Page 11 - Report of the railway accidents investigated in 2023

Annual report 2023
investigation according to modes of transport and its coordinator. It stipulates the procedures for initiating a safety investigation and notification of those involved. Depending on the complexity and workload associated with the occurrence, inclusion of experts and formation of a safety investigation committee is provided. The Directive establishes the procedures for a safety investigation and the tasks of the investigator-in-charge, issuing a safety alert, the format, signing, confirmation and publication of the safety investigation report, completing the safety investigation, proceedings of the safety recommendations, if necessary, the reopening of the safety investigation and procedures for registration of the cases being investigated. Pursuant to the Directive the safety investigation will find out the causes of the occurrences. During the safety investigation, recommendations are developed and presented in the report, the aim of which is to prevent similar occurrences in the future. The Directive contains annexes of which Annex 3 provides the format “Report to the Safety Investigation Bureau on the action taken or planned in response to a recommendation in an accident, serious accident or incident safety investigation report". The safety investigation report is prepared in accordance with the European Commission Implementing Regulation 2020/572 on the reporting structure to be followed when compiling investigation reports on railway accidents or incidents.
1.2 Role and aim
The Safety Investigation Bureau is one link in the transport network. Its role in increasing traffic safety is defined by recommendations made via safety investigations of individual cases. The purpose and task of each individual safety investigation of an accident or incident is to determine the circumstances and causes of the occurrences investigated. The safety investigation ascertains the connections between causes and traffic safety. Based on the circumstances, direct and other causes of the case under investigation, a sequence is constructed through logical connections to various circumstances and causes. Recommendations are formulated to avoid such causes in the future. Every recommendation is case-specific, and its implementation will help to reduce or even prevent cases with similar causes in the future. The role of safety investigations is realised through reports of safety investigations of maritime, aviation and railway accidents. The report completed at the end of the safety investigation presents recommendations for improving traffic safety in the relevant transport sector. In addition to conducting safety investigations, it is the task of the Safety Investigation Bureau to contribute to the formulation of legislation related to maritime, aviation and railway safety. The ESIB has the authority to make recommendations for additions or amendments to current legislation. Within its areas of activity ESIB has a role in formulation and implementation of projects,
policies, strategies, development and international projects and plans.
11