CELEX: 
Language: en
Date: 2020-04-24 00:00:00
Title: COMMISSION IMPLEMENTING REGULATION (EU) …/... on the reporting structure to be followed for railway accident and incident investigation reports

EUROPEAN
                            COMMISSION
                                                      Brussels, 24.4.2020
                                                      C(2020) 2518 final
               COMMISSION IMPLEMENTING REGULATION (EU) …/...
                                          of 24.4.2020
   on the reporting structure to be followed for railway accident and incident investigation
                                             reports
                                   (Text with EEA relevance)
EN                                                                                           EN
 ---pagebreak---                   COMMISSION IMPLEMENTING REGULATION (EU) …/...
                                               of 24.4.2020
    on the reporting structure to be followed for railway accident and incident investigation
                                                  reports
                                        (Text with EEA relevance)
   THE EUROPEAN COMMISSION,
   Having regard to the Treaty on the Functioning of the European Union,
   Having regard to Directive (EU) 2016/798 of the European Parliament and of the Council of
   11 May 2016 on railway safety1, and in particular Article 24(2) thereof,
   Whereas:
   (1)    Directive (EU) 2016/798 provides a framework to ensure that the results of accident
          and incident investigations are disseminated by the national investigating bodies
          (NIBs) in charge of reporting on rail accident and incident investigation across the
          Union, in accordance with its Article 22.
   (2)    The reports on investigations and any findings and subsequent recommendations
          provide crucial information for the future improvement of rail safety in the Single
          European Rail Area. In accordance with Article 26 of the Directive (EU) 2016/798,
          safety recommendations have to be acted upon by the addressees and actions reported
          back to the investigating body.
   (3)    A common structure of the investigation report should facilitate sharing the reports. To
          this end a public database managed under the responsibility of the European Union
          Agency for Railways was established in accordance with Article 37(3)(e) of
          Regulation (EU) 2016/7962, and is accessible through the Agency.
   (4)    To facilitate the access to useful information and its application to other European
          stakeholders, some parts of the report are requested in two European languages.
   (5)    The structure should protect the NIB from external interferences, guarantee that the
          investigation has been carried in an independent manner in accordance with
          Article 21(4) of the Directive (EU) 2016/798.
   (6)    Safety accident and incident investigation reports should ensure that lessons are
          learned from past accidents and incidents. They should facilitate the identification of
          safety hazards and eliminataion of similar safety risk in the future and allow actors in
          the rail sector to review their assessment of the risks related to their operations and
          update their safety management systems where necessary, including where applicable
          to adopt corrective measures, pursuant to point 7.1.3. of Annex I and point 7.1.3. of
   1
           OJ L 138, 26.5.2016, p. 102.
   2
           Regulation (EU) 2016/796 of the European Parliament and of the Council of 11 May 2016 on the
           European Union Agency for Railways and repealing Regulation (EC) No 881/2004 (OJ L138 of
           26.05.2016, p. 1)
EN                                                   1                                                  EN
 ---pagebreak---             Annex II to Commission Regulation (EU) 2018/7623. For this purpose the information
            contained in such reports should be structured to be easily accessible.
   (7)      The European Union Agency for Railways (the ‘Agency’), which collects the reports,
            should maintain the appropriate informatics tool providing an easy retrieval, tailored
            on the specific needs of the user (e.g. using keywords).
   (8)      The measures provided for in this Regulation are in accordance with the opinion of the
            Committee referred to in Article 28(1) of Directive (EU) 2016/798.
   HAS ADOPTED THIS REGULATION:
                                                    Article 1
                                          Subject matter and scope
   This Regulation lays down a common reporting structure for the accident and incident
   investigations referred to in Article 20(1) and (2) of Directive (EU) 2016/798.
                                                    Article 2
                                                   Definitions
   For the purpose of this Regulation the following definitions apply:
   (1)        'causal factor' means any action, omission, event or condition, or a combination
              thereof that if corrected, eliminated, or avoided would have prevented the
              occurrence, in all likelihood;
   (2)        'contributing factor' means any action, omission, event or condition that affects an
              occurrence by increasing its likelihood, accelerating the effect in time or increasing
              the severity of the consequences, but the elimination of which would not have
              prevented the occurrence;
   (3)        ‘systemic factor’ means any causal or contributing factor of an organisational,
              managerial, societal or regulatory nature that is likely to affect similar and related
              occurrences in the future, including, in particular the regulatory framework
              conditions, the design and application of the safety management system, skills of the
              staff, procedures and maintenance.
                                                    Article 3
                                             Reporting structure
   Without prejudice to the provisions of Articles 20, 24(1) and (2) of Directive (EU) 2016/798,
   the investigation reports shall be issued following the structure, as closely as possible, as set
   out in Annex I.
   Points 1, 5 and 6 of the Annex I shall be written in a second official European language. This
   translation should be available no later than 3 months after the delivery of the report.
   The reports shall be made available to the Agency in a digital format allowing access to it, its
   digital indexation and analysis.
   3
            Commission Delegated Regulation (EU) 2018/762 of 8 March 2018 establishing common safety
            methods on safety management system requirements pursuant to directive (EU) 2016/798 of the
            European Parliament and of the Council and repealing Commission Regulation (EU) No 1158/2010 and
            (EU) No 1169/2010 (OJ L 129, 25.5.2018, p. 26)
EN                                                       2                                                   EN
 ---pagebreak---                                                Article 4
                                              Transition
   With regard to accidents and incidents for which a decision to launch the investigations has
   already been taken in accordance with Article 22(3) of Directive (EU) 2016/798 at the time of
   entry into force of this Regulation, the investigation body may decide whether to follow the
   reporting structure as set out in Annex I, or to follow that of Annex V to Directive
   2004/49/EC.
                                               Article 5
                                  Entry into force and application
   This Regulation shall enter into force on the twentieth day following that of its publication in
   the Official Journal of the European Union.
   This Regulation shall be binding in its entirety and directly applicable in all Member States.
   Done at Brussels, 24.4.2020
                                                 For the Commission
                                                 The President
                                                 Ursula VON DER LEYEN
EN                                                 3                                                EN
 ---documentbreak---                             EUROPEAN
                            COMMISSION
                                                      Brussels, 24.4.2020
                                                      C(2020) 2518 final
                                                      ANNEX
                                           ANNEX
                                             to the
                     COMMISSION IMPLEMENTING REGULATION
   on the reporting structure to be followed for railway accident and incident investigation
                                            reports
EN                                                                                           EN
 ---pagebreak---                                                          ANNEX
                                   The structure to follow on the reporting
   According to Article 24(1) of Directive (EU) 2016/798, accident and incident reports shall
   follow as closely as possible the structure here established, adapted to the type and
   seriousness of the accident or incident. This includes input, in principle, to all titles 1 to 6
   including their subtitles in letters, where relevant. Where no relevant information is available
   or not required due to the circumstances of the occurrence, the statement “not applicable”
   shall be introduced for the corresponding titles or subtitles, identifying them as not being
   considered relevant in the context of this investigation. The statement can be done in an
   aggregated manner either at the beginning or at the end of the relevant title or subtitle.
   1.         Summary
   The summary is an integral part of to the report and shall be self-explanatory so that it can be
   read without further context.
   It shall provide an outline of the basic facts of the occurrence: a short description of the
   accident or incident; when, where and how it happened; and a conclusion on its causes and
   consequences. The summary shall refer to all factors (causal, contributing and/or systemic)
   identified by the investigation. Where applicable, the summary shall list the safety
   recommendations and their addressees.
   2.         The investigation and its context
   This part of the report shall give the objectives and the context of the investigation. It shall
   make reference to any factors such as delays that might have detrimental impact or otherwise
   influence the investigation or its conclusions.
   1.      The decision to establish an investigation:
   2.      The motivation to the decision to establish an
           investigation, e.g. by reference to Art. 20.1
           (serious accident) or Art. 20 (2) a) – d):
   3.      The scope and limits of the investigation          Information on scope and limits may further be
           including a justification thereof, as well as an   detailed under point 4.
           explanation of any delay that are considered a
           risk or other impact to the conduct of the
           investigation or its conclusions:
   4.      An aggregated description of the technical         If anonymity is granted to persons or entities please
           capabilities and the functions in the team of      clarify.
           investigators. This includes those belonging to
           other investigation bodies or external parties
           involved, as well as evidence for their
           independence from parties involved in the
           occurrence:
   5.      A description of the communication and             If anonymity is granted to persons or entities please
           consultation process established with persons or
EN                                                          1                                                       EN
 ---pagebreak---           entities involved in the occurrence during the        clarify.
          investigation and in relation to the information
          provided:
   6.     A description of the level of cooperation offered     If anonymity is granted to persons or entities please
          by the entities involved:                             clarify.
   7.     A description of the investigation methods and        e.g. interviews, access to documentation and
          techniques as well as analysis methods applied        recordings on the operating system,
          to establish the facts and findings referred to in
          the report. The facts shall at least establish:
               - events and conditions that led to the
                    occurrence;
               - any precursors that led to the above;
               - instructions, mandatory procedures,
                    feedback mechanisms and/or control
                    mechanisms that led to the occurrence
                    or otherwise played a role regarding it.
   8.     A description of the difficulties and specific
          challenges encountered during the investigation.
   9.     Any interaction with the judicial authorities,
          where appropriate
   10.    Where appropriate, any other information
          relevant in the context of the investigation.
   3.       Description of the occurrence
   This part of the report shall contain a detailed description of the occurrence mechanism, based
   on the information collected during the investigation carried out.
   (a)      The occurrence and background information:
   1.     The description of the occurrence type:
   2.     The date, exact time and location of the
          occurrence:
   3.     The description of the occurrence site, including
          weather and geographical conditions at the
          moment of the occurrence and if any works
          were carried out at or in the vicinity of the site:
   4.     Deaths, injuries and material damage:                 If anonymity is granted to persons or entities please
               - passengers, employees or contractors,          clarify.
                    level crossing users, trespassers, other
                    persons at a platform, other persons not
                    at a platform,
               - cargo, luggage and other property,
               - rolling stock, infrastructure and the
                    environment.
EN                                                            2                                                       EN
 ---pagebreak---    5.     The description of other consequences,
          including the impact of the occurrence in the
          regular operations of the actors involved:
   6.     The identification of the persons, their           If anonymity is granted to persons or entities please
          functions, and entities involved, including        clarify.
          possible interfaces to contractors and/or other
          relevant parties:
   7.     The description and identifiers of train(s) and
          their composition including the rolling stock
          involved and their registration numbers:
   8.     A description of the relevant parts of the
          infrastructure and signalling system – track
          type, switch, interlocking, signal, train
          protection systems:
   9.     Where appropriate, and any other information
          relevant for the purpose of the description of the
          occurrence and background information:
   (b)      The factual description of the events:
   1.     The proximate chain of events leading up to the    e.g. starting point of a train ride, beginning of the
          occurrence, including:                             shift of an involved staff member
               - actions taken by persons involved,
                                                             e.g. measures taken by staff for traffic control and
               - the functioning of rolling stock and
                                                             signalling, exchange of verbal messages and written
                    technical installations,
                                                             orders in connection with the occurrence
               - the functioning of the operating
                    system:                                  e.g. signalling and control command system,
                                                             infrastructure, communications equipment, rolling
                                                             stock, maintenance, etc.
   2.     The chain of events from the occurrence until
          the end of the actions of the rescue services,
          including:
               - measures taken to protect and               e.g. trigger of the railway emergency plan, trigger of
                    safeguard the site of the occurrence,    the emergency plan of the public rescue services, the
               - the efforts of the rescue and emergency     police and the medical services and its chain of
                    services.                                events
   4.       Analysis of the occurrence, where necessary in respect of individual contributing
            factors
   This part of the report shall analyse the established facts and findings (i.e. performance of
   operators, rolling stock and/or technical installations) which caused the occurrence. The
   analysis shall lead to the identification of the safety critical factors that caused or otherwise
   contributed to the occurrence, including facts identified as precursors. An accident or incident
   may be caused by causal, systemic and contributing factors which are equally important and
   should be considered during an investigation.
EN                                                         3                                                        EN
 ---pagebreak---    The analysis may be extended to conditions, feedback mechanisms and/or control
   mechanisms throughout the entire railway system that were identified as actively influencing
   the development of similar occurrences. This could comprise the functioning of safety
   management systems of involved parties and regulatory activities covering certification and
   supervision.
   The following items shall be covered for each of the identified events or factors (causal or
   contributing) that appear safety critical, in line with the flexibility offered by the structure (see
   above).
   (a)       Roles and duties
   Without prejudice to Article 20(4) of Directive (EU) 2016/798 this part of the report shall
   lead to the identification and analysis of roles and duties of individual persons and entities,
   including if necessary relevant staff and their defined tasks and functions, identified as
   having been involved in the occurrence in a safety critical manner, or any activity leading to
   it.
   1.       Railway undertaking(s) and/or infrastructure manager(s):    If anonymity is granted to persons or
                                                                        entities please clarify.
   2.       The entity/entities in charge of maintenance, the           If anonymity is granted to persons or
            maintenance workshops, and/or any other maintenance         entities please clarify.
            suppliers:
   3.       Manufacturers of rolling stock or other supplier of rail    If anonymity is granted to persons or
            products:                                                   entities please clarify.
   4.       National safety authorities and/or the European Union       If anonymity is granted to persons or
            Agency for Railways:                                        entities please clarify.
   5.       Notified bodies, designated bodies and/or risk assessment   If anonymity is granted to persons or
            bodies:                                                     entities please clarify
   6.       Certification bodies of entities in charge of maintenance   If anonymity is granted to persons or
            mentioned under 2:                                          entities please clarify.
   7.       Any other person or entity relevant to the occurrence,      If anonymity is granted to persons or
            documented or not in one of the relevant safety             entities please clarify
            management systems or referred to in a register or relevant
                                                                        e.g. keepers of vehicles, terminal providers,
            legal framework:
                                                                        loaders or fillers
   (b)       Rolling stock and technical installations
   Causal factors to or the consequences of an occurrence that were identified as relating to the
   condition of rolling stock or technical installations, including possible contributing factors
   related to activities and decisions, such as:
   1.         Stemming from the design of the rolling stock,
              railway infrastructure or technical installations:
EN                                                           4                                                     EN
 ---pagebreak---    2.        Stemming from the installation and taking into
             service of the of rolling stock, railway infrastructure
             or technical installation:
   3.        Laying with the manufacturers or other supplier of
             rail products:
   4.        Stemming from the maintenance and/or the
             modification of the rolling stock or technical
             installations:
   5.        Laying with the entity in charge of maintenance, the
             maintenance workshops and other maintenance
             suppliers:
   6.        And any other factors or consequences considered
             relevant for the purpose of the investigation:
   (c)      Human factors
   Where causal or contributing factors or the consequences of an occurrence were related to
   human actions, attention shall be paid to the particular circumstances and the manner in which
   routine activities are performed by staff during normal operations and the human and
   organisational factors that may influence actions and/or decisions, including:
   1.        Human and individual characteristics:
             (a)         training and development, including
                         skills and experience,
             (b)         medical and personal circumstances
                         with influence on the occurrence,
                         including existence of physical or
                         psychological stress,
             (c)         fatigue,
             (d)         motivation and attitude.
   2.        Job factors
             (a)         task design,
             (b)         design of equipment with impact on the
                         man-machine interface,
             (c)         the means of communication,
             (d)         practices and processes,
             (e)         operating rules, local instructions, staff
                         requirements, maintenance prescriptions
                         and applicable standards,
             (f)         working time of the staff involved,
             (g)         risk handling practices
             (h)         context, machinery, equipment and
EN                                                          5                                     EN
 ---pagebreak---                       instructions shaping work practices.
   3.      Organisational factors and assignments:
           (a)        workforce planning and workload,
           (b)        communications, information and team
                      working,
           (c)        recruitment and selection, resources,
           (d)        performance            management         and
                      supervision,
           (e)        compensation (remuneration),
           (f)        leadership, power issues,
           (g)        organisational culture,
           (h)        legal issues (incl. relevant EU and
                      national rules and regulations),
           (i)        the regulatory framework conditions
                      and the application of the safety
                      management system.
   4.      Environmental factors:
           (a)        working conditions (noise, lighting,
                      vibrations, …),
           (b)        weather and geographical conditions,
           (c)        works carried out at or in the vicinity of
                      the site.
   5.      And any other factor relevant for the purpose of the
           investigation in the above points (1),(2),(3),(4):
   (d)   Feedback and control mechanisms, including risk and safety management as well as
         monitoring processes.
   1.  The relevant regulatory framework conditions:
   2.  The processes, the methods, the content and the results
       of risk assessment and monitoring activities, performed
       by any of the involved actors: railway undertakings,
       infrastructure managers, entities in charge of
       maintenance, maintenance workshops, other
       maintenance providers, manufacturers and any other
       actors, and the independent assessment reports referred
       in Article 6 of Implementing Regulation (EU) No
       402/20131:
   1
        Implementing Regulation (EU) No 402/2013 of 30 April 2013 on the common safety method for risk
        evaluation and assessment and repealing Regulation (EC) No 352/2009, (OJ L 121, 3.5.2013, p. 8).
EN                                                       6                                               EN
 ---pagebreak---    3.     The safety management system of the involved railway
          undertaking(s) and infrastructure manager(s) including
          the basic elements stated in Article 9(3) of Directive
          (EU) 2016/798 and any EU legal implementing acts:
   4.     The management system of the entity/entities in charge
          of maintenance and maintenance workshops including
          the functions stated in the Article 14(3) and Annex III of
          Directive (EU) 2016/798 and any subsequent
          implementing acts:
   5.     The results of supervision performed by the national
          safety authorities in accordance with Article 17 of
          Directive (EU) 2016/798:
   6.     The authorisations, certificates and assessment reports
          granted by the Agency, the National Safety Authorities
          or other conformity assessment bodies:
               - Safety authorisation/safety certificates of the
                   involved infrastructure manager(s) and railway
                   undertaking(s),
               - Authorisations for the placing in service of
                   fixed installations and vehicles authorisations
                   for placing on the market,
               - Entity in charge of maintenance and
                   maintenance workshops (incl. certification).
   7.     Other systemic factors:
   (e)      Previous occurrences of a similar character, if available.
   5.       Conclusions
   The conclusions shall contain:
   (a)      A summary of the analysis and conclusions with regard to the causes of the
            occurrence
   The conclusions shall summarise the identification of the causal and contributing factors to
   the occurrence, including both immediate and deeper systemic factors, as well as missing or
   inadequate safety measures for which compensatory measures are recommended. Moreover, it
   shall refer to the capability of the involved organisations to address this via their safety
   management systems, in order to prevent future accidents and incidents.
   (b)      Measures taken since the occurrence
   (c)      Additional observations:
   Safety issues identified during the investigation, but without relevance to the conclusions on
   causes and consequences of an occurrence.
   6.       Safety recommendations
EN                                                         7                                      EN
 ---pagebreak---    Where appropriate this part of the report shall set out safety recommendations for the sole aim
   to prevent similar occurrences in the future.
   The absence of recommendations shall be explained.
   Safety recommendations shall be based on established facts and additional observations
   thereof, as well as their analysis leading to conclusions on safety relevant causes and
   consequences of an occurrence.
   Safety recommendations may also be issued in relation to additional observations in no causal
   or contributing context to the occurrence.
EN                                                 8                                               EN