analyse the impact on any supplementary risk, hazard studies or any other relevant information. G G Decision criteria for when to carry out a formal or local investigation 2.1 Responsibilities common to infrastructure managers and railway Decision criteria for when to carry out a formal or local investigation Infrastructure managers and railway shall use the criteria in Appendices A and B to identify when a formal or local investigation is required. In applying the criteria listed in Appendices A and B, the following factors should also be taken into consideration when deciding whether to instigate an investigation: a) The potential severity of the event. b) For SPAD incidents, the provisional categorisation and risk ranking. c) The need to demonstrate transparency of the investigation process. d) Any requests made by parties to hold a particular category of investigation. 2.1 Responsibilities common to infrastructure managers and railway Decision criteria for when to carry out a formal or local investigation G G Infrastructure managers and railway responsible for employees or contractors involved in an operating incident shall provide the necessary information to the infrastructure manager for the purposes of incident risk ranking. Information relating to SPAD specific incidents would be provided for input into the SPAD risk ranking tool. Lead organisation for formal and local investigations 2.1 Responsibilities common to infrastructure managers and railway Lead organisation for formal and local investigations G Infrastructure managers and railway shall use the criteria shown in Appendices A and B to decide who the lead organisation will be for the purposes of both formal and local investigations. 2.1 Responsibilities common to infrastructure managers and railway Lead organisation for formal and local investigations G Infrastructure managers and railway shall appoint a person who is independent of either organisation to lead the investigation if it is jointly decided that this is the most appropriate action. The possible appointment of a person independent of any party to lead an investigation may arise: a) From situations where the lead organisation is unable to supply a competent person to lead the investigation because of the company s small size. Page 7 of 42

8 b) Because the subject matter or scale of the incident is particularly complex and the investigation is likely to demand the full-time attention of the person appointed to lead it. c) Where involved parties jointly decide that the investigation would be best led by someone independent of those parties to avoid perception of bias in the investigation s findings. G In addition, it may be helpful to invite independent technical experts to advise the investigation panel on technical matters, depending on the circumstances of the accident or incident and the collective expertise of the proposed panel or investigation team. Independent technical expertise may be of value in: a) Traction and rolling stock. b) Track and structures. c) Signalling and telecommunications. d) Train operations. e) Electrification. f) Human factors. g) Road safety if there is a road component to the accident / incident. G G G G Guidance as to the need for, and the names of, appropriate specialists may be obtained from. Designation of responsible persons 2.1 Responsibilities common to infrastructure managers and railway Designation of responsible persons Infrastructure managers and railway shall designate persons to be responsible for managing their processes for leading or contributing to investigations of accidents and incidents. Appendix C contains mandatory requirements for persons designated to be responsible for managing investigation processes. 2.1 Responsibilities common to infrastructure managers and railway Designation of responsible persons Infrastructure managers and railway shall designate persons to be responsible for leading investigations. Appendix D contains mandatory requirements for persons appointed to lead an investigation. G Physical and witness evidence 2.1 Responsibilities common to infrastructure managers and railway Physical and witness evidence Page 8 of 42

9 Infrastructure managers and railway shall record physical and witness evidence of: a) The events leading up to the accident or incident. b) The immediate cause(s) of the accident or incident. c) The consequences of the accident or incident. G d) Any identifiable underlying causes of the accident or incident. The following is a typical list of evidence and information that might need to be collated: a) Training records and records of post event interviews of employees involved in accidents or incidents. b) Maintenance histories and technical tests of equipment involved in accidents or incidents. c) Reports from investigations undertaken at the site of accidents or incidents. d) Witness statements. e) Technical investigation reports required by other standards. f) Train data recorder downloads. g) The results of alcohol and drugs tests. h) Photographs of the accident or incident site and equipment involved. i) Signal box registers. j) Total Operations Process System (TOPS) train lists for the trains immediately involved (or the equivalent for passenger trains). k) Train running system on TOPS (TRUST) reports for the trains involved. l) TOPS train consists for the last train(s) in each direction before the accident / incident. m) TRUST reports for the last train(s) in each direction before the accident or incident. n) Solid state interlocking or integrated electronic control centre (SSI / IECC) event recorder data for a minimum of two hours prior to the accident / incident. o) Telephone and radio recordings, where available, for the signal box and the relevant traffic control room for the two hours immediately prior to the accident. p) Train borne CCTV and visual recording media (interior and exterior). G G Where a witness is called upon to provide oral evidence before an investigation panel, the number of persons present at the time the evidence is given should be sufficient to ensure that the hearing is properly conducted but does not inhibit the process of giving evidence. The lead investigator should determine what that number should be and that those present, collectively, have the necessary competence to evaluate the evidence. When deciding the number of persons that should be present when oral evidence is given, the following factors should be taken into consideration: a) The medical condition of the witness. b) The extent to which a witness s performance might be adversely affected by the number of persons present. Page 9 of 42

10 c) The priority given to the witness s employer and employee representation over others who may wish to be present in an observer capacity. G G G Responsibilities common to infrastructure managers and railway Physical and witness evidence Infrastructure managers and railway shall use the RT/3119 designated Provisional SPAD Data Collection forms when investigating signals passed at danger incidents. The RT/3119/A or C forms are for infrastructure managers, and the RT/3119/B or D forms are for railway. The forms are located on the website. All Provisional SPAD Data Collection forms RT/3119/A,B, C and D can be found at the following website address: The A and B forms should only be used for conventional signalling system SPAD investigations. The C and D forms have been specifically created for application in cases where ERTMS is the primary signalling system. When investigating incidents at transition points between conventional and ERTMS areas, users should make an informed decision on which type of data collection form is most appropriate for the purpose of the investigation. If there was ever a case of a multiple SPAD involving both conventional and ERTMS signalling then normally the data collection form applicable to the first signal passed at danger should be used.there are currently no designated proforma forms for any other type of investigation. Member companies may have or develop such forms for their own use. 2.1 Responsibilities common to infrastructure managers and railway Physical and witness evidence Infrastructure managers and railway shall prioritise the collection of evidence according to the following list of subjects: a) Perishable evidence. For example, assessments of weather, atmospheric and rail head conditions, in-cab indications at the time of the accident or incident, timely retrieval of data logging/event recording / photographic evidence. 2.1 Responsibilities common to infrastructure managers and railway Physical and witness evidence Infrastructure managers and railway shall prioritise the collection of evidence according to the following list of subjects: b) Interviewing of personnel. For example, obtaining written reports from, and interviews of, personnel involved in, or who witnessed the accident or incident. 2.1 Responsibilities common to infrastructure managers and railway Physical and witness evidence Infrastructure managers and railway shall prioritise the collection of evidence according to the following list of subjects: c) Site visits. Page 10 of 42

11 G For example, obtaining photographic evidence (including CCTV footage, where appropriate) of local conditions such as vegetation encroachment. It is permissible for the requirement to be undertaken from the driving cab of a train if necessary. 2.1 Responsibilities common to infrastructure managers and railway Physical and witness evidence Infrastructure managers and railway shall prioritise the collection of evidence according to the following list of subjects: G d) Records of previous related events. For example, timetable change records, obtaining records that relate to previous safety events involving the same persons, location or review of the risk assessment required by GI/RT7006 Prevention and Mitigation of Overruns Risk Assessment, where available. 2.1 Responsibilities common to infrastructure managers and railway Physical and witness evidence G Infrastructure managers and railway shall make the evidence they have gathered available to the person appointed to lead an investigation. The following should be included (as a minimum): a) Alcohol and drug test results. b) Signalling data records. G Action in response to an investigation 2.1 Responsibilities common to infrastructure managers and railway Action in response to an investigation G Infrastructure managers and railway shall evaluate reports of urgent safety problems found during an investigation for relevance to their operations, to identify any need for an immediate response before the completed investigation report and recommendations are published. 2.1 Responsibilities common to infrastructure managers and railway Action in response to an investigation G Infrastructure managers and railway shall evaluate recommendations made in reports of formal investigations for relevance to their operations. 2.1 Responsibilities common to infrastructure managers and railway Action in response to an investigation Page 11 of 42

12 G G G G G G 2.2 G G Infrastructure managers and railway shall document reasons for rejecting any recommendations together with alternative measures for controlling risks identified. 2.1 Responsibilities common to infrastructure managers and railway Action in response to an investigation Infrastructure managers and railway shall report to the Safety Management Information System (SMIS) their progress towards implementing recommendations from industry and Rail Accident Investigation Branch (RAIB) investigations that they have accepted. Appendix E contains non-mandatory information for the reporting of progress towards implementing recommendations. 2.1 Responsibilities common to infrastructure managers and railway Action in response to an investigation Infrastructure managers or railway acting as the lead organisation for an incident investigation shall not, if a Signal Sighting Committee (SSC) has been convened, conclude the detailed analysis of the wider evidence until they are in receipt of the SSC report. Release of information to third parties 2.1 Responsibilities common to infrastructure managers and railway Release of information to third parties Infrastructure managers and railway shall not make public statements or release information to third parties about the progress, evidence or conclusions of an investigation, without the permission of the lead organisation and other railway industry parties involved in the accident or incident being investigated. Responsibilities of the lead organisation for formal investigations Appointment of a person to lead the formal investigation 2.2 Responsibilities of the lead organisation for formal investigations Appointment of a person to lead the formal investigation The lead organisation shall appoint a suitable person to lead the formal investigation according to the mandatory requirements contained in Appendix D. When deciding whether a conflict of interest would be created for a prospective lead investigator, the following factors should be considered: a) Current and previous employment with any party involved in the accident / incident and whether the activities performed in connection with such employment are likely to be significant matters for the investigation in relation to the cause(s) of the event. Page 12 of 42

13 b) Any substantial financial interest (excluding occupational pensions), in any party involved in the accident / incident, the value of which could be significantly affected as a result of the findings and recommendations of the investigation. c) Close personal or commercial relationships with any witnesses likely to be called before the investigation or with persons holding senior office within any commercial corporation involved in the accident / incident. G Remit for person appointed to lead the formal investigation 2.2 Responsibilities of the lead organisation for formal investigations Remit for person appointed to lead the formal investigation The lead organisation shall, at the earliest opportunity after the accident or incident has occurred, consult affected parties on an appropriate remit for the person appointed to lead the formal investigation. The remit shall require: a) Determination of events leading up to the accident or incident, the immediate and underlying cause(s). b) Identification of recommendations that could mitigate or eliminate the risk from such accidents or incidents in future. c) Reporting of urgent problems found during the investigation to the lead organisation and which justify remedial action before the investigation report is completed. d) Completion of the investigation within a defined time limit. G G G e) A written report of the investigation containing any recommendations, and in the case of investigations involving a SPAD, specific and final confirmation of its category as specified in Table 2 of Appendix D, or its alternative conclusion (together with the reasons for such a change). Recommendations identified might include suggested improvements to processes and documents such as European and national standards, operating rules and practices. They might also include suggested physical changes to equipment, infrastructure, rolling stock, environment etc. Whatever changes might be indicated in the recommendations, the likelihood of any recurrence of such an accident or incident and the consequences of not changing identified problems should be addressed. The terms earliest opportunity and defined time limit referred to in should be discussed, ascertained and agreed between all affected parties and the designated lead organisation. This should be done under the principle of cooperation, according to the circumstances of the incident investigation concerned and also taking into account any proposed extentions to time limits required. Time limits for reporting might also be affected by legal issues or official requests from regulatory authorities. In all cases the time limits referred to in the requirements should accord with the nature of the event being investigated and be proportionate to the potential consequences, including those that might have arisen had the circumstances been slightly different. The final confirmation of an incident s SPAD category (if there is one) may involve a change to, or even deletion of, the provisional one that was allocated immediately following the incident. The lead organisation should make this decision based upon their investigation, evidence and professional expertise. In all such cases the lead organisation s final report should contain confirmation categories that accord with the details of Appendix D (see also and associated GN items). 2.2 Responsibilities of the lead organisation for formal investigations Remit for person appointed to lead the formal investigation The lead organisation shall be responsible for communicating the agreed remit to the person appointed to lead the formal investigation. Page 13 of 42

14 G In addition to information provided by the initial stage of evidence gathering, the person designated responsible for preparing the remit should consider whether other issues are relevant for consideration, such as: a) Previous investigations into similar incidents. b) Recent safety incidents involving the same location, equipment or operators. c) Organisational changes. G G G Participation in formal investigation proceedings 2.2 Responsibilities of the lead organisation for formal investigations Participation in formal investigation proceedings The lead organisation shall invite the following to cooperate in formal investigation proceedings: a) Organisations whose employees are directly involved in the accident or incident being investigated, and its cause(s). b) Trades unions, recognised by the employer, who represent employees: Or i) Directly involved in the accident or incident being investigated or its causes. ii) Who are called upon to give evidence. c) Organisations who own or operate rolling stock or infrastructure involved in the accident or incident being investigated. d) Organisations whose personnel or products have been directly involved in the accident or incident. Persons other than employees of infrastructure managers or railway may be called to give evidence, but have no obligation under this document to attend. They may, however, be obliged to cooperate through the requirements of Regulation 22 of the Railways and Other Guided Transport Systems (Safety) Regulations 2006 (ROGS) and contractual agreements with infrastructure managers or railway. At the discretion of the investigation team, representatives of recognised passenger bodies (such as Passenger Focus ) should be considered for involvement. The decision to invite, and the level and type of involvement of such organisations should be commensurate with the severity of the accident or incident concerned. 2.2 Responsibilities of the lead organisation for formal investigations Participation in formal investigation proceedings The lead organisation shall not permit the following to attend a formal investigation: a) Officers of the British Transport Police or inspectors of the Office of Rail Regulation (ORR), other than as direct witnesses of the accident or incident being investigated. b) Legal representatives, including those of any witnesses or other party to the proceedings. G The reason that certain organisations (such as the BTP and the ORR) are excluded from being invited to attend investigations is because they are designated enforcing authorities who have a statutory responsibility for the enforcement of law. In such circumstances it would be inappropriate for representatives of such organisations to take part in the investigation of an incident. It should be noted that the RAIB is not an enforcing authority, and therefore might be invited to attend if appropriate to do so. Page 14 of 42

15 G Informing others of SPAD risk ranking and formal investigation results 2.2 Responsibilities of the lead organisation for formal investigations Informing others of SPAD risk ranking and formal investigation results G The lead organisation for a formal investigation shall input the results of SPAD risk ranking into SMIS. 2.2 Responsibilities of the lead organisation for formal investigations Informing others of SPAD risk ranking and formal investigation results G The lead organisation shall inform infrastructure managers and railway and of system defects found during a formal investigation that justify urgent remedial action before the completed investigation report is published. Consideration should be given for the need to initiate an Urgent Operating Advice should the incident highlight issues of sufficient safety criticality in accordance with the details and process outlined in GO/RT3350 Communication of Urgent Operating Advice. The NIR3350 report form is available on the website. Urgent safety related notices in respect of train / rail vehicle defects are covered by requirements contained in GE/RT8250 Reporting High Risk Defects. 2.2 Responsibilities of the lead organisation for formal investigations Informing others of SPAD risk ranking and formal investigation results G G The lead organisation shall inform infrastructure managers and railway and of the conclusions and recommendations made as a result of a formal investigation. This requirement may be met through reporting to SMIS and may be recorded as inconclusive if the incident category or underlying causes cannot be determined. The recording of an incident as being inconclusive enables lead investigators to state that it is not possible to reach a definitive causation according to evidence obtained. Such evidence may be, for example, contradictory and with no way of achieving absolute proof. It is not the purpose of this RGS to apportion blame or liability for any form or category of incident as a natural outcome of an investigation. Therefore, where the evidence cannot indicate a definitive cause it should be possible for investigators to report accordingly. The lead organisation should ensure that conclusions and recommendations are entered into SMIS to comply with GE/RT8047 Reporting of Safety Related Information. 2.2 Responsibilities of the lead organisation for formal investigations Informing others of SPAD risk ranking and formal investigation results G The lead organisation shall use Table 2 of Appendix D for confirming the categorisation of an incident that has been initially identified as a SPAD once the full causes are established following SPAD incident (formal) investigation. The infrastructure manager (Network Rail) will have initially assessed a SPAD specific incident as falling into one of a number of defined provisional categories (as stated in Table 1 of section 2.4 of the standard) prior to full investigation into the cause and based upon information available at the time. Subsequent investigation may either confirm or change this initial categorisation and the investigators then have the responsibility to duly confirm the status of that original decision. Page 15 of 42

16 G G G G If the original decision to identify the incident as a SPAD, and / or its given category is subsequently changed as a result of the investigation, then the reports should clearly indicate this outcome and apportionment of responsibility may be altered accordingly. In all cases the lead organisation should, if confirming or changing the SPAD category, use the Table 2 List of confirmed category A SPAD event types. If the investigation concludes that the circumstances do not comply with the conditions for one of the SPAD categories stated in the Table, then they may consider re-designating the event (for example, as an operating or possession irregularity, or an operating incident). Guidance item G A.4.11 provides further guidance for lead organisations seeking to re-designate an event as a result of their final investigation report. 2.2 Responsibilities of the lead organisation for formal investigations Informing others of SPAD risk ranking and formal investigation results The lead organisation shall communicate the conclusions of each SPAD incident (formal) investigation and recommendations arising from them to: a) The parties whose employees or contractors were involved in the SPAD incident. b) All railway using the route on which the signal concerned is located or where the in-cab signalled movement authority was exceeded. Infrastructure managers and railway should have processes in place to brief their employees of the circumstances of any accident or incident that is relevant to their work. This brief should include contractors employed by another infrastructure manager or railway undertaking, but whose work involves controlling trains or train movements within the area relevant to the accident or incident. Infrastructure managers and railway should consider, as a minimum: a) Briefing signallers and train drivers about signals on routes over which they control or operate that have been the subject of more than one SPAD incident during the past five years. b) Amending, if appropriate, local instructions or other operational processes. G Report of the formal investigation 2.2 Responsibilities of the lead organisation for formal investigations Report of the formal investigation The lead organisation shall provide a written report of the formal investigation to all infrastructure managers and railway, other railway industry parties involved in the accident or incident and. The report of a formal investigation shall include: a) The remit. b) Details of the event under investigation. c) A description of the sequence of events. d) A summary of the deliberations of the investigation team which relates the evidence to their conclusions. e) The immediate and underlying causes of the accident or incident. f) Recommendations, cross-referenced to the part of the report which justify them and clear as to their purpose of eliminating or minimising the risk from future accidents or incidents by preventing or reducing the likelihood of recurrence or mitigating the consequences. Page 16 of 42

17 G g) In the case of investigations involving a SPAD, final confirmation of the SPAD category allocation according to the requirements of Appendix D.3 Alleged SPAD category confirmation. At the conclusion of the investigation process and before the report is published, the person in the lead organisation responsible for managing the investigation process should review the report to ensure that: a) The remit has been achieved, or where this has not been possible, suitable action has been taken. b) Immediate and underlying causes have been identified. c) The recommendations have been made in accordance with any requirements of this standard. d) Representations made by affected parties have been considered and addressed, and the relevant organisations informed accordingly. G If an SSC report has been completed as part of the investigation into a SPAD related accident or incident, the SSC report should be included as an appendix to the formal investigation report. It should be noted that a SSC may not always be held, which is why the requirement states if appropriate. 2.2 Responsibilities of the lead organisation for formal investigations Report of the formal investigation G The lead organisation shall specifically address each report recommendation to an infrastructure manager or railway undertaking. Infrastructure managers and railway are responsible for considering and implementing recommendations concerning those issues within the scope of their safety certificates and involving their contractors and suppliers to achieve this. In choosing which particular infrastructure manager or railway undertaking a recommendation should be addressed to, the investigation team should consider the following: a) Which infrastructure manager or railway undertaking owns the issue or directly controls the importation of the risk that the recommendation is directed at, for example, railway directly control the risks imported by traction and rolling stock. b) Whether a recommendation, which may prompt submission of a proposal for changes to Railway Group Standards, should be addressed to an infrastructure manager or railway undertaking that has participated in the investigation and has responsibility for applying the measures that are recommended to be changed. c) In addition to the infrastructure manager or railway undertaking, it may be appropriate to direct recommendations to other parties (for example Rolling Stock Companies (ROSCOs) or contractors) that would have a significant role in implementing those recommendations, because the infrastructure manager or railway undertaking needs their cooperation in accordance with Regulation 22 of the Railways and Other Guided Transport Systems (Safety) Regulations 2006 (ROGS). In these situations it is still necessary to clearly indicate the relevant infrastructure manager or railway undertaking to whom the recommendation is addressed and therefore is responsible for ensuring the support of those parties. G Report of Signal Sighting Committee (formal investigations) 2.2 Responsibilities of the lead organisation for formal investigations Report of Signal Sighting Committee (formal investigations) Page 17 of 42

18 G G G 2.3 G G The lead organisation for a formal investigation shall check that any Signal Sighting Committee report includes the SSC s professional judgement as to the significance and contribution of any infrastructure factors to the circumstances of the alleged category A SPAD incident with particular regard to staff error. Signal Sighting Committees are normally only convened to investigate alleged category A type SPAD incidents. 2.2 Responsibilities of the lead organisation for formal investigations Report of Signal Sighting Committee (formal investigations) The lead organisation for a formal investigation shall make the SSC report available to all parties involved in the alleged category A SPAD incident, and check that any relevant conclusions and recommendations are recorded in the incident investigation report. Those SSC report recommendations relating to the cause of the category A SPAD may be included as part of the formal investigation team s own recommendations (if they accept them), as well as any others in the formal investigation report. Responsibilities of the lead organisation for local investigations Remit for person appointed to lead the investigation 2.3 Responsibilities of the lead organisation for local investigations Remit for person appointed to lead the investigation The lead organisation shall provide a remit for the person to lead a local investigation, which requires: a) Determination of the immediate and underlying causes of the event. b) Identification of any local system improvements that could mitigate or eliminate the risk from such accidents or incidents in the future. c) Completion of the investigation within a defined time limit. d) A written report (which may be in a standardised format). In addition to information provided by the initial stage of evidence gathering, the person designated responsible for preparing the remit should consider whether other issues are relevant for consideration, such as: a) Previous investigations into similar incidents. b) Recent safety incidents involving the same location, equipment or operators. c) Organisational changes. G The term defined time limit referred to in should be discussed, ascertained and agreed between all affected parties and the designated lead organisation under the principle of cooperation, and according to the circumstances of the incident investigation concerned. Time limits for reporting might also be affected by legal issues or official requests from regulatory authorities. In all cases the time limits referred to in the requirements should accord with the nature of the event being investigated and be proportionate to the potential consequences, including those that might have arisen had the circumstances been slightly different. 2.3 Responsibilities of the lead organisation for local investigations Remit for person appointed to lead the investigation The lead organisation shall not permit the following to attend a local investigation: Page 18 of 42

19 a) Officers of the British Transport Police or inspectors of the Office of Rail Regulation (ORR), other than as direct witnesses of the accident or incident being investigated. G b) Legal representatives, including those of any witnesses or other party to the proceedings. With regard to participation in local investigation proceedings, according to the circumstances of the accident / incident, the lead organisation should consider inviting the following to co-operate in the investigation proceedings: a) Organisations whose employees are directly involved in the accident or incident being investigated, and its cause(s). b) Trades unions, recognised by the employer, who represent employees: i) Directly involved in the accident or incident being investigated or its causes. Or ii) Who are called upon to give evidence. c) Organisations who own or operate rolling stock or infrastructure involved in the accident or incident being investigated. d) Organisations whose personnel or products have been directly involved in the accident or incident. G Informing others of SPAD risk ranking and local investigation results 2.3 Responsibilities of the lead organisation for local investigations Informing others of SPAD risk ranking and local investigation results G The lead organisation for a local investigation shall input the results of SPAD risk ranking into SMIS. 2.3 Responsibilities of the lead organisation for local investigations Informing others of SPAD risk ranking and local investigation results G The lead organisation shall inform infrastructure managers and railway and of system defects found during a local investigation that justify urgent remedial action before the completed investigation report is published. Consideration should be given for the need to initiate an Urgent Operating Advice should the incident highlight issues of sufficient safety criticality in accordance with the details and process outlined in GO/RT3350 Communication of Urgent Operating Advice. The NIR3350 report form is available on the website. Urgent safety related notices in respect of train / rail vehicle defects are covered by requirements contained in GE/RT8250 Reporting High Risk Defects. 2.3 Responsibilities of the lead organisation for local investigations Informing others of SPAD risk ranking and local investigation results The lead organisation shall inform infrastructure managers and railway and of the conclusions and recommendations made as a result of a local investigation. This requirement may be met through reporting to SMIS and may be recorded as inconclusive if the incident category or underlying causes cannot be determined. Page 19 of 42

20 G G G G G G The recording of an incident as being inconclusive enables lead investigators to state that it is not possible to reach a definitive causation according to evidence obtained. Such evidence may be, for example, contradictory and with no way of achieving absolute proof. It is not the purpose of this RGS to apportion blame or liability for any form or category of incident as a natural outcome of an investigation. Therefore, where the evidence cannot indicate a definitive cause, it should be possible for investigators to report accordingly. The lead organisation should ensure that conclusions and recommendations are entered into SMIS to comply with GE/RT8047 Reporting of Safety Related Information. 2.3 Responsibilities of the lead organisation for local investigations Informing others of SPAD risk ranking and local investigation results The lead organisation shall use Table 2 of Appendix D for confirming the categorisation of an incident that has been initially identified as a SPAD once the full causes are established following SPAD incident (local) investigation. The infrastructure manager (Network Rail) will have initially assessed a SPAD specific incident as falling into one of a number of defined provisional categories (as stated in Table 1 of section 2.4 of the standard) prior to full investigation into the cause and based upon information available at the time. Subsequent investigation may either confirm or change this initial categorisation and the investigators then have the responsibility to duly confirm the status of that original decision. If the original decision to identify the incident as a SPAD, and / or its given category is subsequently changed as a result of the investigation, then the reports should clearly indicate this outcome and apportionment of responsibility may be altered accordingly. 2.3 Responsibilities of the lead organisation for local investigations Informing others of SPAD risk ranking and local investigation results The lead organisation shall communicate the conclusions of each SPAD incident (local) investigation and recommendations arising from them to: a) The parties whose employees or contractors were involved in the SPAD incident. b) All railway using the route on which the signal concerned is located or where the in-cab signalled movement authority was exceeded. Infrastructure managers and railway should have processes in place to brief their employees of the circumstances of any accident or incident that is relevant to their work. This brief should include contractors employed by another infrastructure manager or railway undertaking, but whose work involves controlling trains or train movements within the area relevant to the accident or incident. Infrastructure managers and railway should consider, as a minimum: G a) Briefing signallers and train drivers about signals on routes over which they control or operate that have been the subject of more than one SPAD incident during the past five years. b) Amending, if appropriate, local instructions or other operational processes. Report of the local investigation 2.3 Responsibilities of the lead organisation for local investigations Report of the local investigation The lead organisation shall include, as a minimum, the following information in its local investigation report (which may be in a standardised format): Page 20 of 42