Page 20 - Report of the railway accidents investigated in 2023

Annual report 2023 of the investigation report. During the investigation, the investigator-in-charge
contacts all parties involved, listens to their viewpoints and opinions and if necessary, asks clarifying questions. Before the end of the investigation the investigator-in- charge provides the parties concerned a draft of the safety investigation report marked ‘official use’. The draft or preliminary version of the safety investigation report contains all the material in accordance with Commission Implementing Regulation 2020/572, for which the final discussion will take place at an agreed time with the stakeholders who are representatives of agencies, companies, institutions and, if interested, individuals. During the discussion, all the opinions and positions of the parties involved are heard, and led by the investigator-in-charge, positions are expressed in the safety investigation. As a result of the last discussion, a few possible inconsistencies are clarified in the investigation report. After the discussion, the investigator-in-charge prepares the final safety investigation report which is then published.
Since 2004 when the safety investigations of railway accidents and incidents began, neither the investigator-in-charge nor members of the investigation committee have ever been part of a police criminal investigation, railway company internal investigation, misdemeanour proceedings of the Consumer Protection and Technical Regulatory Authority or any other proceedings or investigation of the given case conducted by another authority. Neither has any person involved in the investigation of a given case participated in a safety investigation.
2.3 Investigation process and approach of the Investigation Body
The proceedings of all accidents, serious accidents and incidents start from the moment a railway undertaking sends an initial verbal notification to the Safety Investigation Bureau. The immediate initial notification arrives from the Emergency Centre into the ESIB information mailbox. The first verbal notification from the railway undertaking is usually made by telephone a little later. By this time, the railway undertaking already has a preliminary internal overview of 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 owners and railway undertakings, and if they have been informed 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 makes a written
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