Page 20 - Report of the railway accidents investigated in 2021

Annual report 2021
2.3 Investigation process and approach of the Investigation Body
The proceedings of all accidents, serious accidents and incidents start from the moment the Safety Investigation Bureau receives the initial, verbal notification from the railway undertaking. The immediate initial notification arrives from the Emergency Centre into the ESIB information mailbox. This is usually duplicated by the railway infrastructure manager verbally by phone if they have anything to add to describe the occurrence. The Emergency Centre notifies the ESIB 24 hours a day by email of all occurrences in air, water, and rail that it has become aware of. In the railway sector, railway infrastructure managers and possessors and railway undertakings and if they have become aware during regulatory activities, the Consumer Protection and Technical Regulatory Agency, notify the Safety Investigation Bureau by means of public communication immediately. The publicly available means of communication is the phone that the investigator of railway accidents has access to 24 hours a day. In the case of an accident or a serious accident the infrastructure manager that made the initial notification also makes a written notification to the ESIB in the agreed format within three working days. The written notice contains the location of the occurrence, specified and verified factual details about the rolling stock, casualties, victims and measures taken. In addition, it contains a short summary of the occurrence and the causes that have been ascertained by the time the notice being drawn up. If the ESIB requests it, a written report with additional information about an incident will also be made within three working days in an agreed format. The incident report is analogous in content to the accident report. All written documents received by the ESIB are systematically stored within a digital document management system Delta as part of the ancillary services.
Over time, a pragmatic and rational agreement has developed with the undertakings that enables the safety investigator to be notified faster without needlessly burdening the ESIB 24 hour emergency phone line. The railway infrastructure manager is immediately informed of any railway accidents and incidents through its internal information channels. He forwards the notification by phone to the official dealing with safety investigations of railway accidents. Since occurrences affecting railway safety are rare it is not practical to use an intermediate link in the form of a helpline telephone. Information is relayed to the helpline if the caller does not know the phone number of the official conducting the safety investigation. This has happened a couple of times in ten years. In the spring of 2021, the ESIB general helpline was suspended for economic and organisational reasons. The official dealing with safety investigations of railway accidents acknowledges the initial notification, assesses the circumstances, asks additional questions, and if necessary, requests clarification of any circumstances but in summary, takes note of the initial notification. Based on the
Railways Act and the safety investigation manual, the official dealing with the safety
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