Scope of accidents and incidents investigated
Investigation of accidents
Accident and incident notification
RAIB's response to notifications
The investigation report
The recommendation process
Board of Transport Accident Investigators
The role of the Rail Accident Investigation Branch
The formation of an organisation to independently investigate railway accidents with the aim of improving safety was recommended in Lord Cullen’s inquiry report on the Ladbroke Grove rail accident in 1999. As a result, the RAIB became operational in October 2005 as the UK’s independent body for investigating accidents and incidents occurring on the railways of Great Britain and Northern Ireland and tramways in England and Wales. Like the Air and Marine Accident Investigation Branches (AAIB and MAIB) it is part of the Department for Transport, but is functionally and operationally independent; the Chief Inspector reports directly to the Secretary of State on matters concerning accident investigation.
The role and duties of the RAIB are set out in the Railways and Transport Safety Act 2003 (the Act) and its associated implementing regulations, the Railways (Accident Investigation and Reporting) Regulations 2005 (the Regulations). The Regulations also include details of the scope of the regulations and the categories of accidents that the industry must notify to the RAIB. Full details can be found by clicking here.
Together, the Act and the Regulations also implement the requirements of the European Railway Safety Directive (2004/49/EC). Click here to read more. The RAIB has a duty to co-operate with other European rail accident investigation branches created under the European Directive: this is particularly relevant for cross-border services such as those in Ireland and the Channel Tunnel. Additionally, the RAIB has a duty to report to the European Rail Agency on accidents and incidents occurring on the railways in the United Kingdom.
Through its investigations, the RAIB’s aim is to improve the safety of the railways and prevent railway accidents and incidents by determining the causes and circumstances of accidents and incidents, along with any other factors that contributed to the event or made the outcome worse. It then publishes investigation reports containing evidence based safety recommendations, which are intended to reduce the likelihood and mitigate the consequences of similar accidents and incidents occurring in the future. Publication of our investigation reports provides all parts of the railway industry, both nationally and internationally, and the public, with the opportunity to consider the findings and learn lessons from our investigations.
The RAIB is not a prosecuting body and it does not apportion blame or liability. Its investigations are focused solely on improving safety and breaches of legislation are dealt with by other organisations; primarily the police and safety authorities, none of their statutory duties have been changed by the creation of the RAIB.
More information about the RAIB can be found in Leaflet 01 - An introduction to the RAIB. Read or download this leaflet here
To improve the safety of the railways by:
- Carrying out investigations to determine the causes and circumstances of railway accidents and incidents.
- Identifying any other factors that contributed to the event or made the outcome worse.
- Publishing investigation reports containing details of the investigation.
- Making evidence based safety recommendations, to reduce the likelihood and mitigate such causes and circumstances recurring in the future.
- Increasing awareness of how railway accidents happen through effective liaison, discussion, and dissemination of intelligence from investigation initiatives.
- Improving national and international co-operation in railway accident investigations.
To satisfy the general public, railway users, and the railway industry that rail accidents are being properly investigated in an efficient and timely manner.
To maintain the Branch’s high standards for the timely and thorough investigation of accidents.
To fulfil the current international obligations to the European Railway Agency in compliance with the EU Railway Safety Directive (2004/49/EC).
To work with the Air and Marine Branches on joint initiatives to help improve efficiency and effectiveness. This would include areas such as:
- sharing good practice and experience;
- developing processes and training for common aspects of accident investigation; and
- sharing technical facilities, equipment and expertise where practical.
The main focus for 2013/14 will be to continue to conduct accidents investigations to the highest standard in order to achieve the aims.
In addition, in 2013/14, the following specific objectives have been identified by the RAIB Senior Management Team:
- To continue to work with the railway industry to develop a common means of identifying from previous investigations repeated or connected areas of risk to improve intelligence of safety issues.
- To develop with ORR and key industry stakeholders a common system to provide accurate and up-to-date information on the actions being taken (and the timescales involved), to address main areas of safety concern (including measures to address RAIB’s recommendations).
- To develop, with the other Accident Investigation Branches, a replacement database for the evidence management system that will reflect current accident investigation processes.
- To continue to work with the ERA in support of their aim of promoting good practice and sharing experience with other National Investigation Bodies.
- To continue to work with the professional institutions, other investigation bodies and the railway industry in the provision of technical and investigation training.
The scope of the RAIB’s work is set out in the Act and it is mandated to investigate any serious railway accident, as defined in the Regulations (Regulation 2(3)), which occurs on a railway, as defined by the Transport and Works Act 1992. This covers:
- the national railway networks in Great Britain and Northern Ireland;
- the Channel Tunnel (in co-operation with its equivalent operation in France);
- the London and Glasgow Underground systems and other metro systems;
- heritage railways (including narrow-gauge systems over 350mm gauge); and
- cable-hauled systems of 1km or longer.
In this context, a serious accident means an accident involving a derailment or collision of rolling stock which has an obvious impact on railway safety regulation or management of safety and includes such an accident that results in:
- the death of at least one person;
- serious injuries to five or more persons; or
- extensive damage to rolling stock, the infrastructure or the environment.
There is no requirement to investigate these accidents if they fall outside of the RAIB’s general aim to improve the safety of railways and to prevent railway accidents and incidents.
Importantly, the Act provides for the RAIB to investigate other accidents and incidents occurring on railway property that are or may be relevant to the operation of the railway, and where the Branch believes that there may be significant safety lessons to be learnt which could improve the safety of railways.
The RAIB does not investigate:
- worker accidents/incidents that are not associated with train movements and which are not relevant to the operation of the railway;
- accidents/incidents involving trespassers or suicides; or
- accidents/incidents that occur within an industrial curtilage, unless it involves a train carrying passengers.
To view the RAIB DVD please click here.
The Regulations place a duty on railway industry bodies (railway infrastructure managers, railway operators, or maintainers), whose staff or property is involved in an accident or incident, to notify the RAIB of accidents and incidents. These range from those resulting in serious injury and damage, through to incidents of “near miss”.
More information on notification can be found here
Contact information to notify the RAIB of an accident or near miss can be found here
The 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, the RAIB’s normal approach is to obtain sufficient further detail to decide how to respond. The RAIB’s 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; or
- 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.
The RAIB employs 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.
The RAIB 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; and
- require people to answer questions and provide information about anything relevant to the investigation.
The RAIB has operational centres in Derby and Farnborough. Having two operational centres provides for quicker responses to accidents occurring in any part of the UK. However, there can be occasions when it requires assistance to ensure a rapid initial presence at the more remote locations. For this purpose, the RAIB can ask the railway industry to assign specific industry personnel from its own staff, known as ‘Accredited Agents’, to carry out these limited activities on behalf of the RAIB until its inspectors arrive on site. These Accredited Agents have all been pre-selected, trained, assessed and approved by the RAIB. Their role is to provide the RAIB 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 about an accident or incident to enable the RAIB to make an informed decision about whether or not to conduct a full investigation. This will often involve investigators going to site to collect or record physical evidence and witness accounts.
The European Railway Safety Directive 2004 and the Railways (Accident Investigation and Reporting) Regulations 2005, require the RAIB to investigate serious accidents where this is consistent with the RAIB's purpose to improve safety on the railways. This legislation also provides the RAIB with discretion to investigate other types of accidents and incidents if this would similarly improve the safety of the railways.
The circumstances of each accident are likely to be unique and hard and fast criteria dictating the decision on whether to conduct a full investigation would be inappropriate. However, the RAIB takes account of the information available shortly after the accident, and that obtained by the preliminary examination, and uses its professional judgement to consider each accident or incident to decide whether a full investigation would be appropriate. The overriding principle is the likelihood of the RAIB being able to make recommendations or share information to enable material improvements in railway safety for the benefit of the public, passengers and workers on the railway .
In addition, in forming the decision on whether to conduct a full investigation, the following factors will also be taken into account:
- The actual or potential seriousness of the accident or incident.
- Whether the accident is part of a series of accidents or accidents involving similar equipment, location, or causal factors.
- The potential for recurrence.
- The potential for material improvements in safety arising from an independent investigation by the RAIB.
If the accident or incident does not warrant a full investigation but the RAIB feels there may still be some learning points, which are issues that the RAIB wishes to draw to the attention of industry bodies and railway staff so that they can take appropriate action, it will publish a short bulletin describing the occurrence and the associated learning points.
While all of the RAIB’s investigations are conducted completely independently of any investigations by other parties, it can share with industry stakeholders, and will share with other statutory investigatory bodies, technical evidence and factual data arising from tests and examinations that it carries out. It 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. Read or download this leaflet here
During investigations the RAIB will maintain contact with the industry stakeholders involved with the accident or incident. The RAIB aims 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.
The RAIB can, and has, conducted ‘class investigations’ when it sees a number of incidents which appear connected by common causes.
If the RAIB decides that a full investigation is disproportionate to the potential safety lessons that might be learned then it might publish a bulletin, which consists of a summary of the findings and identification of safety lessons.
However, if at any time during the investigation the RAIB becomes aware of any safety matter that it believes requires urgent consideration it will formally alert the industry and safety authority by issuing an Urgent Safety Advice.
On completion of the investigation the RAIB produces a draft report for consultation, as required by the Regulations, with the industry stakeholders, safety authority, individuals and anyone involved in the RAIB investigation, and those to whom a recommendation may be directed. The RAIB considers representations and will revise the report if it considers 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 the RAIB’s website www.raib.gov.uk.
Where appropriate, the RAIB investigation reports will include recommendations to improve safety. The RAIB 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 the RAIB’s consultation and being formally sent a copy of the final report by the RAIB.
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 the RAIB details of any implementation measures, or the reasons why no implementation measures are being taken. The RAIB has 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 RAIB’s investigations. Full details of the recommendations made in previous years which have not been closed by the relevant safety authority or public body are published at the end of each year in the most recent Annual Report Section 2.
The RAIB may also identify learning points in its full investigation reports if it believes that an investigation has identified good practice that might be adopted by others, or where it believes 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 the RAIB’s investigations is not just restricted to the parties involved in the investigations, as the reports are readily available to all parts of the industry.
RAIB receives an annual budget in the form of a grant-in-aid from Parliament through the Department for Transport.
To support its investigations and operations, the RAIB employs 26 inspectors (inclusive of the Deputy Chief Inspector, Principal Inspectors and Inspectors) plus an administration team.
View the RAIB organisation chart here
In 2003, the Secretary of State announced the setting up of a Board of Transport Accident Investigators (Hansard 1 May 2003 Column 19WS), consisting of the three Chief Inspectors of accident investigation (Rail, Marine and Air). It is currently chaired by the Chief Inspector of the RAIB.
The Board meets to identify and develop common strategic issues which will further improve independent accident investigation in the UK. It provides a facility for managing any common risks or opportunities, optimising co-operation between the Branches and for peer review - making best use of the professional experience and expertise across the Branches.
Through this approach the Chief Inspectors maintain their functional independence and their reporting lines on modal safety matters to the Secretary of State in accordance with respective legal requirements but also achieve the benefits of the three Branches working together.
Accident Investigation Branch Joint Initiatives
The three Branches, have agreed the following joint initiatives to take advantage of synergies between them:
- Continue to develop common processes and practices for accident investigation.
- Share technical facilities, equipment and expertise where appropriate in order to improve efficiency and effectiveness.
- Use and continue to develop joint accident investigation training for new and established Inspectors.
- Maintain and further develop the AIB’s websites which continue to be facilitated under a joint commercial contact.
- Share resources and expertise in staff recruitment, career progression and personal development and where appropriate specialists in investigations.
*For most of the RAIB’s investigations on the mainland UK the safety authority, which has the legal responsibility for supervising the safety of the railways, is the Office of Railway Regulation (ORR); although there are some recommendations made by the RAIB where the 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 Regional Affairs.
**Guidance on the ALARP process can be found on the Health and Safety Executive website at: www.hse.gov.uk/risk/theory/alarp.htm