Scope of accidents and incidents investigated
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
Lord Cullen’s inquiry report on the Ladbroke Grove rail accident in 1999 recommended the creation of an organisation to independently investigate railway accidents to improve safety. The RAIB became operational in October 2005 as the UK’s independent body for investigating accidents and incidents which take place on the railways of Great Britain and Northern Ireland and tramways in England and Wales. We are part of the Department for Transport, but are operationally independent; the Chief Inspector reports directly to the Secretary of State on matters concerning accident investigation.
The role and duties of 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 RAIB.
Together, the Act and the Regulations implement the requirements of the European Railway Safety Directive (2004/49/EC). Under the Directive, RAIB has a duty to work with other European rail accident investigation branches: this is particularly useful for cross-border services involving Ireland and the Channel Tunnel. We are also required to report to the European Rail Agency on accidents and incidents occurring on the railways in the UK.
RAIB’s role is to improve the safety of the railways and prevent railway accidents and incidents by finding out the causes and circumstances of accidents and incidents, and any other factors that contributed to the event or made the outcome worse. We then publish investigation reports containing evidence based safety recommendations, intended to reduce the likelihood and consequences of similar accidents and incidents happening in the future. Our reports provide 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.
RAIB is not a prosecuting body and it does not apportion blame or liability. Our investigations are focused solely on improving safety and breaches of legislation are dealt with by other organisations; usually 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.
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 European Railway Safety Directive (2004/49/EC).
To work with the Air and Marine Branches on joint initiatives to help improve efficiency and effectiveness.
The main focus for 2014/15 will be to continue to conduct accident investigations to the highest standard in order to achieve the aims set out above.
In addition, in 2014/15, the following specific objectives have been identified by RAIB’s Senior Management Team:
- To continue to improve and review ways we promote safety learning with industry, the public and other public bodies by:
- reviewing methods of communication and dissemination of safety information with stakeholders and the public, this includes further developments on our own website.
- to develop further with the Office of Rail Regulation (ORR) a common platform for sharing information about implementation of RAIB’s recommendations.
- to continue to work with the European Rail Agency (ERA) in sharing, identifying and reviewing best practice in investigation techniques within other National Investigation Bodies in order to ensure we maintain and reflect excellent investigation processes and standards.
- 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 RAIB’s work is set out in the Act and we are 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 our equivalent operation in France)
- the London and Glasgow Underground systems and other metro systems
- heritage railways (including narrow-gauge systems over 350mm gauge)
- 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 results in either:
- 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 RAIB’s general aim to improve the safety of railways and to prevent railway accidents and incidents.
Importantly, the Act provides for 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 we believe there may be significant safety lessons to be learnt which could improve the safety of railways.
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.
The Regulations place a duty on railway industry bodies (railway infrastructure managers, railway operators, or maintainers), to notify RAIB of accidents and incidents involving their staff or property. These range from those resulting in serious injury and damage, through to ‘near miss’ incidents. These are detailed in the schedules to the Regulations and in RAIB’s Guidance to the Regs.
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, RAIB’s normal approach is to obtain sufficient information 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, or
- the safety issues at stake.
Inspectors will be deployed to site to conduct a preliminary examination for accidents or incidents considered 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.
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.
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
- require people to answer questions and provide information about anything relevant to the investigation.
RAIB has operational centres in Derby and Farnborough. Having two centres provides for quicker response times to accidents occurring in any part of the UK. However, sometimes we need help to ensure we get to the more remote locations quickly. In these circumstances we can ask the railway industry to assign personnel from its own staff, known as ‘Accredited Agents’, to carry out agreed limited activities until our inspectors arrive on site. These 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 ensure that important perishable evidence is recorded, protected and identified.
The purpose of a preliminary examination is to gather sufficient details and evidence about an accident or incident to enable 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 Regulations, require RAIB to investigate serious accidents where this is consistent with RAIB's purpose to improve safety on the railways. This legislation also provides 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, 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 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 there are still learning points that we wish to draw to the attention of industry bodies and railway staff, then we may publish a short bulletin for appropriate action.
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 people involved in the accident or incident.
More information about how RAIB protects the identity of witnesses and their statements can be found in Leaflet 02 - Your witness statement.
During investigations RAIB will 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 inform the broader industry of progress and findings during the investigation by way of an interim report.
RAIB can, and has, conducted ‘class investigations’ when we see a number of incidents which appear connected by common causes.
If at any time during the investigation RAIB becomes aware of any safety matter that we believe requires urgent consideration we will formally alert the industry and safety authority by issuing an Urgent Safety Advice.
On completion of the investigation we produce a draft report for consultation with the industry stakeholders, safety authority, individuals and anyone involved in the investigation, and those to whom a recommendation may be directed. We will consider representations and will revise the report if we believe 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 websitewww.raib.gov.uk.
Where appropriate, our reports will include recommendations to improve safety. RAIB can direct recommendations to any organisation or person we think is best placed to implement the changes required (the ‘end implementer’). This includes railway and non-railway, private and public sector organisations. These people or organisations will be informed of the recommendations through involvement in the investigation and/or consultation and being formally sent a copy of the final report.
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 improvement and good practice. The safety authorities are also required to report back to us details of any implementation measures, or the reasons why none are being taken.
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. Therefore this feedback is important in providing information and transparency on the safety improvements and changing environment resulting from our 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.
RAIB 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 widespread or systemic.
The opportunities for learning and improvement from our investigations are not just restricted to the parties involved in the investigations, as the reports are readily available to all parts of the industry. In addition railway operators and infrastructure managers must have processes in place, as part of their safety management systems, for learning from accidents or incidents (as required by the Railways and Other Guided Transport Systems (Safety) Regulations 2006).
RAIB receives an annual budget in the form of a grant-in-aid from Parliament through the Department for Transport.
To support our investigations and operations, RAIB employs 25 inspectors (inclusive of the Deputy Chief Inspector, Principal Inspectors and Inspectors) plus an administration team.
You can view the RAIB organisation chart by following this link.
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 RAIB.
The Board meets to identify and develop common strategic issues to 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.
Through this approach the Chief Inspectors maintain their operational independence and their reporting lines on modal safety matters to the Secretary of State (in line with our 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:
- 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
- work together to ensure smooth transition of the three AIB websites into the GOV.UK group of government department websites
- share resources and expertise in staff recruitment, career progression and personal development and where appropriate specialists in investigations.
*For most of 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 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.