Page 22 - Report of the railway accidents investigated in 2021

Annual report 2021
individuals or organisations. The investigator-in-charge organises and performs all necessary activities.
Depending on the specifics of the case, the investigator-in-charge selects the working methods and style that are suitable for him and most appropriate for achieving the objective. When communicating with natural as well legal persons he chooses the means of communication and methods that seem the most expedient. The objective is to ascertain the causes and circumstances of the occurrence in cooperation with the victims, state and local government authorities, businesses, and organisations. The more important verbally obtained information is recorded and written information is stored within the document management system Delta. Railway undertakings retain all evidence and details of items, technical assemblies, documents, recordings of the data recording equipment and other information which might be important in determining the causes of the occurrence. If requested by the investigator-in-charge, they would present this to the ESIB. The safety investigation identifies the causes and circumstances of the case, which shall be in accordance with the requirements established by the European Commission implementing regulation 2020/572 regarding the reporting structure to be followed when compiling the investigation reports. The provisions of Annex R5 of the Safety Investigation Manual are also considered when determining the causes of the occurrence. Information about the safety investigation is usually issued by the investigator-in- charge. By prior agreement, a member of the investigation committee or the Director of the ESIB may also do this. An alert is issued on behalf of the Safety Investigation Bureau in the event of a persistently high risk.
A joint Annex (AMR1) of the Safety Investigation Manual includes instructions for hearing, questioning, and taking statements from all individuals and parties concerned, specifies the objectives, planning, conducting, and documenting the activities. A safety investigation is conducted as publicly as possible. Disclosure must not start hindering identification of causes or development of recommendations necessary for increasing safety. All parties concerned whom the investigator-in- charge addresses or who turn to the investigator-in-charge themselves have an opportunity to present their opinions, attitude, position and understanding of the proceedings of the safety investigation and its results. Information that has restricted access pursuant to cases specified by The Public Information Act is not disclosed during or after the safety investigation. Specific dates have been designated by law to restrictions of disclosure.
In most cases connections with human behaviour play an important part in the circumstances of occurrences affecting railway safety. Analysis of human factors during the safety investigation is based on the implementation regulation 2020/572 and the guidelines set out in Annex R6 of the Safety Investigation Manual.
22