Rail Safety Investigation Reports

Rail safety investigations are performed when rail safety has been compromised or near misses have been reported.  The investigations are usually very thorough and are performed with the intention of finding the root causes of the particular incident.

It is important that we learn from these investigations and seek to avoid repetition of the circumstances and hopefully look beyond the particular circumstances.  In this section of the web site Aitken & Partners have collated investigation reports from a variety of sources.  The reports have been made freely available by the publishing organisations and they are freely available here. The reports are provided here exactly as they were originally published.

There is an abstract or summary for each report.  To the abstract we have added comments where there is a communications aspect to the report or investigation.  There have been too many incidents where the communications equipment has worked perfectly but the communications process has failed.  This part of the web site is a small contribution towards understanding and correcting such failures.

Categories

Dutch Safety Board

Dutch Safety Board ( 10 Files )

The Dutch Safety Board performs independent, comprehensive investigations into the causes or probable causes of individual – or categories of – ‘incidents’. An incident is not only defined as the term ‘incidents’ to include not only disasters and accidents but also ‘incidents that could have turned out badly’. The Dutch Safety Board is an autonomous administrative body set up under a Kingdom Act The Board is authorised to investigate incidents in any conceivable field but in practice is currently active in the following sectors: aviation, shipping, rail transport, road transport, defence, healthcare (human and animal welfare), industry and networks, pipelines, construction and services, water, and crisis management and aid provision.

The organisation consists of a Board with five permanent members, in addition to a number of standing committees. Special guidance committees are set up for the purpose of conducting specific investigations. The Dutch Safety Board is supported by a bureau consisting of investigators and support staff. The Safety Board conducts independent investigations into the causes of incidents. Its investigations look for any systematic safety-related shortcomings and it issues appropriate reports to the parties involved and to the general public. Accordingly, investigations constitute our primary process, with the product being a report in all cases. The key goal of this investigation is to establish the truth rather than to apportion blame.

The purpose of the Dutch Safety Board’s work is to ‘prevent incidents or to limit their after-effects’. Accordingly, the Board’s investigation aims not only to uncover the actual causes of incidents but also – and in particular – to bring to light the underlying causes of the incident, so that any shortcomings in the applied system can be revealed. If the investigation reveals any systematic safety-related shortcomings then the Board can formulate recommendations so that these shortcomings can be put right. Any recommendations are usually addressed to the authorities but others may be intended for individuals, organisations or companies.

The reports from the Dutch Safety Board are mainly in Dutch but some are published in English.  For the full set of reports please see the Dutch Safety Board Railway Reports.  The available English reports are available here for your convenience.

Bureau d'Enquêtes sur les Accidents de Transport Terrestre

Bureau d'Enquêtes sur les Accidents de Transport Terrestre ( 25 Files )

The Land Transport Accident Investigation Bureau (BEA-TT)’s activities cover a wide variety of areas.  The Bureau deals with railway transport, urban guided transportation systems (underground, tramcars), cable haulage systems, road transport (notably heavy goods vehicles and public transport by coach and bus) as well as navigable waterways. Each of these sectors has its own regulations and its own economic, technical, professional and even cultural logic.

Each investigation will also have to scrutinise the occurrence under a multiplicity of angles, be it infrastructure, operations, rolling stock, staff training, medical aspects, regulations, etc.

This diversity in investigations to be conducted necessitates for the BEA-TT to call upon temporary investigators and experts whenever necessary in order to secure all required competencies.

Finally, the BEA-TT will need to promote among the main players of land transport systems, the circulation of all the knowledge that the Bureau and its partners will have acquired through all the accident investigations or the studies they will have carried out. The BEA-TT will also be entitled to launch studies or research on the subject of accidentology.

BEA-TT reports are published in French, with an summary available in English.  The reports in this category are therefore all in French and the English summaries are copied below.  For the original reports and the full set of BEA-TT reports, please see the BEA-TT Web Site.

Accident Investigation Board Norway

Accident Investigation Board Norway ( 7 Files )

 

The Accident Investigation Board Norway (AIBN) is required to be competent, innovative, credible and compassionate.  For more than 20 years, AIBN has been a permanent, independent body of inquiry for transport accidents. AIBN started out investigating aviation accidents in 1989, and has seen its area of authority expand to include railway, road traffic and shipping accidents.

The investigation has as its goal clarification of the sequence of events and causes, as well as discussing other significant conditions that could prevent rail accidents and serious rail incidents in order to improve railway safety. The investigation does not apportion blame and liability.

The AIBN Reports are published on the AIBN web site.  The majority of the railway reports have been added to the Aitken & Partners web site for convenient searching.  Most of the reports are in Norwegian but all the reports published on this site have English summaries.

 

Accident Investigation Board of Finland

Accident Investigation Board of Finland ( 193 Files )

 

 

 

In Finland the Safety Investigation Authority investigates all major accidents regardless of their nature as well as all aviation, maritime and rail accidents and their incidents.

The purpose of the investigation of accidents is to improve safety and prevent future accidents. The flow of events during the accident, its causes and results as well as the rescue operation are dealt with in the investigation. A report is prepared on the results of the investigation. The report also presents the recommendations, which are based on the conclusions of the investigation. All reports are written in Finnish with English summaries. An English version is prepared from important reports.

In addition the Safety Investigation Authority takes care of the readiness to conduct investigations and of the development of accident investigation methods. The training of investigators, the preparation of guidelines for the process of investigation, publication of the reports and international cooperation are handled by the Board. In Finland the Safety Investigation Authority is located within the Ministry of Justice.

Most of the Finnish rail accident reports are available on this web site and can be searched with the Aitken & Partners search engine.  The Accident Investigation Board of Finland web site has all Finnish Rail Reports and other reports and analysis.

 

National Transportation Safety Board - USA

National Transportation Safety Board - USA ( 127 Files )

 

The National Transportation Safety Board was established in 1967 to conduct independent investigations of all civil aviation accidents in the United States and major accidents in the other modes of transportation. It is not part of the Department of Transportation, nor organizationally affiliated with any of DOT's modal agencies, including the Federal Aviation Administration. The Safety Board has no regulatory or enforcement powers.

To ensure that Safety Board investigations focus only on improving transportation safety, the Board's analysis of factual information and its determination of probable cause cannot be entered as evidence in a court of law.

The rail investigation reports from the NTSB are available on their website.  The majority of the reports are also available from the Aitken & Partners web site.  We collate accident investigation reports from many agencies for ease of access and searching.  The search engine on this site gives a more targetted search than a general search engine.

Office of the Chief Investigator (Victoria, Australia)

Office of the Chief Investigator (Victoria, Australia) ( 43 Files )

The Chief Investigator, Transport Safety is a statutory position established under Part 7 of the Transport Integration Act 2010.

The objective of the position is to seek to improve transport safety by providing for an independent no-blame investigation of transport safety matters consistent with the vision statement and the transport system objectives of the Act.

The Chief Investigator prepares reports following investigations into major occurrences involving public transport and marine services. Further information about these investigations can be obtained in the reports below and on the Chief Investigator's website.

Railway Accident Investigation Unit - Ireland

Railway Accident Investigation Unit - Ireland ( 32 Files )

 

 

The Railway Accident Investigation Unit (RAIU) is the independent accident investigation unit in Ireland.  It is responsible for the investigation of accidents or incidents on the national railway, the DART, the LUAS and heritage railways.

The purpose of the RAIU is to improve railway safety by establishing the cause ot causes of an accident or incident with a view to making recommendations for the avoidance of accidents in the future and the improvement of railway safety. It is not the purpose of the RAIU to attribute blame or liability.

The RAIU investigation reports are published on their RAIU Web Site. Most of the reports are also available on the Aitken & Partners web site for your convenience and to facilitate searches through reports from many organisations. (Use the search facility on this page.)  To ensure you have the latest information from RAIU you should check their RAIU Web Site.

Transportation Safety Board of Canada

Transportation Safety Board of Canada ( 173 Files )

The Transportation Safety Board of Canada (TSB) is an independent agency created to advance transportation safety through the investigation of occurrences in the marine, pipeline, rail and air modes of transportation.

 

Please see the Transportation Safety Board web site for full details of TSB Rail Safety Reports and other investigations.

ATSB Rail Safety Investigations

ATSB Rail Safety Investigations ( 82 Files )

The Australian Transport Safety Bureau (ATSB) is an independent Commonwealth Government statutory Agency. The Bureau is governed by a Commission and is entirely separate from transport regulators, policy makers and service providers. The ATSB's function is to improve safety and public confidence in the aviation, marine and rail modes of transport through excellence in:

  • independent investigation of transport accidents and other safety occurrences
  • safety data recording, analysis and research
  • fostering safety awareness, knowledge and action.

The ATSB does not investigate for the purpose of apportioning blame or to provide a means for determining liability.

The ATSB web site has full information about ATSB and all the ATSB reports.  

Miscellaneous

Miscellaneous ( 6 Files )

The NSW Government created Special Commissions of Inquiry for the Waterfall and Glenbrook rail accidents.  Other special commissions have been created from time to time and reports from such investigations are made available in this section. 

Changes in government department organisation have sometimes resulted in reports becoming very difficult to find.  Some such reports are available here.

New Zealand TAIC

New Zealand TAIC ( 155 Files )

The principal purpose of the Transport Accident Investigation Commission (TAIC) is to determine the circumstances and causes of accidents and incidents with a view to avoiding similar occurrences in future, rather than to ascribe blame to any person. TAIC investigates significant aviation, rail, and marine accidents and incidents. TAIC does not investigate road events except when the circumstances may have significant implications for rail safety, for example. TAIC is a standing Commission of Inquiry and an independent Crown entity.
An inquiry will usually lead to the publication of a report by the Commission which sets out the facts of an event, analyses them, lists the contributing factors, identifies the safety lessons, notes safety actions taken since, and makes recommendations that might help to reduce the chances of a similar event happening again.
Every inquiry has the potential to be systemic and wide-ranging - looking beyond the immediate people, vehicle and environment of the event to consider the likes of human factors, organisational, cultural and other issues within the training, regulatory, traffic control, vehicle design and maintenance, operator, training, industry and other systems or organisations involved.
Please see the NZ TAIC web site for full details.
OTSI Rail Safety Investigations

OTSI Rail Safety Investigations ( 50 Files )

The Office of Transport Safety Investigations (OTSI) is an independent statutory body established by the government of New South Wales, Australia. Its head, the Chief Investigator, reports directly to the Minister for Transport.

OTSI was established as an independent body to investigate safety occurrences involving bus, ferry and rail transportation. The purpose of these investigations is to identify why an occurrence took place and make recommendations to prevent recurrence. To support this style of investigation, a 'just culture' approach is used.

OTSI's Chief Investigator has the discretion to choose which transport safety occurrences OTSI will investigate. The Minister may also direct that an investigation takes place. In determining what to investigate, the Chief Investigator considers the following aspects:

  • The potential safety value that may be gained by conducting an investigation.
  • The number of fatalities or injuries and level of property damage.
  • The public profile of the occurrence.
  • The availability of OTSI resources to perform the investigation.
  • The risk associated with not investigating the occurrence.
  • The requirement to investigate at the direction of the Minister.
  • All investigations conducted by OTSI are solely for the purpose of identifying why an accident or incident happened and to make recommendations to prevent a similar occurrence happening in the future.

As a result of this objective, investigations are conducted within a 'just culture' that does not seek to apportion blame. However, if it is apparent that the safety occurrence was the direct result of a malicious act, then the matter will be passed to the appropriate regulator or enforcement agency.

The OTSI web site is http://www.otsi.nsw.gov.au/.  Please refer to this site for full details of OTSI and all OTSI reports.

RAIB

RAIB ( 182 Files )

The Rail Accident Investigation Branch (RAIB) is the independent railway accident investigation organisation for the UK. It investigates railway accidents and incidents on the UK's railways to improve safety, not to establish blame.

The RAIB website provides a range of information about acccidents and investigations.  The published reports are made available on this web site for your convenience.  Where we have identified a communication aspect to the report we have added a comment to the summary.  The reports themselves have crown copyright and are exactly as published by the RAIB.

Please check the RAIB web site for further information and the latest reports.


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"Things that have never happened before happen all the time."

 

Scott D Sagan, The Limits of Safety

"The enemy of safety is complexity."

 

Behind Human Error, Woods et al, Ashgate 2010 p 23

"Knowledge and error flow from the same mental sources, only success can tell one from another."

 

 

Ernst Mach, 1905

 

 

 

"Enhancing error tolerance, error detection, and error recovery together produce safety."

 

Behind Human Error, Woods et al, Ashgate 2010 p 26