Uncontrolled When Printed
Document comes into force 02/03/2013
Supersedes GOGN3519 Iss 2 on 02/03/2013
© Copyright 2012
Rail Safety and Standards Board Limited
Issue Three: December 2012
Rail Industry Guidance Note for GO/RT3119
RSSB
Block 2
Angel Square
1 Torrens Street
London
EC1V 1NY
Guidance on Accident and Incident Investigation
Published by:
GO/GN3519
GN
Uncontrolled When Printed
Document comes into force 02/03/2013
Supersedes GOGN3519 Iss 2 on 02/03/2013
Guidance on Accident and Incident Investigation
Issue record
Issue
Date
Comments
One
04 October 2008
Original document
Two
04 September
2010
Contains new and reworded SPAD categories and
some additional requirements for lead
organisations for investigations.
Three
01 December
2012
Contains revised definition of a SPAD and some
additional requirements when reporting local
investigations.
Amended or additional parts of revised pages have been marked by a vertical black line
in the adjacent margin.
Superseded documents
The following Railway Group documents are superseded, either in whole or in part as
indicated:
Superseded documents
GO/GN3519 Guidance on Accident and Incident
Investigation, issue two
Sections
superseded
All
Date when
sections are
superseded
02 March 2013
Supply
The authoritative version of this document is available at www.rgsonline.co.uk.
Uncontrolled copies of this document can be obtained from Communications, RSSB,
Block 2, Angel Square, 1 Torrens Street, London EC1V 1NY, telephone 020 3142 5400
or e-mail enquirydesk@rssb.co.uk. Other Standards and associated documents can also
be viewed at www.rgsonline.co.uk.
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Uncontrolled When Printed
Document comes into force 02/03/2013
Supersedes GOGN3519 Iss 2 on 02/03/2013
Guidance on Accident and Incident Investigation
Contents
Section
Description
Part 1
G 1.1
G 1.2
G 1.3
G 1.4
G 1.5
G 1.6
G 1.7
Introduction
Purpose of this document
Background
Principles
Related requirements in other documents
The structure of this document
Copyright
Approval and authorisation of this document
4
4
4
4
5
5
5
5
Part 2
G 2.1
Guidance for accident and incident investigation
Responsibilities common to infrastructure managers and railway
undertakings
Responsibilities of the lead organisation for formal investigations
Responsibilities of the lead organisation for local investigations
Responsibilities of infrastructure managers
Responsibilities of railway undertakings
6
G 2.2
G 2.3
G 2.4
G 2.5
RSSB
Page
6
12
18
21
26
Appendices
Appendix A Decision criteria – formal investigations
Appendix B Decision criteria – local investigations
Appendix C Requirements for persons responsible for managing the investigation
process
Appendix D Requirements for persons appointed to lead an investigation
Appendix E Explanatory note on progress reporting requirements
33
35
39
Definitions
40
References
42
28
31
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GO/GN3519 Issue Three: December 2012
Uncontrolled When Printed
Document comes into force 02/03/2013
Supersedes GOGN3519 Iss 2 on 02/03/2013
Guidance on Accident and Incident Investigation
Part 1
Introduction
G 1.1
Purpose of this document
G 1.1.1
GO/RT3119 Accident and Incident Investigation mandates requirements for the
investigation of accidents and incidents involving more than one infrastructure manager
or railway undertaking so that system improvements (including changes to European and
national standards, national operating rules and company systems and procedures)
necessary to prevent or reduce the likelihood of recurrence, or mitigate the
consequences, are identified and implemented.
G 1.1.2
The entitlements and role in the investigation process of railway industry parties and
others not directly involved in the event subject to investigation are defined.
G 1.1.3
This guidance document has been published by Rail Safety and Standards Board to give
guidance on interpreting the requirements of Railway Group Standard GO/RT3119. It
does not constitute a recommended method of meeting any set of mandatory
requirements.
G 1.2
Background
G 1.2.1
The requirements from GO/RT3119 reproduced in Part 2 of this document define a
procedural framework and common processes for the investigation of accidents and
incidents to enable:
a)
Infrastructure managers, railway undertakings and other railway industry parties
cooperate to investigate immediate and underlying causes, identify measures and
make recommendations to eliminate or prevent recurrence and to mitigate
consequences of accidents and incidents.
b)
The results of investigations and recommendations to be reported in a structured
way.
c)
Investigations to be completed and the findings made known in a timely way so that
lessons are learned (including the need to review risk controls) at the earliest
opportunity.
d)
An awareness of safety lessons relevant to infrastructure managers' and railway
undertakings' operations and the recommended actions to apply them.
e)
Information necessary to support the development of the industry's safety strategies
and safety risk models to be produced and reported.
f)
Changes to Railway Group or European standards or working instructions to be
progressed promptly.
G 1.2.2
The requirements from GO/RT3119 reproduced in Part 2 of this document permit
infrastructure managers and railway undertakings to appoint a person independent of
either party involved to lead or participate in a formal investigation if required.
G 1.3
Principles
G 1.3.1
The requirements from GO/RT3119 as reproduced in this document are based on the
following principles:
a)
Investigations determine the facts of an accident or incident, its immediate and
underlying causes, and make recommendations to eliminate or minimise the risk
from such events by addressing the frequency of occurrence and the consequences
of the event.
b)
The investigation processes mandated in this document are not intended as a
process for allocating blame or liability.
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Guidance on Accident and Incident Investigation
c)
The information included in a report of an investigation carried out in compliance with
this document is not intended to create any presumption of blame or liability.
d)
No degree of severity or importance is implied either by the use of the provisional
collective term or between any of the post-investigation SPAD categories described
in GO/RT3119.
G 1.4
Related requirements in other documents
G 1.4.1
The following Railway Group Standards contain requirements that are relevant to the
scope of this document:
a)
GO/RT3118 Incident Response Planning and Management.
b)
Guidance on SPAD incident categorisation and risk ranking referred to in this
document, together with associated Provisional SPAD Data Collection Forms
RT/3119/A, B, C and D, can be found on the RSSB website www.rssb.co.uk.
G 1.5
The structure of this document
G 1.5.1
Relevant requirements from Railway Group Standard GO/RT3119 are reproduced with a
grey background in this document.
G 1.5.2
Guidance is provided as a series of sequentially numbered clauses prefixed ‘G’
immediately below the greyed text to which it relates.
G 1.5.3
Specific responsibilities and compliance requirements are laid down in the Railway Group
Standard itself.
G 1.6
Copyright
G 1.6.1
Copyright in the Railway Group documents is owned by Rail Safety and Standards Board
Limited. All rights are hereby reserved. No Railway Group document (in whole or in part)
may be reproduced, stored in a retrieval system, or transmitted, in any form or means,
without the prior written permission of Rail Safety and Standards Board Limited, or as
expressly permitted by law.
G 1.6.2
RSSB members are granted copyright licence in accordance with the Constitution
Agreement relating to Rail Safety and Standards Board Limited.
G 1.6.3
In circumstances where Rail Safety and Standards Board Limited has granted a particular
person or organisation permission to copy extracts from Railway Group documents, Rail
Safety and Standards Board Limited accepts no responsibility for, nor any liability in
connection with, the use of such extracts, or any claims arising therefrom. This
disclaimer applies to all forms of media in which extracts from Railway Group Standards
may be reproduced.
G 1.7
Approval and authorisation of this document
G 1.7.1
The content of this document was approved by Traffic Operation and Management
Standards Committee on 18 September 2012.
G 1.7.2
This document was authorised by RSSB on 29 October 2012.
RSSB
Page 5 of 42
GO/GN3519 Issue Three: December 2012
Uncontrolled When Printed
Document comes into force 02/03/2013
Supersedes GOGN3519 Iss 2 on 02/03/2013
Guidance on Accident and Incident Investigation
Part 2
Guidance for accident and incident investigation
G 2.1
Responsibilities common to infrastructure managers and railway
undertakings
G 2.1.1
Requirement to investigate accidents or incidents
Extract from GO/RT3119 Accident and Incident Investigation
2.1
Responsibilities common to infrastructure managers and railway
undertakings
2.1.1
Requirement to investigate accidents or incidents
2.1.1.1
Infrastructure managers and railway undertakings shall investigate accidents or
incidents to establish:
a) The events leading up to the accident or incident.
b) The immediate cause(s).
G 2.1.1.1
c) The underlying cause(s).
No additional guidance provided.
Extract from GO/RT3119 Accident and Incident Investigation
2.1
Responsibilities common to infrastructure managers and railway
undertakings
2.1.1
Requirement to investigate accidents or incidents
2.1.1.2
G 2.1.1.2
G 2.1.1.3
Infrastructure managers and railway undertakings shall identify system
improvements necessary to eliminate or minimise the risk from such accidents
or incidents by addressing the likelihood of recurrence and the consequences.
Regulation 22 of the Railways and Other Guided Transport (Safety) Regulations 2006
sets a wide-ranging duty of cooperation between transport operators whose activities
affect, or are affected by, each other. It also applies to contractors carrying out work on
an infrastructure manager's or railway undertaking's premises or plant.
In addition to the basic establishing purposes of an investigation, as listed in requirement
2.1.1.1, the following general reasons should be considered (non-exhaustive list):
a)
To establish the role that infrastructure and train borne systems might have played in
the events leading up to the incident. This might include such items as (according to
the incident concerned) SPAD incident history of a signal or group of signals,
operation of signals, management systems, braking distances, transitions between
signal types, staff supervision, training and working time patterns of those people
involved, vehicle systems and equipment etc.
b)
To assess human factors issues, including, but not limited to, fitness for work, the
working environment, distraction issues, compliance with and fitness for purpose of
rules and procedures.
c)
To examine the process for the input of data into equipment (including train data for
in-cab signalling systems).
d)
To determine the effectiveness and relevance of previously introduced mitigations
relating to the incident type concerned and to identify any residual risks.
e)
To help determine how any lessons learnt from an incident might be communicated
to people.
f)
To provide data for input to SMIS for analysis and use by all organisations that might
benefit from it.
g)
To help assess the potential severity of an incident and the likelihood of
reoccurrence.
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Guidance on Accident and Incident Investigation
G 2.1.2
h)
To help consider the system risks arising from the circumstances of an incident.
i)
To analyse the impact on any supplementary risk, hazard studies or any other
relevant information.
Decision criteria for when to carry out a formal or local investigation
Extract from GO/RT3119 Accident and Incident Investigation
2.1
Responsibilities common to infrastructure managers and railway
undertakings
2.1.2
Decision criteria for when to carry out a formal or local investigation
2.1.2.1
G 2.1.2.1
Infrastructure managers and railway undertakings shall use the criteria in
Appendices A and B to identify when a formal or local investigation is required.
In applying the criteria listed in Appendices A and B, the following factors should also be
taken into consideration when deciding whether to instigate an investigation:
a) The potential severity of the event.
b) For SPAD incidents, the provisional categorisation and risk ranking.
c) The need to demonstrate transparency of the investigation process.
d) Any requests made by parties to hold a particular category of investigation.
Extract from GO/RT3119 Accident and Incident Investigation
2.1
Responsibilities common to infrastructure managers and railway
undertakings
2.1.2
Decision criteria for when to carry out a formal or local investigation
2.1.2.2
G 2.1.2.2
G 2.1.3
Infrastructure managers and railway undertakings responsible for employees or
contractors involved in an operating incident shall provide the necessary
information to the infrastructure manager for the purposes of incident risk
ranking.
Information relating to SPAD specific incidents would be provided for input into the SPAD
risk ranking tool.
Lead organisation for formal and local investigations
Extract from GO/RT3119 Accident and Incident Investigation
2.1
Responsibilities common to infrastructure managers and railway
undertakings
2.1.3
Lead organisation for formal and local investigations
2.1.3.1
G 2.1.3.1
Infrastructure managers and railway undertakings shall use the criteria shown in
Appendices A and B to decide who the lead organisation will be for the
purposes of both formal and local investigations.
No additional guidance provided.
Extract from GO/RT3119 Accident and Incident Investigation
2.1
Responsibilities common to infrastructure managers and railway
undertakings
2.1.3
Lead organisation for formal and local investigations
2.1.3.2
G 2.1.3.2
Infrastructure managers and railway undertakings shall appoint a person who is
independent of either organisation to lead the investigation if it is jointly decided
that this is the most appropriate action.
The possible appointment of a person independent of any party to lead an investigation
may arise:
a)
RSSB
From situations where the lead organisation is unable to supply a competent person
to lead the investigation because of the company’s small size.
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Guidance on Accident and Incident Investigation
G 2.1.3.3
b)
Because the subject matter or scale of the incident is particularly complex and the
investigation is likely to demand the full-time attention of the person appointed to
lead it.
c)
Where involved parties jointly decide that the investigation would be best led by
someone independent of those parties to avoid perception of bias in the
investigation’s findings.
In addition, it may be helpful to invite independent technical experts to advise the
investigation panel on technical matters, depending on the circumstances of the accident
or incident and the collective expertise of the proposed panel or investigation team.
Independent technical expertise may be of value in:
a)
Traction and rolling stock.
b)
Track and structures.
c)
Signalling and telecommunications.
d)
Train operations.
e)
Electrification.
f)
Human factors.
g)
Road safety if there is a road component to the accident / incident.
G 2.1.3.4
Guidance as to the need for, and the names of, appropriate specialists may be obtained
from RSSB.
G 2.1.4
Designation of responsible persons
Extract from GO/RT3119 Accident and Incident Investigation
G 2.1.4.1
2.1
Responsibilities common to infrastructure managers and railway
undertakings
2.1.4
Designation of responsible persons
2.1.4.1
Infrastructure managers and railway undertakings shall designate persons to be
responsible for managing their processes for leading or contributing to
investigations of accidents and incidents.
Appendix C contains mandatory requirements for persons designated to be
responsible for managing investigation processes.
No additional guidance provided.
Extract from GO/RT3119 Accident and Incident Investigation
2.1
Responsibilities common to infrastructure managers and railway
undertakings
2.1.4
Designation of responsible persons
2.1.4.2
Infrastructure managers and railway undertakings shall designate persons to be
responsible for leading investigations.
G 2.1.4.2
Appendix D contains mandatory requirements for persons appointed to lead an
investigation.
No additional guidance provided.
G 2.1.5
Physical and witness evidence
Extract from GO/RT3119 Accident and Incident Investigation
2.1
Responsibilities common to infrastructure managers and railway
undertakings
2.1.5
Physical and witness evidence
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Guidance on Accident and Incident Investigation
2.1.5.1
Infrastructure managers and railway undertakings shall record physical and
witness evidence of:
a) The events leading up to the accident or incident.
b) The immediate cause(s) of the accident or incident.
c) The consequences of the accident or incident.
G 2.1.5.1
d) Any identifiable underlying causes of the accident or incident.
The following is a typical list of evidence and information that might need to be collated:
a)
Training records and records of post event interviews of employees involved in
accidents or incidents.
b)
Maintenance histories and technical tests of equipment involved in accidents or
incidents.
c)
Reports from investigations undertaken at the site of accidents or incidents.
d)
Witness statements.
e)
Technical investigation reports required by other standards.
f)
Train data recorder downloads.
g)
The results of alcohol and drugs tests.
h)
Photographs of the accident or incident site and equipment involved.
i)
Signal box registers.
j)
Total Operations Process System (TOPS) train lists for the trains immediately
involved (or the equivalent for passenger trains).
k)
Train running system on TOPS (TRUST) reports for the trains involved.
l)
TOPS train consists for the last train(s) in each direction before the accident /
incident.
m) TRUST reports for the last train(s) in each direction before the accident or
incident.
n)
Solid state interlocking or integrated electronic control centre (SSI / IECC) event
recorder data for a minimum of two hours prior to the accident / incident.
o)
Telephone and radio recordings, where available, for the signal box and the relevant
traffic control room for the two hours immediately prior to the accident.
p)
Train borne CCTV and visual recording media (interior and exterior).
G 2.1.5.2
Where a witness is called upon to provide oral evidence before an investigation panel,
the number of persons present at the time the evidence is given should be sufficient to
ensure that the hearing is properly conducted but does not inhibit the process of giving
evidence. The lead investigator should determine what that number should be and that
those present, collectively, have the necessary competence to evaluate the evidence.
G 2.1.5.3
When deciding the number of persons that should be present when oral evidence is
given, the following factors should be taken into consideration:
RSSB
a)
The medical condition of the witness.
b)
The extent to which a witness’s performance might be adversely affected by the
number of persons present.
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Guidance on Accident and Incident Investigation
c)
The priority given to the witness’s employer and employee representation over
others who may wish to be present in an observer capacity.
Extract from GO/RT3119 Accident and Incident Investigation
2.1
Responsibilities common to infrastructure managers and railway
undertakings
2.1.5
Physical and witness evidence
Infrastructure managers and railway undertakings shall use the ‘RT/3119’
designated Provisional SPAD Data Collection forms when investigating signals
passed at danger incidents. The RT/3119/A or C forms are for infrastructure
managers, and the RT/3119/B or D forms are for railway undertakings. The
forms are located on the RSSB website.
All Provisional SPAD Data Collection forms RT/3119/A ,B, C and D can be found at the
following RSSB website address: http://www.rgsonline.co.uk. The A and B forms should
only be used for conventional signalling system SPAD investigations. The C and D forms
have been specifically created for application in cases where ERTMS is the primary
signalling system. When investigating incidents at transition points between conventional
and ERTMS areas, users should make an informed decision on which type of data
collection form is most appropriate for the purpose of the investigation. If there was ever a
case of a multiple SPAD involving both conventional and ERTMS signalling then normally
the data collection form applicable to the first signal passed at danger should be
used.There are currently no RSSB designated proforma forms for any other type of
investigation. Member companies may have or develop such forms for their own use.
2.1.5.2
G 2.1.5.4
Extract from GO/RT3119 Accident and Incident Investigation
G 2.1.5.5
2.1
Responsibilities common to infrastructure managers and railway
undertakings
2.1.5
Physical and witness evidence
2.1.5.3
Infrastructure managers and railway undertakings shall prioritise the collection
of evidence according to the following list of subjects:
a) Perishable evidence.
For example, assessments of weather, atmospheric and rail head conditions, in-cab
indications at the time of the accident or incident, timely retrieval of data logging/event
recording / photographic evidence.
Extract from GO/RT3119 Accident and Incident Investigation
G 2.1.5.6
2.1
Responsibilities common to infrastructure managers and railway
undertakings
2.1.5
Physical and witness evidence
2.1.5.3
Infrastructure managers and railway undertakings shall prioritise the
collection of evidence according to the following list of subjects:
b) Interviewing of personnel.
For example, obtaining written reports from, and interviews of, personnel involved in, or
who witnessed the accident or incident.
Extract from GO/RT3119 Accident and Incident Investigation
2.1
Responsibilities common to infrastructure managers and railway
undertakings
2.1.5
Physical and witness evidence
2.1.5.3
Infrastructure managers and railway undertakings shall prioritise the
collection of evidence according to the following list of subjects:
c) Site visits.
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Guidance on Accident and Incident Investigation
G 2.1.5.7
For example, obtaining photographic evidence (including CCTV footage, where
appropriate) of local conditions such as vegetation encroachment. It is permissible for the
requirement to be undertaken from the driving cab of a train if necessary.
Extract from GO/RT3119 Accident and Incident Investigation
G 2.1.5.8
2.1
Responsibilities common to infrastructure managers and railway
undertakings
2.1.5
Physical and witness evidence
2.1.5.3
Infrastructure managers and railway undertakings shall prioritise the
collection of evidence according to the following list of subjects:
d) Records of previous related events.
For example, timetable change records, obtaining records that relate to previous safety
events involving the same persons, location or review of the risk assessment required by
GI/RT7006 Prevention and Mitigation of Overruns – Risk Assessment, where available.
Extract from GO/RT3119 Accident and Incident Investigation
2.1
Responsibilities common to infrastructure managers and railway
undertakings
2.1.5
Physical and witness evidence
2.1.5.4
G 2.1.5.9
G 2.1.6
Infrastructure managers and railway undertakings shall make the evidence they
have gathered available to the person appointed to lead an investigation.
The following should be included (as a minimum):
a)
Alcohol and drug test results.
b)
Signalling data records.
Action in response to an investigation
Extract from GO/RT3119 Accident and Incident Investigation
2.1
Responsibilities common to infrastructure managers and railway
undertakings
2.1.6
Action in response to an investigation
2.1.6.1
G 2.1.6.1
Infrastructure managers and railway undertakings shall evaluate reports of
urgent safety problems found during an investigation for relevance to their
operations, to identify any need for an immediate response before the
completed investigation report and recommendations are published.
No additional guidance provided.
Extract from GO/RT3119 Accident and Incident Investigation
2.1
Responsibilities common to infrastructure managers and railway
undertakings
2.1.6
Action in response to an investigation
2.1.6.2
G 2.1.6.2
Infrastructure managers and railway undertakings shall evaluate
recommendations made in reports of formal investigations for relevance to their
operations.
No additional guidance provided.
Extract from GO/RT3119 Accident and Incident Investigation
RSSB
2.1
Responsibilities common to infrastructure managers and railway
undertakings
2.1.6
Action in response to an investigation
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Guidance on Accident and Incident Investigation
2.1.6.3
G 2.1.6.3
Infrastructure managers and railway undertakings shall document reasons for
rejecting any recommendations together with alternative measures for
controlling risks identified.
No additional guidance provided.
Extract from GO/RT3119 Accident and Incident Investigation
G 2.1.6.4
2.1
Responsibilities common to infrastructure managers and railway
undertakings
2.1.6
Action in response to an investigation
2.1.6.4
Infrastructure managers and railway undertakings shall report to the Safety
Management Information System (SMIS) their progress towards implementing
recommendations from industry and Rail Accident Investigation Branch (RAIB)
investigations that they have accepted.
Appendix E contains non-mandatory information for the reporting of progress
towards implementing recommendations.
No additional guidance provided.
Extract from GO/RT3119 Accident and Incident Investigation
2.1
Responsibilities common to infrastructure managers and railway
undertakings
2.1.6
Action in response to an investigation
2.1.6.5
G 2.1.6.5
Infrastructure managers or railway undertakings acting as the lead organisation
for an incident investigation shall not, if a Signal Sighting Committee (SSC) has
been convened, conclude the detailed analysis of the wider evidence until they
are in receipt of the SSC report.
No additional guidance provided.
G 2.1.7
Release of information to third parties
Extract from GO/RT3119 Accident and Incident Investigation
2.1
Responsibilities common to infrastructure managers and railway
undertakings
2.1.7
Release of information to third parties
2.1.7.1
G 2.1.7.1
Infrastructure managers and railway undertakings shall not make public
statements or release information to third parties about the progress, evidence
or conclusions of an investigation, without the permission of the lead
organisation and other railway industry parties involved in the accident or
incident being investigated.
No additional guidance provided.
G 2.2
Responsibilities of the lead organisation for formal investigations
G 2.2.1
Appointment of a person to lead the formal investigation
Extract from GO/RT3119 Accident and Incident Investigation
2.2
Responsibilities of the lead organisation for formal investigations
2.2.1
Appointment of a person to lead the formal investigation
2.2.1.1
G 2.2.1.1
The lead organisation shall appoint a suitable person to lead the formal
investigation according to the mandatory requirements contained in Appendix
D.
When deciding whether a conflict of interest would be created for a prospective lead
investigator, the following factors should be considered:
a)
Current and previous employment with any party involved in the accident / incident
and whether the activities performed in connection with such employment are likely
to be significant matters for the investigation in relation to the cause(s) of the event.
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G 2.2.2
b)
Any substantial financial interest (excluding occupational pensions), in any party
involved in the accident / incident, the value of which could be significantly affected
as a result of the findings and recommendations of the investigation.
c)
Close personal or commercial relationships with any witnesses likely to be called
before the investigation or with persons holding senior office within any commercial
corporation involved in the accident / incident.
Remit for person appointed to lead the formal investigation
Extract from GO/RT3119 Accident and Incident Investigation
2.2
Responsibilities of the lead organisation for formal investigations
2.2.2
Remit for person appointed to lead the formal investigation
2.2.2.1
The lead organisation shall, at the earliest opportunity after the accident or
incident has occurred, consult affected parties on an appropriate remit for the
person appointed to lead the formal investigation. The remit shall require:
a) Determination of events leading up to the accident or incident, the immediate
and underlying cause(s).
b) Identification of recommendations that could mitigate or eliminate the risk
from such accidents or incidents in future.
c) Reporting of urgent problems found during the investigation to the lead
organisation and which justify remedial action before the investigation report
is completed.
d) Completion of the investigation within a defined time limit.
G 2.2.2.1
e) A written report of the investigation containing any recommendations, and in
the case of investigations involving a SPAD, specific and final confirmation of
its category as specified in Table 2 of Appendix D, or its alternative
conclusion (together with the reasons for such a change).
Recommendations identified might include suggested improvements to processes and
documents such as European and national standards, operating rules and practices.
They might also include suggested physical changes to equipment, infrastructure, rolling
stock, environment etc. Whatever changes might be indicated in the recommendations,
the likelihood of any recurrence of such an accident or incident and the consequences of
not changing identified problems should be addressed.
G 2.2.2.2
The terms ‘earliest opportunity’ and ‘defined time limit’ referred to in 2.2.2.1 should be
discussed, ascertained and agreed between all affected parties and the designated lead
organisation. This should be done under the principle of cooperation, according to the
circumstances of the incident investigation concerned and also taking into account any
proposed extentions to time limits required. Time limits for reporting might also be
affected by legal issues or official requests from regulatory authorities. In all cases the
time limits referred to in the requirements should accord with the nature of the event
being investigated and be proportionate to the potential consequences, including those
that might have arisen had the circumstances been slightly different.
G 2.2.2.3
The final confirmation of an incident’s SPAD category (if there is one) may involve a
change to, or even deletion of, the provisional one that was allocated immediately
following the incident. The lead organisation should make this decision based upon their
investigation, evidence and professional expertise. In all such cases the lead
organisation’s final report should contain confirmation categories that accord with the
details of Appendix D (see also 2.2.4.4 and associated GN items).
Extract from GO/RT3119 Accident and Incident Investigation
RSSB
2.2
Responsibilities of the lead organisation for formal investigations
2.2.2
Remit for person appointed to lead the formal investigation
2.2.2.2
The lead organisation shall be responsible for communicating the agreed remit
to the person appointed to lead the formal investigation.
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Guidance on Accident and Incident Investigation
G 2.2.2.4
G 2.2.3
In addition to information provided by the initial stage of evidence gathering, the person
designated responsible for preparing the remit should consider whether other issues are
relevant for consideration, such as:
a)
Previous investigations into similar incidents.
b)
Recent safety incidents involving the same location, equipment or operators.
c)
Organisational changes.
Participation in formal investigation proceedings
Extract from GO/RT3119 Accident and Incident Investigation
2.2
Responsibilities of the lead organisation for formal investigations
2.2.3
Participation in formal investigation proceedings
2.2.3.1
The lead organisation shall invite the following to cooperate in formal
investigation proceedings:
a) Organisations whose employees are directly involved in the accident or
incident being investigated, and its cause(s).
b) Trades unions, recognised by the employer, who represent employees:
i)
Directly involved in the accident or incident being investigated or its
causes.
ii)
Who are called upon to give evidence.
Or
c) Organisations who own or operate rolling stock or infrastructure involved in
the accident or incident being investigated.
G 2.2.3.1
G 2.2.3.2
d) Organisations whose personnel or products have been directly involved in
the accident or incident.
Persons other than employees of infrastructure managers or railway undertakings may be
called to give evidence, but have no obligation under this document to attend. They may,
however, be obliged to cooperate through the requirements of Regulation 22 of the
Railways and Other Guided Transport Systems (Safety) Regulations 2006 (ROGS) and
contractual agreements with infrastructure managers or railway undertakings.
At the discretion of the investigation team, representatives of recognised passenger
bodies (such as ‘Passenger Focus’) should be considered for involvement. The decision
to invite, and the level and type of involvement of such organisations should be
commensurate with the severity of the accident or incident concerned.
Extract from GO/RT3119 Accident and Incident Investigation
2.2
Responsibilities of the lead organisation for formal investigations
2.2.3
Participation in formal investigation proceedings
2.2.3.2
The lead organisation shall not permit the following to attend a formal
investigation:
a) Officers of the British Transport Police or inspectors of the Office of Rail
Regulation (ORR), other than as direct witnesses of the accident or incident
being investigated.
b) Legal representatives, including those of any witnesses or other party to the
proceedings.
G 2.2.3.3
The reason that certain organisations (such as the BTP and the ORR) are excluded from
being invited to attend investigations is because they are designated enforcing authorities
who have a statutory responsibility for the enforcement of law. In such circumstances it
would be inappropriate for representatives of such organisations to take part in the
investigation of an incident. It should be noted that the RAIB is not an enforcing authority,
and therefore might be invited to attend if appropriate to do so.
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RSSB
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Guidance on Accident and Incident Investigation
G 2.2.4
Informing others of SPAD risk ranking and formal investigation results
Extract from GO/RT3119 Accident and Incident Investigation
2.2
Responsibilities of the lead organisation for formal investigations
2.2.4
Informing others of SPAD risk ranking and formal investigation results
2.2.4.1
G 2.2.4.1
The lead organisation for a formal investigation shall input the results of SPAD
risk ranking into SMIS.
No additional guidance provided.
Extract from GO/RT3119 Accident and Incident Investigation
2.2
Responsibilities of the lead organisation for formal investigations
2.2.4
Informing others of SPAD risk ranking and formal investigation results
2.2.4.2
G 2.2.4.2
The lead organisation shall inform infrastructure managers and railway
undertakings and RSSB of system defects found during a formal investigation
that justify urgent remedial action before the completed investigation report is
published.
Consideration should be given for the need to initiate an Urgent Operating Advice should
the incident highlight issues of sufficient safety criticality in accordance with the details
and process outlined in GO/RT3350 Communication of Urgent Operating Advice. The
NIR3350 report form is available on the www.railnotices.net website. Urgent safety
related notices in respect of train / rail vehicle defects are covered by requirements
contained in GE/RT8250 Reporting High Risk Defects.
Extract from GO/RT3119 Accident and Incident Investigation
2.2
Responsibilities of the lead organisation for formal investigations
2.2.4
Informing others of SPAD risk ranking and formal investigation results
2.2.4.3
G 2.2.4.3
G 2.2.4.4
The lead organisation shall inform infrastructure managers and railway
undertakings and RSSB of the conclusions and recommendations made as a
result of a formal investigation. This requirement may be met through reporting
to SMIS and may be recorded as ‘inconclusive’ if the incident category or
underlying causes cannot be determined.
The recording of an incident as being ‘inconclusive’ enables lead investigators to state
that it is not possible to reach a definitive causation according to evidence obtained. Such
evidence may be, for example, contradictory and with no way of achieving absolute proof.
It is not the purpose of this RGS to apportion blame or liability for any form or category of
incident as a natural outcome of an investigation. Therefore, where the evidence cannot
indicate a definitive cause it should be possible for investigators to report accordingly.
The lead organisation should ensure that conclusions and recommendations are entered
into SMIS to comply with GE/RT8047 Reporting of Safety Related Information.
Extract from GO/RT3119 Accident and Incident Investigation
2.2
Responsibilities of the lead organisation for formal investigations
2.2.4
Informing others of SPAD risk ranking and formal investigation results
2.2.4.4
G 2.2.4.5
RSSB
The lead organisation shall use Table 2 of Appendix D for confirming the
categorisation of an incident that has been initially identified as a SPAD once
the full causes are established following SPAD incident (formal) investigation.
The infrastructure manager (Network Rail) will have initially assessed a SPAD specific
incident as falling into one of a number of defined provisional categories (as stated in
Table 1 of section 2.4 of the standard) prior to full investigation into the cause and based
upon information available at the time. Subsequent investigation may either confirm or
change this initial categorisation and the investigators then have the responsibility to duly
confirm the status of that original decision.
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Guidance on Accident and Incident Investigation
G 2.2.4.6
If the original decision to identify the incident as a SPAD, and / or its given category is
subsequently changed as a result of the investigation, then the reports should clearly
indicate this outcome and apportionment of responsibility may be altered accordingly.
G 2.2.4.7
In all cases the lead organisation should, if confirming or changing the SPAD category,
use the Table 2 List of confirmed category A SPAD event types. If the investigation
concludes that the circumstances do not comply with the conditions for one of the SPAD
categories stated in the Table, then they may consider re-designating the event (for
example, as an operating or possession irregularity, or an operating incident). Guidance
item G A.4.11 provides further guidance for lead organisations seeking to re-designate an
event as a result of their final investigation report.
Extract from GO/RT3119 Accident and Incident Investigation
2.2
Responsibilities of the lead organisation for formal investigations
2.2.4
Informing others of SPAD risk ranking and formal investigation results
2.2.4.5
The lead organisation shall communicate the conclusions of each SPAD
incident (formal) investigation and recommendations arising from them to:
a) The parties whose employees or contractors were involved in the SPAD
incident.
G 2.2.4.8
G 2.2.4.9
G 2.2.5
b) All railway undertakings using the route on which the signal concerned is
located or where the in-cab signalled movement authority was exceeded.
Infrastructure managers and railway undertakings should have processes in place to brief
their employees of the circumstances of any accident or incident that is relevant to their
work. This brief should include contractors employed by another infrastructure manager
or railway undertaking, but whose work involves controlling trains or train movements
within the area relevant to the accident or incident.
Infrastructure managers and railway undertakings should consider, as a minimum:
a)
Briefing signallers and train drivers about signals on routes over which they control
or operate that have been the subject of more than one SPAD incident during the
past five years.
b)
Amending, if appropriate, local instructions or other operational processes.
Report of the formal investigation
Extract from GO/RT3119 Accident and Incident Investigation
2.2
Responsibilities of the lead organisation for formal investigations
2.2.5
Report of the formal investigation
2.2.5.1
The lead organisation shall provide a written report of the formal investigation to
all infrastructure managers and railway undertakings, other railway industry
parties involved in the accident or incident and RSSB. The report of a formal
investigation shall include:
a) The remit.
b) Details of the event under investigation.
c) A description of the sequence of events.
d) A summary of the deliberations of the investigation team which relates the
evidence to their conclusions.
e) The immediate and underlying causes of the accident or incident.
f) Recommendations, cross-referenced to the part of the report which justify
them and clear as to their purpose of eliminating or minimising the risk from
future accidents or incidents by preventing or reducing the likelihood of
recurrence or mitigating the consequences.
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Guidance on Accident and Incident Investigation
G 2.2.5.1
G 2.2.5.2
g) In the case of investigations involving a SPAD, final confirmation of the
SPAD category allocation according to the requirements of Appendix D.3
Alleged SPAD category confirmation.
At the conclusion of the investigation process and before the report is published, the
person in the lead organisation responsible for managing the investigation process
should review the report to ensure that:
a)
The remit has been achieved, or where this has not been possible, suitable action
has been taken.
b)
Immediate and underlying causes have been identified.
c)
The recommendations have been made in accordance with any requirements of this
standard.
d)
Representations made by affected parties have been considered and addressed,
and the relevant organisations informed accordingly.
If an SSC report has been completed as part of the investigation into a SPAD related
accident or incident, the SSC report should be included as an appendix to the formal
investigation report. It should be noted that a SSC may not always be held, which is why
the requirement states ‘if appropriate’.
Extract from GO/RT3119 Accident and Incident Investigation
2.2
Responsibilities of the lead organisation for formal investigations
2.2.5
Report of the formal investigation
2.2.5.2
G 2.2.5.3
G 2.2.6
The lead organisation shall specifically address each report recommendation to
an infrastructure manager or railway undertaking.
Infrastructure managers and railway undertakings are responsible for considering and
implementing recommendations concerning those issues within the scope of their safety
certificates and involving their contractors and suppliers to achieve this. In choosing
which particular infrastructure manager or railway undertaking a recommendation should
be addressed to, the investigation team should consider the following:
a)
Which infrastructure manager or railway undertaking owns the issue or directly
controls the importation of the risk that the recommendation is directed at, for
example, railway undertakings directly control the risks imported by traction and
rolling stock.
b)
Whether a recommendation, which may prompt submission of a proposal for
changes to Railway Group Standards, should be addressed to an infrastructure
manager or railway undertaking that has participated in the investigation and has
responsibility for applying the measures that are recommended to be changed.
c)
In addition to the infrastructure manager or railway undertaking, it may be
appropriate to direct recommendations to other parties (for example Rolling Stock
Companies (ROSCOs) or contractors) that would have a significant role in
implementing those recommendations, because the infrastructure manager or
railway undertaking needs their cooperation in accordance with Regulation 22 of the
Railways and Other Guided Transport Systems (Safety) Regulations 2006 (ROGS).
In these situations it is still necessary to clearly indicate the relevant infrastructure
manager or railway undertaking to whom the recommendation is addressed and
therefore is responsible for ensuring the support of those parties.
Report of Signal Sighting Committee (formal investigations)
Extract from GO/RT3119 Accident and Incident Investigation
RSSB
2.2
Responsibilities of the lead organisation for formal investigations
2.2.6
Report of Signal Sighting Committee (formal investigations)
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Guidance on Accident and Incident Investigation
2.2.6.1
G 2.2.6.1
The lead organisation for a formal investigation shall check that any Signal
Sighting Committee report includes the SSC’s professional judgement as to the
significance and contribution of any infrastructure factors to the circumstances
of the alleged category A SPAD incident with particular regard to staff error.
Signal Sighting Committees are normally only convened to investigate alleged category A
type SPAD incidents.
Extract from GO/RT3119 Accident and Incident Investigation
2.2
Responsibilities of the lead organisation for formal investigations
2.2.6
Report of Signal Sighting Committee (formal investigations)
2.2.6.2
G 2.2.6.2
The lead organisation for a formal investigation shall make the SSC report
available to all parties involved in the alleged category A SPAD incident, and
check that any relevant conclusions and recommendations are recorded in the
incident investigation report.
Those SSC report recommendations relating to the cause of the category A SPAD may
be included as part of the formal investigation team’s own recommendations (if they
accept them), as well as any others in the formal investigation report.
G 2.3
Responsibilities of the lead organisation for local investigations
G 2.3.1
Remit for person appointed to lead the investigation
Extract from GO/RT3119 Accident and Incident Investigation
2.3
Responsibilities of the lead organisation for local investigations
2.3.1
Remit for person appointed to lead the investigation
2.3.1.1
The lead organisation shall provide a remit for the person to lead a local
investigation, which requires:
a) Determination of the immediate and underlying causes of the event.
b) Identification of any local system improvements that could mitigate or
eliminate the risk from such accidents or incidents in the future.
c) Completion of the investigation within a defined time limit.
G 2.3.1.1
G 2.3.1.2
d) A written report (which may be in a standardised format).
In addition to information provided by the initial stage of evidence gathering, the person
designated responsible for preparing the remit should consider whether other issues are
relevant for consideration, such as:
a)
Previous investigations into similar incidents.
b)
Recent safety incidents involving the same location, equipment or operators.
c)
Organisational changes.
The term ‘defined time limit’ referred to in 2.3.1.1 should be discussed, ascertained and
agreed between all affected parties and the designated lead organisation under the
principle of cooperation, and according to the circumstances of the incident investigation
concerned. Time limits for reporting might also be affected by legal issues or official
requests from regulatory authorities. In all cases the time limits referred to in the
requirements should accord with the nature of the event being investigated and be
proportionate to the potential consequences, including those that might have arisen had
the circumstances been slightly different.
Extract from GO/RT3119 Accident and Incident Investigation
2.3
Responsibilities of the lead organisation for local investigations
2.3.1
Remit for person appointed to lead the investigation
2.3.1.2
The lead organisation shall not permit the following to attend a local
investigation:
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Guidance on Accident and Incident Investigation
a) Officers of the British Transport Police or inspectors of the Office of Rail
Regulation (ORR), other than as direct witnesses of the accident or incident
being investigated.
G 2.3.1.3
b) Legal representatives, including those of any witnesses or other party to the
proceedings.
With regard to participation in local investigation proceedings, according to the
circumstances of the accident / incident, the lead organisation should consider inviting the
following to co-operate in the investigation proceedings:
a)
Organisations whose employees are directly involved in the accident or incident
being investigated, and its cause(s).
b)
Trades unions, recognised by the employer, who represent employees:
i)
Directly involved in the accident or incident being investigated or its causes.
Or
ii)
G 2.3.2
Who are called upon to give evidence.
c)
Organisations who own or operate rolling stock or infrastructure involved in the
accident or incident being investigated.
d)
Organisations whose personnel or products have been directly involved in the
accident or incident.
Informing others of SPAD risk ranking and local investigation results
Extract from GO/RT3119 Accident and Incident Investigation
2.3
Responsibilities of the lead organisation for local investigations
2.3.2
Informing others of SPAD risk ranking and local investigation results
2.3.2.1
G 2.3.2.1
The lead organisation for a local investigation shall input the results of SPAD
risk ranking into SMIS.
No additional guidance provided.
Extract from GO/RT3119 Accident and Incident Investigation
2.3
Responsibilities of the lead organisation for local investigations
2.3.2
Informing others of SPAD risk ranking and local investigation results
2.3.2.2
G 2.3.2.2
The lead organisation shall inform infrastructure managers and railway
undertakings and RSSB of system defects found during a local investigation
that justify urgent remedial action before the completed investigation report is
published.
Consideration should be given for the need to initiate an Urgent Operating Advice should
the incident highlight issues of sufficient safety criticality in accordance with the details
and process outlined in GO/RT3350 Communication of Urgent Operating Advice. The
NIR3350 report form is available on the www.railnotices.net website. Urgent safety
related notices in respect of train / rail vehicle defects are covered by requirements
contained in GE/RT8250 Reporting High Risk Defects.
Extract from GO/RT3119 Accident and Incident Investigation
RSSB
2.3
Responsibilities of the lead organisation for local investigations
2.3.2
Informing others of SPAD risk ranking and local investigation results
2.3.2.3
The lead organisation shall inform infrastructure managers and railway
undertakings and RSSB of the conclusions and recommendations made as a
result of a local investigation. This requirement may be met through reporting to
SMIS and may be recorded as ‘inconclusive’ if the incident category or
underlying causes cannot be determined.
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Guidance on Accident and Incident Investigation
G 2.3.2.3
The recording of an incident as being ‘inconclusive’ enables lead investigators to state
that it is not possible to reach a definitive causation according to evidence obtained. Such
evidence may be, for example, contradictory and with no way of achieving absolute proof.
It is not the purpose of this RGS to apportion blame or liability for any form or category of
incident as a natural outcome of an investigation. Therefore, where the evidence cannot
indicate a definitive cause, it should be possible for investigators to report accordingly.
G 2.3.2.4
The lead organisation should ensure that conclusions and recommendations are entered
into SMIS to comply with GE/RT8047 Reporting of Safety Related Information.
Extract from GO/RT3119 Accident and Incident Investigation
2.3
Responsibilities of the lead organisation for local investigations
2.3.2
Informing others of SPAD risk ranking and local investigation results
2.3.2.4
G 2.3.2.5
G 2.3.2.6
The lead organisation shall use Table 2 of Appendix D for confirming the
categorisation of an incident that has been initially identified as a SPAD once
the full causes are established following SPAD incident (local) investigation.
The infrastructure manager (Network Rail) will have initially assessed a SPAD specific
incident as falling into one of a number of defined provisional categories (as stated in
Table 1 of section 2.4 of the standard) prior to full investigation into the cause and based
upon information available at the time. Subsequent investigation may either confirm or
change this initial categorisation and the investigators then have the responsibility to duly
confirm the status of that original decision.
If the original decision to identify the incident as a SPAD, and / or its given category is
subsequently changed as a result of the investigation, then the reports should clearly
indicate this outcome and apportionment of responsibility may be altered accordingly.
Extract from GO/RT3119 Accident and Incident Investigation
2.3
Responsibilities of the lead organisation for local investigations
2.3.2
Informing others of SPAD risk ranking and local investigation results
2.3.2.5
The lead organisation shall communicate the conclusions of each SPAD
incident (local) investigation and recommendations arising from them to:
a) The parties whose employees or contractors were involved in the SPAD
incident.
G 2.3.2.7
G 2.3.2.8
G 2.3.3
b) All railway undertakings using the route on which the signal concerned is
located or where the in-cab signalled movement authority was exceeded.
Infrastructure managers and railway undertakings should have processes in place to brief
their employees of the circumstances of any accident or incident that is relevant to their
work. This brief should include contractors employed by another infrastructure manager
or railway undertaking, but whose work involves controlling trains or train movements
within the area relevant to the accident or incident.
Infrastructure managers and railway undertakings should consider, as a minimum:
a)
Briefing signallers and train drivers about signals on routes over which they control
or operate that have been the subject of more than one SPAD incident during the
past five years.
b)
Amending, if appropriate, local instructions or other operational processes.
Report of the local investigation
Extract from GO/RT3119 Accident and Incident Investigation
2.3
Responsibilities of the lead organisation for local investigations
2.3.3
Report of the local investigation
2.3.3.1
The lead organisation shall include, as a minimum, the following information in
its local investigation report (which may be in a standardised format):
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Guidance on Accident and Incident Investigation
a) A brief description of the event.
b) A summary of the relevant facts.
c) Findings as to the immediate and underlying causes.
d) Identification of recommendations that could mitigate or eliminate the risk
from such accidents or incidents in future.
G 2.3.3.1
e) In the case of investigations involving a SPAD, specific and final confirmation
of its category as specified in Table 2 of Appendix D, or its alternative
conclusion (together with the reasons for such a change).
Depending on the complexity of the incident being investigated, the length and depth of
the report should be proportionate to the circumstances of the incident. For example, in
the case of a lower SPAD risk incident the report may consist of the completed
Provisional SPAD data collection forms, with suitable narrative added to record causation
details and any recommendations.
Extract from GO/RT3119 Accident and Incident Investigation
2.3
Responsibilities of the lead organisation for local investigations
2.3.3
Report of the local investigation
2.3.3.2
G 2.3.3.2
The lead organisation shall specifically address each local investigation report
recommendation to an infrastructure manager or railway undertaking.
No additional guidance provided.
G 2.3.4
Report of Signal Sighting Committee (local investigations)
Extract from GO/RT3119 Accident and Incident Investigation
2.3
Responsibilities of the lead organisation for local investigations
2.3.4
Report of Signal Sighting Committee (local investigations)
2.3.4.1
G 2.3.4.1
The lead organisation for a local investigation shall check that any Signal
Sighting Committee report includes the SSC’s professional judgement as to the
significance and contribution of any infrastructure factors to the circumstances
of the alleged category A SPAD incident with particular regard to staff error.
SSC’s are usually only convened to investigate category A SPAD incidents. If a SSC was
convened and their report contains recommendations relating to the cause of the
category A SPAD, these may be included (if accepted) as part of the local investigation
team’s own recommendations, as well as any others in the local investigation report.
Extract from GO/RT3119 Accident and Incident Investigation
2.3
Responsibilities of the lead organisation for local investigations
2.3.4
Report of Signal Sighting Committee (local investigations)
2.3.4.2
G 2.3.4.2
The lead organisation for a local investigation shall make the SSC report
available to all parties involved in the alleged category A SPAD incident, and
check that any relevant conclusions and recommendations are recorded in the
incident investigation report.
No additional guidance provided.
G 2.4
Responsibilities of infrastructure managers
G 2.4.1
Preliminary designation of an incident as a SPAD
Extract from GO/RT3119 Accident and Incident Investigation
RSSB
2.4
Responsibilities of infrastructure managers
2.4.1
Preliminary designation of an incident as a SPAD
2.4.1.1
The infrastructure manager (Network Rail only) shall make the initial
assessment of an incident in order to designate it as a provisional SPAD.
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Guidance on Accident and Incident Investigation
G 2.4.1.1
In the unlikely event that there is apparently insufficient immediate information for
Network Rail to make an initial categorisation according to the Table 1 descriptions
shown below, liaison should be sought between affected duty holders and should be
considered as part of the statutory requirements for co-operation between infrastructure
managers and railway undertakings. This is as specified in Regulation 22 of the Railways
and Other Guided Transport Systems (Safety) Regulations 2006 (ROGS). This should
enable a decision to be made on the provisional SPAD allocation prior to its full
investigation by lead organisation.
Extract from GO/RT3119 Accident and Incident Investigation
2.4
Responsibilities of infrastructure managers
2.4.1
Preliminary designation of an incident as a SPAD
2.4.1.2
The infrastructure manager (Network Rail only) shall identify its initial
assessment of each alleged SPAD specific incident as ‘provisional’ by using the
information shown in Table 1, prior to full cause investigation and incident
confirmation by the designated lead organisation.
Description
(Notes: No degree of severity or importance is implied within or
between these provisional SPAD event types.)
Provisional Category
A (p) SPAD types
G 2.4.1.2

When a SPAD has occurred and, according to
available evidence, a stop aspect, indication or
end of in-cab signalled movement authority was
displayed or given correctly and in sufficient time
for the train to be stopped safely at it.

When a SPAD has occurred and, according to
available evidence, the stop aspect, indication or
end of in-cab signalled movement authority
concerned was not displayed or given correctly,
but was preceded by the correct aspects or
indications.

When a SPAD has occurred and, according to
available evidence, verbal and/or visual
permission to pass a signal at danger was given
by a handsignaller or other authorised person
without the authority of the signaller.

When a SPAD has occurred and, according to
available evidence, a stop aspect, indication or
end of in-cab signalled movement authority was
displayed or given correctly and in sufficient time
for the train to be stopped safely at it, but the train
driver was unable to stop his train owing to
circumstances beyond his control (for example,
poor rail head adhesion, train braking equipment
failure or malfunction etc).
Table 1: List of provisional Category A (p) SPAD event types
Table 1 List of provisional Category A (p) SPAD event types – General Guidance: The list
of provisional Category A SPAD event types contained in Table 1 is presented in tabular
format in order to present the types of incident in a clear and distinct layout, rather than a
block of text. Designating the incident as a provisional Category A SPAD can be done by
the designated persons in the knowledge that all cases will be investigated fully by the
lead organisation. The lead organisation for the investigation will be aware that
provisional categorisations are made at the time of the incident with information that was
available at that time. RSSB recognises that each SPAD specific incident will have its
own individual causation eventuality or circumstance, and it is not the intention of either
the RGS requirements or this guidance note to provide an exhaustive list of possible
causes as the variables are too great. The guidance notes provided here should be used
to support and inform the correct and appropriate selection of the type of Category A
SPAD event type – rather than every single detail of an individual event. Further detailed
guidance of Category A SPAD event types can be found by referring to Appendix D
guidance.
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G 2.4.1.3
All SPAD-specific incidents will be investigated by the lead organisation appointed to do
so and the correct Category A event type confirmed (or changed to an operating incident)
in their final report. Industry reporting processes should reflect the provisional nature of
SPAD categories prior to investigation and no liability or blame should be inferred
accordingly.
G 2.4.2
Post-SPAD incident inspection – infrastructure and related factors
Extract from GO/RT3119 Accident and Incident Investigation
2.4
Responsibilities of infrastructure managers
2.4.2
Post-SPAD incident inspection – infrastructure and related factors
2.4.2.1
G 2.4.2.1
Infrastructure managers shall make arrangements for an immediate post-SPAD
incident inspection of the infrastructure concerned. The type and amount of
inspection shall be commensurate with the circumstances of the SPAD incident
and the potential consequences that could have arisen.
No additional guidance provided.
Extract from GO/RT3119 Accident and Incident Investigation
2.4
Responsibilities of infrastructure managers
2.4.2
Post-SPAD incident inspection – infrastructure and related factors
2.4.2.2
G 2.4.2.2
G 2.4.2.3
G 2.4.3
The infrastructure manager (Network Rail only) shall undertake a technical
investigation of the signalling system when a specific allegation is made against
it.
The allegation might also include cases where a driver disputes that a SPAD had taken
place, if technical investigation of the signalling system can provide the evidence of proof.
A post-SPAD incident inspection should consider the following factors as appropriate
(non-exhaustive list):
a)
Rail conditions.
b)
Weather (including sunlight obscuration).
c)
Signal visibility and condition (including structure, head alignment, lens cleanliness
and red aspect filament and LED component condition, where applicable).
d)
General signal structure condition.
e)
Vegetation encroachment.
Investigation of SPAD incidents - risk ranking
Extract from GO/RT3119 Accident and Incident Investigation
2.4
Responsibilities of infrastructure managers
2.4.3
Investigation of SPAD incidents - risk ranking
2.4.3.1
G 2.4.3.1
The infrastructure manager (Network Rail only) shall complete the SPAD risk
ranking process using the SPAD risk ranking tool.
No additional guidance provided.
Extract from GO/RT3119 Accident and Incident Investigation
2.4
Responsibilities of infrastructure managers
2.4.3
Investigation of SPAD incidents - risk ranking
2.4.3.2
G 2.4.3.2
RSSB
The infrastructure manager (Network Rail only) shall inform railway
undertakings of the results of the SPAD risk ranking process and consult with
railway undertakings on appropriate measures to mitigate identified risks.
No additional guidance provided.
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Guidance on Accident and Incident Investigation
Extract from GO/RT3119 Accident and Incident Investigation
2.4
Responsibilities of infrastructure managers
2.4.3
Investigation of SPAD incidents - risk ranking
2.4.3.3
G 2.4.3.3
The infrastructure manager (Network Rail only) shall complete the SPAD risk
ranking before the investigation team meets and provide the results to them as
evidence for their consideration and for inputting into SMIS.
No additional guidance provided.
G 2.4.4
Criteria for deciding when a Signal Sighting Committee (SSC) is required
Extract from GO/RT3119 Accident and Incident Investigation
2.4
Responsibilities of infrastructure managers
2.4.4
Criteria for deciding when a Signal Sighting Committee (SSC) is required
GE/RT8037 Signal Positioning and Visibility sets out the requirements for the
sighting of signals and the composition of SSCs.
2.4.4.1
The infrastructure manager (Network Rail only) shall convene a SSC to assist
investigation of any alleged category A SPAD incident, with the following
specific exceptions:
a) One was convened following a previous category A SPAD incident at that
signal and all the following apply:
i)
Its report is comprehensive and is available to the investigators.
ii)
The investigators are satisfied that all the factors relevant to the latest
alleged category A SPAD incident were considered.
iii)
The investigators are satisfied that no change has taken place to the
signal or at its location, which could affect those factors.
b) The signal had been commissioned within the previous 12 months.
G 2.4.4.1
c) The train was wrongly authorised to pass the signal at danger after coming
to a stand at the signal.
Signal Sighting Committees are normally only convened to investigate alleged category A
type SPAD incidents.
Extract from GO/RT3119 Accident and Incident Investigation
2.4
Responsibilities of infrastructure managers
2.4.4
Criteria for deciding when a Signal Sighting Committee (SSC) is required
2.4.4.2
G 2.4.4.2
The infrastructure manager (Network Rail only) shall document the decision not
to convene a SSC, and keep the decision details with the alleged category A
SPAD incident investigation report to be published with the formal investigation
report.
No additional guidance provided.
G 2.4.5
Remit of Signal Sighting Committee
Extract from GO/RT3119 Accident and Incident Investigation
2.4
Responsibilities of infrastructure managers
2.4.5
Remit of Signal Sighting Committee
2.4.5.1
The infrastructure manager (Network Rail only) shall set the remit of the SSC
after consulting the railway undertakings involved in the alleged category A
SPAD incident.
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G 2.4.5.1
It is important that all possible contributory causes should be considered. Therefore, it
has become standard practice to undertake a detailed examination of all cautionary
signals in the sequence leading to the signal at red, as well as the SPAD incident signal
itself. Since it is important to understand the driver's perspective of events, this means
that the normal boundary of the committee's investigation is the point at which the
outermost cautionary aspect became visible. From this point onwards, all significant
features of the infrastructure, as well as any significant features outside the Network Rail
boundary that could have had a material effect on the driver's actions, should be
examined. Where the signal previous to the SPAD incident signal was a shunting signal,
then the investigation should extend back at least as far as the point at which the
shunting signal became visible.
G 2.4.5.2
Wherever it is possible for a driver to see the aspects of other signals, apart from those
immediately applicable to the train, then misreading error (because of cross-reading one
or more parallel signals, or reading-through to a signal ahead) is a possibility. In such
cases the committee should consider the likelihood of such an error occurring. The
scope of the investigation should therefore be expanded to take in such signals.
G 2.4.5.3
When agreeing an exact scope for the signal sighting investigation, the committee should
beware of applying a rigid formula; No two SPAD incidents are ever exactly the same. A
full examination of the SPAD incident signal itself should always be undertaken. Beyond
that, the scope of the exercise should take in all factors that could possibly have had a
bearing on the incident. The committee should always consider the possibility that the
conditions for an error to occur were set up before the first cautionary aspect came into
view. For example, it is possible that irregular spacing between green aspects, a change
between two, three, or four aspect signalling systems, or even the presence of a
significant landmark contributed to a SPAD incident at some distance ahead.
G 2.4.5.4
In certain cases, examination of the full aspect sequence may not be necessary.
However, this only applies in cases where it is safe to take the view that the signals (or
other infrastructure) in question could not possibly have contributed to the incident. In
areas of four-aspect signalling it may only be necessary to go back as far as the point at
which the single-yellow became visible, if any of the following scenarios apply:
a)
The signal on the approach to the SPAD incident signal was subject to approach
release from red, and the train was being controlled correctly at that point.
b)
The train was detained at a signal which then changed to single-yellow, and after the
train started away, a SPAD incident occurred at the next signal ahead.
c)
The train had stopped in a properly controlled fashion for any reason (such as a
station stop) within the cautionary aspect sequence.
d)
The SPAD incident occurred when the train started away against the red aspect,
having previously made a properly controlled stop.
G 2.4.5.5
In the course of the SSC investigation, a considerable amount of detailed information
should emerge. After the evidence has been collected, it should be a matter of routine to
consider whether or not the initial planned scope of the investigation was sufficient.
Sometimes during an investigation, the emerging facts indicate that the scope of the work
should be extended. For example, the potential for misreading error (due to crossreading or reading-through to other signals) may not be immediately obvious until a
detailed site examination is carried out.
G 2.4.5.6
The SSC also has a duty of care to consider potentially sub-standard conditions that lie
strictly outside the narrow confines of the incident itself. For example, where more than
one route leads to the SPAD incident signal, and the committee has doubts about its
approach view, then the view from all other directions should be checked. The adequacy
and effectiveness of all aspects and indications at the SPAD incident signal should
always be examined, even though it is only the red aspect that will have strict relevance
in the circumstances of the incident.
RSSB
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Extract from GO/RT3119 Accident and Incident Investigation
2.4
Responsibilities of infrastructure managers
2.4.5
Remit of Signal Sighting Committee
2.4.5.2
G 2.4.5.7
The infrastructure manager (Network Rail only) shall include, for consideration
in the remit, all risk factors that could contribute to, or result from, a category A
SPAD incident.
Examples of risk factors that could contribute to, or result from a SPAD incident, and
should be considered when setting the remit for a SSC are:
a)
The previous record of SPAD incidents at that signal and other signals in the vicinity.
b)
Reports from train drivers about the approach view.
c)
Local conditions, including vegetation and light sources.
d)
The sighting of signals, lineside signs, indicators and other features preceding the
signal under investigation.
e)
Signal spacing on the approach to a signal passed at danger.
f)
Aspect sequences on approach to and beyond the signal at which the SPAD incident
occurred.
g)
Gradients.
h)
Distances at which the signals become readable.
i)
Stopping position of trains (in regard to starting against red or yellow aspects at
platforms).
j)
Train dispatch methodology (in regard to starting against red or yellow aspects at
platforms).
Extract from GO/RT3119 Accident and Incident Investigation
2.4
Responsibilities of infrastructure managers
2.4.5
Remit of Signal Sighting Committee
2.4.5.3
G 2.4.5.8
The infrastructure manager (Network Rail only) shall check previous records to
take into account any renumbering of the signal within the period covered or
any minor changes in signal position as a result of a re-signalling scheme.
No additional guidance provided.
G 2.5
Responsibilities of railway undertakings
G 2.5.1
Post-SPAD incident inspection – train and related factors
Extract from GO/RT3119 Accident and Incident Investigation
2.5
Responsibilities of railway undertakings
2.5.1
Post-SPAD incident inspection – train and related factors
2.5.1.1
G 2.5.1.1
Railway undertakings shall make arrangements for an immediate post-SPAD
incident inspection of the train and related factors. The amount of inspection
shall be commensurate with the circumstances of incident and the potential
consequences that could have arisen.
Examples of factors that could be considered in an inspection are:
a)
Visibility through windscreen (such as cleanliness and cracks, condition of sun visors
etc).
b)
In-cab environment (such as heating and ventilation).
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c)
Effects of sunlight on the driving cab.
d)
Results of wheel and brake disc swabs.
Extract from GO/RT3119 Accident and Incident Investigation
2.5
Responsibilities of railway undertakings
2.5.1
Post-SPAD incident inspection – train and related factors
2.5.1.2
G 2.5.1.2
Railway undertakings shall carry out a functional brake test on the train involved
in the SPAD incident, except where there is evidence to support that the braking
system of the train was not a factor for consideration as a cause of the SPAD
incident.
No additional guidance provided.
Extract from GO/RT3119 Accident and Incident Investigation
2.5
Responsibilities of railway undertakings
2.5.1
Post-SPAD incident inspection – train and related factors
2.5.1.3
G 2.5.1.3
Railway undertakings shall undertake a technical investigation of the train
braking system when a specific allegation is made against it.
No additional guidance provided.
Extract from GO/RT3119 Accident and Incident Investigation
2.5
Responsibilities of railway undertakings
2.5.1
Post-SPAD incident inspection – train and related factors
2.5.1.4
G 2.5.1.4
RSSB
Railway undertakings shall conduct a technical investigation into any train borne
equipment associated with the signalling and communications systems if they
might have been a contributory factor to the incident.
Examples of train borne equipment that could be considered are (non exhaustive list):
a)
In-cab signalling (including European Rail Traffic Management System (ERTMS)
equipment).
b)
Automatic Warning System (AWS).
c)
Train Protection and Warning System (TPWS).
d)
Automatic Train Protection (ATP) equipment.
e)
Radio Electronic Token Block (RETB) equipment.
f)
Cab Secure Radio (CSR) systems.
g)
National Radio Network (NRN).
h)
GSM-R system equipment.
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Appendix A Decision criteria – formal investigations
G A.1
Formal investigations
G A.1.1
This section reproduces the mandatory requirements of the Appendix A contained in
GO/RT3119. Appendix A states in A.1.1.2, A.1.1.4, A.2.1.1 and A.2.2.1 that these
conditions are to be ‘normally’ carried out in the circumstances specified. This allows
infrastructure managers and railway undertakings to apply a common sense and
proportionate response to the circumstances of a given accident or incident. If, for
example, the causes and circumstances of an accident or incident are so clear as to
indicate a degree of certainty of cause and effect, then the duty holders concerned may
decide as part of their initial joint review (sometimes referred to as ‘table top meeting’),
that a reduced and more proportionate type of investigation be held. In this case the
parties concerned should be able to justify their decision on a risk based basis in order to
make sure that the decision is fully justified.
Extract from GO/RT3119 Accident and Incident Investigation
A.1
Criteria for deciding when a formal investigation is required
A.1.1
Criteria
A.1.1.1
Infrastructure managers and railway undertakings shall hold a formal
investigation following an event where there may have been a significant failure
of control measures under their direct control, leading to a fatality, major injury
or a potentially high risk incident.
A.1.1.2
A formal investigation shall normally be carried out when an event has resulted
in:
a) An alleged SPAD incident which has led to a collision or derailment (Part 2
SPAD accident vulnerability ranking A – accident occurred).
b) A higher risk alleged SPAD incident not leading to an accident (Part 3 SPAD
risk ranking greater than or equal to 18) or ‘near miss’ SPAD incidents (Part
2 accident vulnerability ranking B to G inclusive).
c) Other alleged category A SPAD incidents when:
i)
It is clear from early evidence that infrastructure may be a causal factor.
ii)
The signal is defined as a multi-SPAD signal or will be so defined
because of the incident concerned.
iii)
The driver disputes that a category A SPAD incident has occurred,
unless there is objective evidence (SSI data, OTMR, etc) which shows
a category A SPAD incident has occurred.
Or
d) Major injury or fatality to members of the public not at a station when struck
by a train, including level crossing users (other than suspected suicide or
trespass).
e) Major injury or fatality to members of the workforce employed by or
contracted to the infrastructure manager when struck by a train.
f) Major injury to passengers or members of the public when struck by a train
at a station (other than suspected attempted suicide, or trespass).
g) Fatality to passengers or members of the public at a station, when boarding
or alighting from or when struck by a train (other than suspected suicide or
trespass).
h) A derailment on a running line.
i) A collision on a running line other than in a station, where no SPAD incident
has occurred.
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j) A collision between trains in a station, where no SPAD incident has
occurred.
k) A train fire where there is injury to or requiring the evacuation of passengers
at a location other than a station.
l) A buffer stop collision at a station where there is injury to people or
significant damage to infrastructure or train.
m) Runaway vehicle incidents where there has been, or there was the potential
for, consequent injury to people or significant damage to infrastructure or
train.
A.1.1.3
It is not mandatory to carry out a formal investigation into an event meeting the
criteria in clause A.1.1.1 and A.1.1.2 if the RAIB decides to conduct an
investigation into the accident or incident, provided the lead organisation shows
that:
a) A formal investigation would duplicate (in terms of objectives and evidence
requirements) that by the RAIB and its costs and impact on individuals would
exceed the benefits from a formal investigation.
b) The RAIB investigation will enable the infrastructure manager or railway
undertaking to meet the objectives set out in section 1.2.1.1 of this
document.
A.1.1.4
A formal investigation shall normally be carried out into an accident or incident
meeting the criteria in clause A.1.1.1 and A.1.1.2, when it is within the scope of
a study by RAIB of a class of events but the RAIB study is not specific to that
accident or incident.
A.1.1.5
Exclusion of a category of incident from the criteria above does not prevent
infrastructure managers and railway undertakings deciding to carry out a formal
investigation into such an accident or incident.
A.2
Criteria for deciding the lead organisation for a formal investigation
A.2.1
Formal investigation to be led by the infrastructure manager
A.2.1.1
The infrastructure manager shall normally lead a formal investigation when
there has been:
a) An alleged SPAD incident which has led to a collision or derailment (Part 2
accident vulnerability ranking A – accident has happened).
b) A higher risk alleged SPAD incident not leading to an accident (Part 3 SPAD
risk ranking greater than or equal to 18) or ‘near miss’ SPAD incidents (Part
2 accident vulnerability ranking B to G inclusive).
c) Other alleged category A SPAD incidents when:
i)
It is clear from early evidence that infrastructure may be a causal factor.
ii)
The signal is defined as a multi-SPAD signal or will be so defined
because of the incident concerned.
ii)
The driver disputes that a category A SPAD incident has occurred,
unless there is objective evidence (SSI data, OTMR, etc) which shows
a category A SPAD incident has occurred.
d) Major injury or fatality to members of the public not at a station when struck
by a train, including level crossing users (other than suspected suicide or
trespass).
e) Major injury or fatality to members of the workforce employed by or
contracted to the infrastructure manager when struck by a train.
f) Major injury or fatality to passengers or members of the public when struck
by a train at a station (other than suspected attempted suicide, or trespass).
g) Fatality to passengers or members of the public at a station, when boarding
or alighting a train (other than suspected suicide or trespass).
RSSB
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h) A derailment on a running line.
i) A collision on a running line other than in a station, where no SPAD incident
has occurred.
A.2.1.2
The infrastructure manager responsible for the management and operation of
the station concerned shall normally be the lead organisation for events at
stations in category e) and events in categories f) and g).
A.2.2
Formal investigation to be led by the railway undertaking
A.2.2.1
The railway undertaking shall normally lead a formal investigation when there
has been:
a) An alleged category A SPAD incident except where shown in A.2.1.1 c) i) to
iii).
b) Major injury or fatality to members of the workforce employed by or
contracted to the railway undertaking when struck by a train not at a station.
c) A collision between trains in a station where no SPAD incident has occurred.
d) A train fire where there is injury to or requiring the evacuation of passengers
at a location other than a station.
e) A buffer stop collision at a station where there is injury to people or
significant damage to infrastructure or train.
A.2.2.2
Where more than one railway undertaking is involved and one of the criteria
listed in section A.2.2.1 applies, negotiation between them will be needed to
determine which takes the role of lead organisation.
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Appendix B Decision criteria – local investigations
G A.2
Local investigations
G A.2.1
This section reproduces the mandatory requirements of the Appendix B contained in
GO/RT3119. Appendix B states in B.1.1.1, B.2.1.1 and B.2.2.1 that these conditions are
to be ‘normally’ carried out in the circumstances specified. This allows infrastructure
managers and railway undertakings to apply a common sense and proportionate
response to the circumstances of a given accident or incident. If, for example, the causes
and circumstances of an accident or incident are so clear as to indicate a degree of
certainty of cause and effect, then the duty holders concerned may decide as part of their
initial joint review (sometimes referred to as ‘table top meeting’), that a reduced and more
proportionate type of investigation be held. In this case the parties concerned should be
able to justify their decision on a risk based basis in order to make sure that the decision
is fully justified.
Extract from GO/RT3119 Accident and Incident Investigation
B.1
Criteria for deciding when a local investigation is required
B.1.1
Criteria
B.1.1.1
A local investigation shall normally be carried out into the following events:
a) Lower risk alleged category A SPAD incidents not leading to an accident
(Part 3 SPAD risk ranking less than 18 and Part 2 accident vulnerability
ranking H, I or J).
b) Station overruns (not involving a SPAD incident).
c) Runaway vehicle incidents where there is no actual, or potential for, injury to
people or significant damage to infrastructure or train.
d) Buffer stop collisions where there is no injury to people or significant damage
to infrastructure or train.
e) Traction and rolling stock defects on a running line likely to affect system
safety or resulting in the evacuation of the train.
f) Train fires where there is no injury to passengers and no evacuation is
required other than at a station.
B.2
Criteria for deciding the lead organisation for a local investigation
B.2.1
Local investigation to be led by the infrastructure manager
B.2.1.1
The infrastructure manager shall normally lead a local investigation into a lower
risk alleged category A SPAD incidents not leading to an accident (Part 3 SPAD
risk ranking less than 18), and near miss SPAD incidents (Part 2 accident
vulnerability ranking H, I or J), if it is clear from the early evidence that the
infrastructure may be a causal factor.
B.2.2
Local investigation to be led by the railway undertaking
B.2.2.1
The railway undertaking shall normally lead a local investigation into:
a) Lower risk alleged category A SPAD incidents not covered by clause B.2.1.1
and not leading to an accident (Part 3 SPAD risk ranking less than 18), and
near miss SPAD incidents (Part 2 accident vulnerability ranking H, I or J).
b) Station overruns (not involving a SPAD incident).
c) Runaway vehicle incidents where there is no actual, or potential for, injury to
people or significant damage to infrastructure or train.
d) Buffer stop collisions where there is no injury to people or significant damage
to infrastructure or train.
e) Traction and rolling stock defects on a running line likely to affect system
safety or resulting in the evacuation of the train.
RSSB
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f) Train fires where there is no injury to passengers and no evacuation is
required other than at a station.
B.2.2.2
Where more than one railway undertaking is involved and one of the criteria
listed in section B.2.2.1 applies, agreement between them will be needed to
determine which takes the role of lead organisation.
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Appendix C Requirements for persons responsible for
managing the investigation process
G A.3
Requirements for persons responsible for managing the
investigation process
G A.3.1
This section reproduces the mandatory requirements of the Appendix C contained in
GO/RT3119.
Extract from GO/RT3119 Accident and Incident Investigation
C.1
Requirements
C.1.1
Designation and role
C.1.1.1
Infrastructure managers and railway undertakings shall designate one or more
persons within their organisation who will:
a) Manage the organisation’s processes for leading or contributing to
investigations of accidents and incidents.
b) Establish a system for the downloading, security and analysis of event
recording equipment such as train data recorders, signalling equipment
event recorders and voice recording media.
c) Manage the interface with other railway industry parties when required by
GO/RT3119.
d) Establish the remit for an investigation.
G A.3.2
The remit set by the person responsible for managing the investigation process should be
tailored to the individual accident or incident and take account of the outputs of the initial
gathering and collation of evidence, including an assessment of collision potential and
any other particular circumstances. When setting remits for accident or incident
investigation, it should be recognised that even a low-risk event can provide the
opportunity to learn much about the integrity of management systems and therefore make
improvements before a further accident or incident with higher consequences occurs.
G A.3.3
A generic remit may lead to an investigation that is neither proportionate to the potential
consequences of the accident or incident, nor to the risk associated with that specific
location. It is important to recognise that the remit should be suitably modified to focus the
attention of the investigation team on specific aspects of the accident or incident that
require to be examined; failure to do so may lead to an inadequate determination of
causes, risks, etc.
G A.3.4
Using a SPAD incident as an example, there are occasions when a train driver’s initial
reaction to his train having passed a signal at danger is an immediate oral admission that
he made an error. The significance of such an admission should not automatically be
allowed to lead to a narrowly defined remit that does not, for example, lead the
investigation team to consider an unmitigated SPAD trap that has resulted in several
SPAD incidents in recent years. Remits should therefore be written in a manner that
encourages the team to consider all relevant issues, including the caution signals on the
approach to the signal involved in the SPAD incident. This encouragement should lead
to the team retaining an open mind and a healthy scepticism when considering any early
preconceptions as to the causal model lying behind the SPAD incident in question.
G A.3.5
When developing the remit, the person responsible for the investigation process should
involve the other parties to the investigation so that collectively they agree the extent to
which similar accidents or incidents, past or related events involving the same equipment,
facilities, signals, personnel or rolling stock and changes to standards, management
systems and organisations should be specifically referenced within the remit. The person
responsible for the investigation process should discuss the remit with the person
appointed to lead the investigation to ensure that the remit and scope of the investigation
is understood and accepted. Additionally, the person appointed to lead the investigation
should ensure that all other team members similarly understand its scope.
RSSB
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G A.3.6
The need for a SSC should be considered while the remit for the investigation is being
developed. Where signal sighting is necessary, the investigation remit should specifically
require the investigation team to consider the findings of the SSC as an input to, rather
than output from, the investigation process.
Extract from GO/RT3119 Accident and Incident Investigation
C.1
Requirements
C.1.1
Designation and role
C.1.1.1
Infrastructure managers and railway undertakings shall designate one or more
persons within their organisation who will:
e) Provide administrative support for the investigation process, including
facilities for witnesses.
f) Confirm that the remit has been met at the end of the process.
g) Update company and railway industry safety management information
records.
h) Track the organisation’s progress in implementing recommendations from
investigations (including those to which it was not a party) that it has
accepted as applicable to its operations.
C.1.2
Competence
C.1.2.1
Infrastructure managers’ and railway undertakings’ persons designated to
manage the investigation process shall be conversant with:
a) The requirements of GO/RT3119 and its application.
b) The organisation’s activities, safety management system and interfaces.
c) The statutory framework for railway safety and accident investigation.
d) The appropriate railway operations and engineering environment (or have
access to appropriate competent technical advice) to enable them to prepare
remits and evaluate reports and recommendations.
e) The appropriate administrative skills to support the investigation process,
including the allocation of sufficient time and adequate facilities.
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Appendix D Requirements for persons appointed to lead an
investigation
G A.4
Requirements for persons appointed to lead an investigation.
G A.4.1
This section reproduces the mandatory requirements of the Appendix D contained in
GO/RT3119.
Extract from GO/RT3119 Accident and Incident Investigation
D.1
Persons appointed to lead a formal investigation
D.1.1
Requirements
D.1.1.1
Infrastructure managers and railway undertakings shall designate persons
within their organisation to lead formal investigations, unless a person
independent of the parties involved in the accident or incident is chosen to lead
the investigation of an accident or incident.
D.1.1.2
The person appointed to lead a formal investigation shall not have any direct
line management responsibility for the staff, contractors or equipment involved
in the accident or incident under investigation.
D.1.2
Competence
D.1.2.1
Persons appointed to lead formal investigations shall be conversant with the
requirements of GO/RT3119 and its application and have appropriate:
a) Experience in accident or incident investigation (or be provided with the
necessary training and other support to develop the necessary skills).
b) Technical competence to conduct the investigation, or access to competent
technical advice on those aspects outside their own technical competence.
c) Technical competence to identify safety matters which justify urgent action
before the final report is completed.
d) Technical competence to identify the need for and make recommendations.
D.2
Persons appointed to lead a local investigation
D.2.1
Requirements
D.2.1.1
Infrastructure managers and railway undertakings shall designate persons
within their organisation who will lead local investigations.
D.2.2
Competence
D.2.2.1
Persons appointed to lead local investigations shall:
a) Be conversant with the requirements of the relevant sections of GO/RT3119.
b) Possess (or be provided with the necessary training and other support to
develop) the necessary skills for investigations within scope of their
responsibility.
c) Possess the technical competence covering the matters raised by the
accident or incident under investigation.
d) Be able to meet record keeping and reporting requirements.
RSSB
D.3
Alleged SPAD category confirmation
D.3.1
Requirements
D.3.1.1
The lead organisation shall confirm provisional SPAD categories in their final
written report using the details in Table 2.
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Description
(Notes: No degree of severity or importance is implied within or between
these confirmed category A SPAD types).
A1
When a SPAD has occurred and, according to available evidence,
a stop aspect, indication or end of in-cab signalled movement
authority was displayed or given correctly and in sufficient time for
the train to be stopped safely at it.
A2
Confirmed
Category A
SPAD types
When a SPAD has occurred and, according to available evidence,
the stop aspect, indication or end of in-cab signalled movement
authority concerned was not displayed or given correctly, but was
preceded by the correct aspects or indications.
A3
When a SPAD has occurred and, according to available evidence,
verbal and/or visual permission to pass a signal at danger was
given by a handsignaller or other authorised person without the
authority of the signaller.
A4
When a SPAD has occurred and, according to available evidence,
a stop aspect, indication or end of in-cab signalled movement
authority was displayed or given correctly and in sufficient time for
the train to be stopped safely at it, but the train driver was unable
to stop his train owing to circumstances beyond his control (for
example, poor rail head adhesion, train braking equipment failure
or malfunction etc).
Table 2: List of confirmed SPAD categories
G A.4.2
The general guidance contained in items G.2.4.1.2 and G.2.4.1.3 may also be applied to
this section.
G A.4.3
Category A General Guidance on identification: Category A SPADs are split into four
distinct and numbered types that exactly match the detail contained in the provisional
categories stated in Table 1. There is no implied degree of importance or severity
between them. In all cases they specify events that have, or might have, led to a signal
being passed at danger without authority in the circumstances described. The distinct
numbering of Category A SPAD types is intended to enable more accurate analysis of
SPADs and help to better understand the circumstances of the incident. The categories
are not in themselves intended for the purposes of blame or liability.
G A.4.4
Category A1 Guidance: This category should be used to describe an event where the
signal passed at danger was displayed or indicated correctly, and with any correct
preceding indications (such as cautionary aspects and AWS warnings). In previous
versions of this RGS it was suggested that there may be occasions when a driver
voluntarily tells the signaller that he has passed a signal at danger, and that therefore this
is automatically described as a category A event. In this, as with the previous, version of
GO/RT3119 and its GN document, RSSB took the view that SPAD categorisations should
not be dependent on whether a driver has actually reported his train as having passed a
signal at danger. If such an occasion occurs it may, for example, be allocated a
provisional category A(p), with the knowledge that the incident will be investigated and
final confirmation of the category duly confirmed by the appropriate lead organisation.
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G A.4.5
Category A2 Guidance: This category should be used to describe a SPAD where the
signal passed at danger was not displayed or given correctly, but where the preceding
indications were present and correct (such as cautionary aspects and AWS). The reason
for the signal not displaying correctly might be because it was, for example, obscured (or
partially obscured) by foliage, snow or other obstruction; where the signal lighting had
totally failed (dark signal) and the driver had had all the correct preceding warning
signals, or no signal shown where there should be one. In all cases, however, the
principle is that the driver should have reacted to preceding warnings (including instances
where a signaller may have actually informed a driver that a certain signal he was
approaching was not displaying correctly) and had the train under according control for
the signalled stop. The driver’s route knowledge would normally be expected to be
sufficient for him to sight such signals in time to slow down and stop.
G A.4.6
Category A3 Guidance: A category A3 event is for situations where permissions have
apparently been given to a driver by a person who does not have the correct and proper
authority of the designated signaller for the signal or indication concerned. It should be
noted that, in full accordance with text in the Rule Book, a Person In Charge Of the
Possession (PICOP) and Engineering Supervisors (ES) are not handsignallers. Therefore
a situation where a driver passes a signal at danger in a possession without the PICOP
or ESs authority should be categorised as an A1 SPAD (and not an A3 SPAD). Similarly,
Level Crossing Attendants (LCA) should not to be construed as handsignallers, as they
cannot authorise drivers to pass signals at danger.
G A.4.7
The term ‘other authorised person’ stated in the A3 category might, for example, refer to
a designated pilotman. The Rule Book gives clear requirements for situations where
defined persons might or might not give permissions and authorities to drivers. The
categories shown in Tables 1 (provisional) and Table 2 (confirmed) of this RGS fully
support the activities described in the Rule Book.
G A.4.8
Category A4 Guidance: This category should be used to describe an event where the
signal passed at danger was correctly given or displayed, and where the preceding
indications were present and correct (such as cautionary aspects and AWS), but where
the driver was unable to stop his train in time owing to circumstances that were outside
his control. This might have been because of poor rail head adhesion, train braking
equipment failure or malfunctions etc. In all cases it should be where the driver will not
have had any reasonable way of preventing his train from passing the signal or indication
showing danger.
G A.4.9
Now that ROGS has redefined what is and what is not to be considered as a SPAD, the
old categories B, C and D have been removed from this version of GO/RT3119 and its
associated guidance. Incidents that occur involving any of the old SPAD category events
should continue to be investigated in their own right and according to the circumstances
concerned in each individual case. Guidance to the now discontinued SPAD categories of
B, C and D event has therefore been removed as it would no longer be required in
alignment to a SPAD event.
Extract from GO/RT3119 Accident and Incident Investigation
G A.4.10
RSSB
D.3
Alleged SPAD category confirmation
D.3.1
Requirements
D.3.1.2
The lead organisation shall, if their investigation concludes that the incident is
not to be confirmed as one of the SPAD categories in Table 2, liaise with the
infrastructure manager to consider recording the event as an operating incident.
The lead organisation may conclude that the circumstances of the alleged SPAD incident
do not accord with any of the details contained in the Table 2 list. In such cases they may
consider recording the event as something other than a SPAD, for example an operating
incident, an operating irregularity or a possession irregularity (this list is not exhaustive).
There are so many types of events that have the potential to be considered as operating
incidents that it is not practical to attempt a list of them in this guidance. Typically (though
not exclusively) such events might be breaches of rules, regulations or instructions.
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G A.4.11
The liaison referred to between the lead organisation and the infrastructure manager is
for them to reach a decision on how the incident can be most accurately and
appropriately re designated. This liaison is purely a communications issue between the
lead organisation and the infrastructure manager. The lead organisation retains full
authority and responsibility to either confirm the incident as a SPAD, or not, according to
the findings of its investigation.
G A.4.12
RGS users should note that there is no category stating an event where a signaller (or his
authorised agent thereof) gives incorrect authorisation to a driver to pass a signal at
danger. Such an event cannot be a SPAD as a train driver could have no logical basis for
questioning what, to him, should be a proper authorisation. If the lead organisation for the
investigation discovers that an incorrect authorisation was passed to the driver then that
event should be treated as an operating irregularity.
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Appendix E Explanatory note on progress reporting
requirements
G A.5
Explanatory note on progress reporting requirements
G A.5.1
This section reproduces the non-mandatory requirements of the Appendix D contained in
GO/RT3119. No guidance is offered as the contents are self-explanatory.
Extract from GO/RT3119 Accident and Incident Investigation
RSSB
E.1
Reporting of progress towards implementing recommendations
E.1.1
Clause G 2.1.6.4 of this document requires infrastructure managers and railway
undertakings to report to RSSB, their progress made towards implementing
recommendations from RAIB investigations that they have accepted. It is the
result of an agreement between the Office of Rail Regulation (ORR) and RSSB.
E.1.2
ORR will use the Safety Management Information System (SMIS), managed by
RSSB on behalf of infrastructure managers and railway undertakings, as the
source of information for tracking progress to make its reports to the RAIB
under regulation 12 of the Railways (Accident Investigation and Reporting)
Regulations, 2005.
E.1.3
A single reporting process is provided, enabling infrastructure managers and
railway undertakings to report progress to the safety authority, as well as to
meet the requirement in clause 2.2.4.2 of GO/RT3119, to report to RSSB
progress made on recommendations accepted from formal investigations. One
process will suffice for industry and ORR purposes.
E.1.4
The ORR is the safety authority for the GB railway network.
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Definitions
Accident
An unwanted or unintended sudden event or a specific chain of such events which have
harmful consequences; accidents are divided into the following categories: collisions,
derailments, level-crossing accidents, accidents to persons caused by rolling stock in
motion, fires and others.
Formal Investigation
A formally structured investigation of an accident or incident, led by an infrastructure
manager, railway undertaking or a person independent of all the parties involved in the
accident or incident, applying processes mandated in this document.
Immediate cause(s)
An unsafe act or unsafe condition which causes an accident or incident.
Incident
Any occurrence, other than accident or serious accident, associated with the operation of
trains and affecting the safety of operation.
Infrastructure manager
’'Infrastructure manager’ means a person who:
a)
In relation to infrastructure other than a station, is responsible for developing and
maintaining that infrastructure or, in relation to a station, the person who is
responsible for managing and operating that station, except that it shall not include
any person solely on the basis that he carries out the construction of that
infrastructure or station or its maintenance, repair or alteration.
b)
Manages and uses that infrastructure or station, or permits it to be used, for the
operation of a vehicle.
(Note: This definition is sourced from The Railways and Other Guided Transport Systems (Safety) Regulations
2006).
Investigation
A process conducted for the purpose of accident and incident prevention which includes
the gathering and analysis of information, the drawing of conclusions, including the
determination of causes and, when appropriate, the making of safety recommendations.
Lead organisation
The railway undertaking or infrastructure manager responsible for managing the processes
of local or formal investigations defined in this document and identified by applying criteria
defined in Appendix B of this document.
Local investigation
An investigation of an accident or incident, for which a formal investigation is not required,
by an infrastructure manager or a railway undertaking, using its defined company
procedures and requirements in respect of remit and results defined in this document.
Railway undertaking
A transport undertaking, as defined in the Railways and Other Guided Systems
Regulations 2006, whose safety certification covers operation of trains on the managed
infrastructure, as defined in the Railway Group Standards Code.
Safety authority
The national body entrusted with the tasks regarding railway safety in accordance with
Directive 2004/49/EC (the Railway Safety Directive). In Great Britain the safety authority is
the Office of Rail Regulation (ORR).
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SMIS
Safety Management Information System: a computer database managed by RSSB
containing details of events reported by or on behalf of infrastructure managers and railway
undertakings.
SPAD
“Signal passed at danger” means any occasion when any part of a train proceeds beyond
its authorised movement to an unauthorised movement;
“unauthorised movement” means to pass (a) a trackside colour light signal or semaphore at danger, order to STOP, where an
Automatic Train Control System (ATCS) or train protection system is not
operational;
(b) the end of a safety related movement authority provided in an ATCS or train
protection system;
(c) a point communicated by verbal or written authorisation laid down in regulations.
or
(d) stop boards (buffer stops are not included) or hand signals,
but excludes cases in which –
(e) vehicles without any traction unit attached or a train that is unattended run away
past a signal at danger;
or
(f) for any reason, the signal is not turned to danger in time to allow the driver to stop
the train before the signal.
Note: The above definition is taken from The Railways and Other Guided Transport
Systems (Safety) (Amendment) Regulations 2011.
Further information (together with associated forms) on the SPAD incident categorisation
and risk ranking system used in this document can be found on the RSSB website at
www.rssb.co.uk
Underlying cause(s)
Any factors which led to the immediate causes of accidents or incidents, or which resulted
in such causes not being identified and mitigated.
RSSB
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References
The Catalogue of Railway Group Standards gives the current issue number and status of
documents published by RSSB. This information is also available from
www.rgsonline.co.uk.
RGSC 01
RGSC 02
Railway Group Standards Code
The Standards Manual
Documents referenced in the text
Railway Group Standards
GO/RT3119
GO/RT3350
GO/RT3118
GI/RT7006
GE/RT8047
GE/RT8250
GE/RT8037
RSSB documents
RT/3119/A
RT/3119/B
RT/3119/C
RT/3119/D
Accident and Incident Investigation
Communication of Urgent Operating Advice
Incident Response Planning and Management
Prevention and Mitigation of Overruns – Risk Assessment
Reporting of Safety Related Information
Reporting High Risk Defects
Signal Positioning and Visibility
Provisional SPAD Data Collection Form (Infrastructure
Managers)
Provisional SPAD Data Collection Form (Railway
Undertakings)
Provisional SPAD Data Collection Form (Infrastructure
Managers) for ERTMS
Provisional SPAD Data Collection Form (Railway
Undertakings) for ERTMS
Other references
NIR3350
GE/RT8000/M3
Directive 2004/49/EC Railway Safety Directive
The Railways and Other Guided Transport Systems
(Safety) Regulations 2006
The Railways and Other Guided Transport Systems
(Safety) (Amendment) Regulations 2011
The Railways (Accident Investigation and Reporting)
Regulations 2005
National Incident Report form ( www.railnotices.net)
Managing incidents, floods and snow
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