Final report on a strategy to deal with accidents in the transport sector

3.7.2006 Group of Experts to advise the Commission on a strategy to deal with accidents in the transport sector FINAL REPORT OF THE GROUP OF EXPERTS TO ADVISE THE COMMISSION ON A STRATEGY TO DEAL WITH ACCIDENTS IN THE TRANSPORT SECTOR 2004 – 2006 1. GENERAL INTRODUCTION Safety investigations1 in accidents and incidents are an essential element in the drive to improve transport safety. The technical analysis into the circumstances and the causes of accidents and incidents leads to recommendations being made to prevent them happening again. The Commission’s White Paper European transport policy for 2010: time to decide 2 established an ongoing need for proper safety investigation of transport accidents and the extension of relevant legislation to all modes of transport. As a consequence the European Commission (EC) decided on 11 June 2003 to create a Group of Experts to advise it on a strategy for dealing with accidents in the transport sector. 3 The Group of Experts was mandated to advise the Commission on a European strategy for safety investigation. Its twelve members were appointed from a list of candidates with expertise in transport safety and investigation of accidents within the various modes. Once selected the group of Experts assembled in Brussels for seven plenary meetings. Whenever necessary it split up into six subgroups covering: aviation, maritime, rail, road, pipelines and general methodology. The subgroups were to invite further expertise from ad hoc experts with specific skills. 1 The term “Safety Investigation” complies with the European methodology for safety investigation of transport accidents and incidents in the transport sector elaborated by the Group of Experts. It is intended to clearly distinguish between safety investigations and investigations of accidents for other purposes than that to improve safety, as for example judicial investigations. The term safety investigation is also considered more accurate and more comprehensible than the term “technical investigation” also commonly used. White Paper "European transport policy for 2010: time to decide” COM(2001)370 of 12.9.2001, available at http://europa.eu.int/comm/energy_transport/en/lb_en.html. Commission Decision EC/425/2003, OJ L 144 12/06/2003, pp. 0010-11 2 3 One of the Group of Expert’s most notably achievement was to develop a common European methodology for safety investigation of accidents and incidents in the transport sector designed to produce a harmonised and consistent approach to safety investigation of transport accidents and incidents within the European Union. The methodology adopted establishes the principles, standards and powers that are seen as vital to pursue safety investigations in an independent, effective and competent way. It also made a number of recommendations to the Commission on ongoing legislative work and some suggestions for future action. Details are listed in this report. This final report represents the key findings, conclusions and recommendations of the Group of Experts per mode of transport as well as general recommendations aiming to cover all modes. 2. AVIATION4 Since 1991 Aviation Safety Investigation Authorities have established coordination and meet regularly within an ECAC context. Additionally the aviation sector has had ten years experience of working with the provisions of Council Directive 94/56/EC, “Establishing the fundamental principles governing the investigation of civil aviation accidents and incidents”. The Aviation Working Group’s primary task was a review of Member State’s experience of working within the framework of the Directive. In December 2004 the Aviation Working group sent a comprehensive questionnaire to Member States and detailed responses were received from 23 of the 25 States. In early 2006 the Commission has launched a procedure for internally assessing the options for revision of Directives 94/56 and 2003/42. The Experts group’s recommendations contribute to that exercise. 2.1. Present Situation Information gathered from Member States confirmed that a number of issues arise in relation to safety investigation of aviation accidents and incidents such as: • Difficulties and tensions between the safety investigation and judicial investigations. • Issues in relation to the publication of Safety reports relating to accident and incident. • Lack of a follow-up system for safety recommendations in most Member States and the fact that current reporting requirements are overly onerous and often a cause for delays of safety investigation of more important air transport accidents or incidents. 4 Experts participating in the work of the Aviation Working group were: Mr Ken Smart (UK) as chairman and Mr Paul Louis Arslanian (France). Ad hoc experts invited to this group were Mr Yves Benoist, Mr Kevin Humphreys, Mr Akrivos Tsolakis and Mr Lou Van Munster. 2 • In particular smaller Member States identify a need for European Union based training for investigators, both on the coordination of training and in relation to training standards. 2.2. Recommendations to the Commission As a result of this current situation the Commission is advised: (1) to revise the Directive 94/56/EC taking into account the items Member States raised in relation to the Expert Groups request for information (see above), for example, relations with judicial proceedings, the protection of confidential aspects of investigations and the possibility to select the events that are to be investigated, to consider whether the Memorandum of Understanding between the accident investigation bodies and the State Prosecutor in the UK could be used as a model for a European wide initiative to resolve the current difficulties between the safety and judicial investigations, to introduce legislative protection from disclosure for confidential documents listed in Chapter 5.12 of Annex 13 to the Chicago Convention, to introduce a legislative requirement that provides transparency in relation to official replies to and implementation of safety recommendations. The Commission is asked to initiate the establishment of a European database for safety recommendations for aviation, to formally recognise the coordination role of Aviation Safety Investigation Authorities in a European context. (2) (3) (4) (5) Discussion of aviation experts identified a need for a more developed coordination structure for Safety Investigation Authorities involved in aviation accidents at European level, in the light of existing coordination fora as well as the establishment of the European Aviation Safety Agency. 3. MARITIME TRANSPORT5 The Maritime Working Group met formally on five occasions between September 2004 and May 2006 and corresponded electronically at other times as necessary. The Working Group also consulted freely with the marine casualty section of the European Maritime Safety Agency (EMSA) in 2005.At the outset of its work, the maritime sub group reviewed existing practices for marine accident investigation by member states and noted that: • There was reluctance in some instances to publish the findings of any investigation. 5 Experts participating in the work of the Maritime Working group were: Mr John Lang (UK) as chairman, Mrs Pirjo Valkama-Joutsen (Finland) and Mr Salvatore Furnari (Italy). 3 • A number of the investigations undertaken to improve transport safety, were either accorded less priority than, or were not separated from, those undertaken by the regulatory or judicial authorities whose aim was to determine blame or liability and the prosecution of those judged responsible. Where an accident led to the environment being damaged, some states made no distinction between deliberate acts of pollution and genuine accidents. This meant that these specific events were treated as criminal acts and not as accidents to be investigated with the specific aim of determining the underlying causes. The approach also ensured that those involved did not give their full co-operation in trying to understand the circumstances and causes. • • Priority in collecting and analysing evidence was often given to those pursuing the civil or criminal investigations rather than to technical safety investigators whose ultimate aim was to recommend measures to prevent the same thing happening again. • Witness testimony given to a safety investigation was, to a large extent, given little protection and could be used in either civil or criminal proceedings. This encouraged defensiveness and deterred witnesses from being open about what happened so that the true circumstances and causes could be determined. • The safety investigation of marine accidents suffered from an obvious lack of cooperation between some Member States. Many of these initial observations aligned with the views of other sub groups within the Group of Experts. The Methodology Guidelines adopted by the Group of Experts touch on the relationship between those conducting safety investigations and those pursuing civil or criminal inquiries. The Guidelines reflect the Maritime sub group’s view that independent marine accident investigations, conducted entirely separately from those concerned with civil or criminal matters, are the most effective way of improving safety at sea. 3.1. (1) Recommendations to the Commission Because it provides the most effective way of improving safety at sea it is strongly recommended that the investigation of marine accidents should be a mandatory requirement for all member states. The Marine sub group, in line with the Methodology guidelines adopted by the Expert group, recommends that the Commission should continue its efforts to produce legislation on marine casualty investigations that embraces the following principles: (a) (b) National legislation shall require all marine accidents to be reported directly to the safety investigation authority with the minimum of delay. In addition to the principal that the safety investigation authority is best placed to choose which accidents to investigate, very severe accidents should always be fully investigated. Investigation of severe accidents should be investigated to a level that allows the issuing of appropriate safety recommendations and the dissemination of any lessons to be learned. 4 (2) (c) (d) (e) Those involved in, or witnesses to, marine accidents should be protected against prosecution or imprisonment. Particular attention needs to be paid to the human factor in safety investigations. The European Commission and EU Member States should support the revision of the IMO Code on casualty investigation and in particular, these aspects that encourage co-operation between investigating bodies. The European Maritime Safety Agency (EMSA) should be given a facilitating role and encouraged to maintain an accident data base, but it should have no power over the national safety investigation authorities. The highest priority should be given to the effective implementation by all the EU Member States of mandatory IMO instruments. (f) (g) 4. ROAD TRANSPORT6 The Road Working Group of the Group of experts met at seven occasions, held a series of hearings and information exchanges with international experts, maintained virtual contacts (through telephone conferences and using the EC’s Communication & Information Resource Centre Administrator - CIRCA), cooperated with other members of the Group of Experts and visited The Dutch Safety Board in The Hague. The final result of this work is a 90 pages report on road safety issues containing a list of 34 remarks, conclusions and recommendations issued to trigger improvements both at national and at EU level. The following gives a summary of key aspects of the findings and main conclusions. 4.1. Present Situation The expert group compared safety investigation in road transport accidents to activities in other transport sectors. Several important conclusions were drawn: • Despite the fact that a vast majority of transport casualties are a consequence of road accidents there is no legislation at European level on road accident investigation like in the other transport sectors. • Transport modes considered to be safer are also those where accidents and incidents have been investigated more profoundly and over a long period of time. • Due to the high number of accidents in the road sector systematic investigations of all accidents and incidents is out of proportion. For the same reason, alternative forms of investigation into accidents at all levels are considered essential parts of an efficient road safety investigation system: • Collection of basic statistical data; 6 Experts participating in the work of the Road Working group were: Mr Jesus Monclus (ES) as chairman, Mr Lars-Göran Löwenadler (SE) and Mr Reinhold Maier (DE). 5 • Intermediate investigations by police; insurance companies or road authorities; • In-depth safety investigations of a representative sample of crashes and • Ad-hoc safety investigations of special cases. For the road sector, both in-depth and ad-hoc investigations are considered as primarily focusing on improving transport safety, whereas all other investigations listed are normally undertaken for different purposes. 4.2. Recommendations to the Commission When analysing various opportunities for improvement in the field of safety investigation in road transport accidents the following initiatives are recommended to the European Commission: (1) The Commission shall launch a wide consultation process at different levels (political, technical…) on the options for action at European level, including legislation. (=not sector specific but methodology related) In addition to the collection of basic statistical data or investigations conducted by road authorities and police, in-depth safety investigations in the causes and circumstances of a representative number of accidents shall be undertaken in a systematic and permanent way. The Commission shall endorse the following principals with Member States: (a) Besides safety investigations into road accidents with human casualties also accidents with material damage and sites of repeated incidents need to be investigated due to their high potential for severe future accidents. In-depth investigations should contribute to the definition of priorities and the identification of feasible and cost-efficient countermeasures. (2) (3) (b) (4) It is necessary to promote special ad-hoc safety investigations into accidents of European-wide importance because of the large number of casualties or the specific lessons to be learned thereof. A Safety Investigation Authorities for road accidents7 shall be set up in each of the Member States, charge at least with the task of in-depth safety investigation and/or special safety investigations of the most severe road accidents and incidents. Furthermore the European Commission is advised to launch a broad debate in order to establish mechanisms and tools for exchange of best practice on road (5) (6) 7 It is recognised that whether such an independent organisation should deal only with road accidents or with all kinds of transport accidents shall be left to the decision of Member State based on available resources and past experience in investigating transport accidents. 6 safety investigation. For that purpose it shall carefully examine the opportunities for continuing and expanding the work of the research project SafetyNet8. 5. RAIL9 5.1. Present Situation In April 2004 Directive 2004/49/EC on the safety of the Community’s railways10 was adopted by the European Parliament and Council as part of the second railway package. This directive establishes a transparent and visible safety regulatory framework for the European railways and also includes provisions related to rail accident investigation and the creation of national independent rail accident investigation bodies. Also included within the second rail package is regulation 881/2004/EC which establishes the European Railway Agency. With regards to accident investigation the rail accident investigation bodies are obliged to conduct an active exchange of views and experience for the purpose of developing common investigation methods and drawing up common principles for the follow-up of safety recommendations. The Agency shall organise and facilitate co-operation between the national safety authorities and the investigating bodies in support of this task and also maintain an overview of the activities of the national rail accident investigation bodies through the receipt of investigation notifications and final accident investigation reports. The Rail Accident Investigation Working Group carried out a detailed examination of the provisions of directive 2004/49/EC, and also prepared a questionnaire which was sent out the rail accident investigation bodies established across Europe (including Norway). Based on the analyses carried out, and the responses to the questionnaires, the following areas of good practice and major concern have been identified. Implementation guidelines for the provisions of Directive 2004/49/EC relating to accident investigation need to be considered on issues like cooperation between rail accident investigation bodies, the relationship with judicial accident investigation, and how best to facilitate and support the work of the European Railway Agency. 8 SAFETYNET (“the European Road Safety Observatory – an information system to support road safety policy in Europe”) is an ongoing Integrated Project (6th Framework Research Programme) aiming at helping the EC in defining the future European Road Safety Observatory: http://www.erso.eu/ . Experts participating in the work of the Rail Working group were: Mr Victor Risota (PT) as chairman replaced by Mr Knut Rygh (NO) in 2006, Mr Antonio Dominguez Chala (ES) in 2005 and Mr Pieter Van Vollenhoven (NL), chairman of the Methodology Working group. Ad hoc experts invited to this group were Mrs Caroline Griffiths, Mr Rob Rumping, Mr Jean-Gérard Koenig and Mr Anders Lundstrom Directive 2004/49/EC of the European Parliament and of the Council of 29 April 2004 on safety on the Community's railways and amending Council Directive 95/18/EC on the licensing of railway undertakings and Directive 2001/14/EC on the allocation of railway infrastructure capacity and the levying of charges for the use of railway infrastructure and safety certification (Railway Safety Directive), OJ L 164/44 of 30.4 2004 and corrigendum in OJ L 220/16 of 21.6 2004. 7 9 10 5.2. Recommendations to the Commission The following recommendations are important in relation to safety investigation in rail accidents: (1) European Railway Agency shall review together with Rail Accident Investigation bodies (RAIB) – Safety Investigation Authorities to be established in each Member State under the European Railway Safety Directive11 - how it can assist sharing of specialist training. RAIBs shall review with the support of European Railway Agency how the investigations carried out by railway undertakings and/or infrastructure managers in Members States can be shared to the extent they might be of value to the RAIB. RAIBs shall establish informal networks with the support of European Railway Agency to share information and to organise joint seminars. The European Railway Agency shall provide structured information on safety occurrences in the form of bulletins. With the support of the Commission and European Railway Agency, RAIBs shall review the practical implementation of Article 20(3) of the Railway Safety Directive and how to avoid potential conflicts with other investigators. For example, on how to establish clear national rules distinguishing between the tasks of the RAIB and other national investigators, such as police forces or the rail Safety Authority12, including the conditions determining the lead investigator and other actions in order to best serve the public interest. The European Commission shall review what provisions can be made to enable the RAIB in one country to require information from an undertaking in another country for the purpose of the accident investigation. The European Railway Agency shall establish a means of sharing information between the RAIBs regarding investigation on other railways such as tramways and metros. RAIB shall review with the Commission and the support of the European Railway Agency the practicalities of implementing Article 22(3) of the European Railway Safety Directive in such a way that sufficient transparency is achieved without jeopardizing the investigation itself and that also the requirements of the European Human Rights Convention are met. A best practice guide should be developed on these issues. RAIB shall develop common and public guidelines with the Commission and the support of European Railway Agency on the interpretation of Article 25(2) of the European Railway Safety Directive regarding the handling of recommendations. (2) (3) (4) (5) (6) (7) (8) (9) 11 Body according to Article 21 of the Railway Safety Directive 2004/49/EC Body according to Article 16 of the Railway Safety Directive 2004/49/EC 8 12 (10) RAIBs with the support of the European Railway Agency shall develop a common interpretation of Article 3(l) of the European Railway Safety Directive to allow the 2 million euros limit (in the definition of serious accident) apply to direct costs, not indirect. European Railway Agency together with RAIBs shall continue review of RAIB’s operations and, together with the Commission, the implementation of the European Railway Safety Directive with the aim to establish a common framework. When considered useful the RAIB shall invite RAIBs from other Member States to participate in the investigation. In the case of cross-border operations, competent RAIBs should draw up an agreement of co-operation beforehand to confirm the conditions of carrying out such investigations. European Railway Agency shall assist RAIBs in learning from other modes of transport (e.g. air and marine safety investigations). (11) (12) (13) 6. PIPELINES13 In view of the comprehensive incident statistics from the EU gas and oil industry which include an analysis of causes, the Pipeline Working Group decided to focus on the prevention of accidents involving onshore oil pipelines and gas transmission pipelines operating above 16 barg. Chemicals pipelines were excluded. The term safety includes threats to people, assets and the environment. 6.1. Present Situation Oil and gas by pipelines are essential to the energy supply of the EU and statistics show that they are a reliable and safe way to transport energy products. Pipelines legislation and regulation differs significantly between EU Member States, from comprehensive to almost non-existent. There is, however, no data available to support whether legislation significantly affects safety performance or not. Self-regulation has filled in many cases the gaps of national controls, in particular where national legislation is absent. • The main cause of accidents is third party interference. Industry self-regulation cannot fully cover third party interference. Although pipeline operators can contribute to tackling the problem of third party interference through surveillance procedure and systems, a large part of the activities occurring in the vicinity of pipelines fall outside their control. The regulator must therefore take his share of responsibility through appropriate regulation and control of such activities particularly when it comes to excavations. • Self-regulation has proven to be a valuable approach. 13 The expert chairing the work of the Pipelines Working Group was Mr Servie Simons (UK). Ad hoc experts invited to this group were Mr Alessandro Cigni, Mr Daniel Hec, Mr Marinus Kornalijnslijper, Mr Jean-François Larivé, Mr Gerald Linke, Mr A. Georgios Papadakis, Mr Anthony Taylor and Mr Dick Van den Brand. 9 Any legislation or regulation aimed at improving pipeline safety should build on the sector's achievements and on the mechanisms of self-regulation that are in place and have proven their worth. Failing to recognize this might render the measures counterproductive. Accordingly legislation and regulation should focus on goal setting and facilitate, for those who can demonstrate competence, a high degree of self regulation. • Effective Pipeline Integrity Management Systems (PIMS) are essential. PIMS is a reflection of best practice, throughout Europe and it covers all aspects of the operation, maintenance, overall systems management and development of the gas supply networks in Europe. It also covers isolated gas supply networks transporting wet and sour gas, landfill gas, LPG/Air and gas from gas gathering schemes. The definition of a gas supply system includes not only the pipelines themselves but associated plant and equipment such as pig traps, blending plants, compressors, scrubbers, pressure stations and volumetric governors. • There is a need for improving regulatory controls relating to third party interference. EU-legislation targeting the reduction of third party interference would be of great benefit to all stakeholders also including electricity, telecom and water. The industry is taking all reasonable steps in pipeline design, maintenance and surveillance in order to minimise third party interference and its consequences. It has, however, no power to regulate or control those who put the pipelines at risk and other stakeholders, particularly authorities and public bodies must accept their share of responsibility if this problem is to be properly controlled. 6.2. (1) (2) (3) Recommendations to the Commission Develop effective Pipeline Integrity Management Systems (PIMS) Regulation and legislation should focus on tackling third party interference European regulation should therefore recognise the responsibilities of all parties as follows: (a) Pipeline operators should have a pipeline integrity management system in operation to show beyond doubt that risks have been identified and are controlled. Public authorities should be responsible for the setting realistic goals for the pipeline branch, for the creation of the circumstances which help to prevent external interference and for ensuring that legislation is based on sound cost-benefit analysis. (b) 7. GENERAL CONCLUSIONS 1° The Group of Experts very much insists on the importance of the Methodology guidelines for future action on national as well as on European level. Some of the experts considered that priority for safety investigation before investigation for any other 10 purpose should even go further. For example witnesses important for safety investigation shall benefit form a high degree of protection from civil or criminal investigation. 2° It is increasingly recognised that there is a need for European coordination in respect of safety investigation matters and in particular liaison with the European safety agencies and other bodies responsible for safety related matters at international or European level. For this purpose, the Group of Experts proposes to institute sector specific (or modal) Councils constituted of the heads of the relevant national Safety Investigation Authorities. It considers that there is a high potential for such Councils in relation to institutionalising and standardising coordination and exchange of views, developing and coordinating dialogue with international and European organisations (or entities), establishing common databases, harmonising data collection and regular exchange of expertise, developing of training standards and offering specified training, improving and standardising conditions for cooperation in case of accidents and possible cooperation fees, and promoting equal access to documentation and know-how, continuing inter-modal exchange of views and expertise as launched by the present Group of Experts. The Group of Experts strongly recommends clarifying the role of bodies at European level, especially that of the three agencies already established: the European Aviation Safety Agency (EASA), the European Maritime Safety Agency (EMSA) and European Railway Agency (ERA). 3° The Group of Experts considers the Commission’s initiative in establishing this group as a good example for both consultation and exchange of views between experts of different sectors. It judges this experience worth to be repeated at other levels. There is a strong feeling among experts represented that available expertise of safety investigators throughout the EU are not made use of in an appropriate and efficient way and that more needs to be done to disseminate know-how and systematically consult experts on safety investigation in a suitable way, both when preparing legislation on transport safety as well as when implementing legislative requirements. 4° In order to facilitate access to information on the Group of Experts recommends to set up a Commission safety investigation site rendering public the present Final Report of the Group of Experts to advise the Commission on a strategy to deal with accidents in the transport sector and the European methodology for safety investigation of accidents and incidents in the transport sector. The Group of Experts also considers advisable that the Commission undertakes in approximately two years time an analysis of the developments concerning initiatives launched based on the work of this group. 11 ANNEX A List of experts of the group of experts to advise the Commission on a strategy to deal with accidents in the transport sector Name M. Paul Louis ARSLANIAN Nationality FR Organisation Director of the Bureau d’Enquêtes et d’Analyses in French Ministry of transport France mail : directeur@bea.aero Former director of Safety of Circulation with RENFE Spain mail : adchala@renfe.es Manager with AMADEUS Italy mail : essecieffe@tin.it Safety Director with Volvo Truck Corporation Sweden mail : lars-goran.lowenadler@volvo.com Professor at the Technische Universität Dresden Germany mail : Reinhold.Maier@tu-dresden.de Crash research director with FITSA Spain mail : j.monclus@fundacionfitsa.org Safety Officer with CP - Caminhos de Ferro Portugueses Portugal mail : risas@mail.telepac.pt Norwegian Aircraft & Railway Accident Investigation Board Norway mail : kr@aibn.no Shell UK Exploration and Production United Kingdom mail : servie.simons@shell.com Former UK Chief Inspector of Air Accidents with the UK Departement for Transport United Kingdom mail : ksmart@aaib.gov.uk Independent Maritime Accident Investigation Adviser and IMO adviser United Kingdom mail : js.lang@virgin.net Administrative Director with the Accident Investigation Board Finland mail : pirjo.valkama-joutsen@om.fi Chairman of the Dutch Safety Board Netherlands mail : Loo@DKH.nl M. Antonio (2005) DOMINGUEZ CHALA SP M. Salvatore FURNARI IT M. Lars-Göran LÖWENADLER SE M. Reinhold MAIER D M. Jesus MONCLUS SP M. Victor RISOTA (2005) PT M. Knut RYGH (2006) NO M. Servie SIMONS NL M. Ken SMART EN M. John STEWART LANG EN Mrs Pirjo VALKAMA-JOUTSEN FI M. Pieter VAN VOLLENHOVEN NL