Directive 2004/49/EC of the European Parliament and of the Council (repealed)Show full title

ANNEX V Principal content of accident and incident investigation report

(1)

Summary

The summary shall contain a short description of the occurrence, when and where it took place and its consequences. It shall state the direct causes as well as contributing factors and underlying causes established by the investigation. The main recommendations shall be quoted and information shall be given on the addressees.

(2)

Immediate facts of the occurrence

1.

The occurrence:

• date, exact time and location of the occurrence,

• description of the events and the accident site including the efforts of the rescue and emergency services,

• the decision to establish an investigation, the composition of the team of investigators and the conduct of the investigation.

2.

The background to the occurrence:

• staff and contractors involved and other parties and witnesses,

• the trains and their composition including the registration numbers of the items of rolling stock involved,

• the description of the infrastructure and signalling system - track types, switches, interlocking, signals, train protection,

• means of communication,

• works carried out at or in the vicinity of the site,

• trigger of the railway emergency plan and its chain of events,

• trigger of the emergency plan of the public rescue services, the police and the medical services and its chain of events.

3.

Fatalities, injuries and material damage:

• passengers and third parties, staff, including contractors,

• cargo, luggage and other property,

• rolling stock, infrastructure and the environment.

4.

External circumstances:

• weather conditions and geographical references.

(3)

Record of investigations and inquiries

1.

Summary of testimonies (subject to the protection of identity of the persons):

• railway staff, including contractors,

• other witnesses.

2.

The safety management system:

• the framework organisation and how orders are given and carried out,

• requirements on staff and how they are enforced,

• routines for internal checks and audits and their results,

• interface between different actors involved with the infrastructure.

3.

Rules and regulations:

• relevant Community and national rules and regulations,

• other rules such as operating rules, local instructions, staff requirements, maintenance prescriptions and applicable standards.

4.

Functioning of rolling stock and technical installations:

• signalling and control command system, including registration from automatic data recorders,

• infrastructure,

• communications equipment,

• rolling stock, including registration from automatic data recorders.

5.

Documentation on the operating system:

• measures taken by staff for traffic control and signalling,

• exchange of verbal messages in connection with the occurrence, including documentation from recordings,

• measures taken to protect and safeguard the site of the occurrence.

6.

Man-machine-organisation interface:

• working time applied to the staff involved,

• medical and personal circumstances with influence on the occurrence, including existence of physical or psychological stress,

• design of equipment with impact on man-machine interface.

7.

Previous occurrences of a similar character.

(4)

Analysis and conclusions

1.

Final account of the event chain:

• establishing the conclusions on the occurrence, based on the facts established in heading (3).

2.

Discussion:

• analysis of the facts established in heading (3) with the aim of drawing conclusions as to the causes of the occurrence and the performance of the rescue services.

3.

Conclusions:

• direct and immediate causes of the occurrence including contributory factors relating to actions taken by persons involved or the condition of rolling stock or technical installations,

• underlying causes relating to skills, procedures and maintenance,

• root causes relating to the regulatory framework conditions and application of the safety management system.

4.

Additional observations:

• deficiencies and shortcomings established during the investigation, but without relevance to the conclusions on causes.

(5)

Measures that have been taken

• Record of measures already taken or adopted as a consequence of the occurrence.

(6)

Recommendations