Ref: NR/L2/INV/002 Issue: 13 Date: 3 December 2011 ... · Ref: NR/L2/INV/002 Issue: 13 Date: 3 December 2011 Compliance date: 3 March 2012 Page 2 of 10 User information This Network

Ref: NR/L2/INV/002 Issue: 13 Date: 3 December 2011 Compliance date: 3 March 2012

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User information

This Network Rail standard contains colour-coding according to the following Red–Amber–Green classification.

Red requirements – No deviations, could stop the railway

• Red requirements shall always be complied with and achieved.

• Red requirements shall be presented in a red box with the word “shall” or expressed as a direct instruction.

• Accountability for the efficacy of red requirements lies with the Professional Head/Standard Owner.

• Red requirements are monitored for compliance.

• Corrective actions shall be enforced if deviations are discovered through functional checks (e.g. engineering verification visits, audit or Operations Self-Assurance).

Amber requirements – Controlled deviations, approved risk analysis and mitigation

• Amber requirements shall be complied with unless deviation has been approved in advance.

• Amber requirements shall be presented with an amber sidebar and with the word “shall” or expressed as a direct instruction.

• Accountability for the efficacy of these requirements lies with the Professional Head/Standard Owner, or their nominated Delegated Authority.

• Amber requirements are monitored for compliance.

• Deviations may be permitted. Deviations are approved by the Standard Owner or through existing Delegated Authority arrangements.

• Corrective actions shall be enforced if non-approved deviations are discovered through functional checks (e.g. engineering verification visits, audit or Operations Self-Assurance).

Green – Guidance

• Guidance is based on good practice. Guidance represents supporting information to help achieve Red and Amber requirements.

• Guidance shall be presented with a dotted green sidebar and with the word “should” (usually in notes) or as a direct instruction.

• Guidance is not mandatory and is not monitored for compliance.

• Alternative solutions may be used. Alternative solutions do not need to be formally approved.

• Decisions made by a competent person to use alternative solutions should be backed up by appropriate evidence or documentation.


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Issue record

Issue Date Comments

1 December 1996

Original Document

2 June 1998 Complete revision & re-title 3 April 2000 Revised to improve process 4 Emergency August 2001 Emergency re-issue to address compliance with

GO/RT3434/3 and update company and post titles 5 Emergency February

2002 Complete revision to support issue of GO/RT3473 and GO/GN3673

6 February 2003

Revised to improve process and support reissue of GO/RT3473 and GO/GN3673

7 June 2004 Revised to reflect company reorganisation 8 October

2004 Transfer-in of investigation requirements for SPADs from RT/D/P/010. Scope to include environment and fire events. Revision to distribution of reports.

9 October 2006

Complete revision to reflect the requirements of ROGS Regulations and the SAF5 organisational change

10 December 2007

Complete revision to incorporate NR/SP/RSC/01701 and reissue of GO/RT3473 and GO/GN3673

11 September 2009

Revision to reflect changes in Railway Group standards

12 September 2010

Changes to definitions, including removal of preliminary investigation definition, and amendment to NRMI scope to be consistent with Health & Safety Management System (HSMS)

13 December 2011

Changes resulting from the conversion of the Reporting & Investigation Manual standards to a modular format and the transfer of some requirements to the modules

Compliance

This Network Rail standard is mandatory and shall be complied with by Network Rail and its contractors if applicable from 3 March 2012.

When this standard is implemented, it is permissible for all projects that have formally completed GRIP Stage 3 (Option Selection) to continue to comply with the issue of any relevant Network Rail standards current when GRIP Stage 3 was completed and not to comply with requirements contained herein, unless stipulated otherwise in the scope of this standard.


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Reference documentation

GO/RT3119 Accident and Incident Investigation

GO/GN3519 Guidance on Accident and Incident Investigation

GE/RT8047 Reporting of Safety Related Information

GE/RT8250 Reporting High Risk Defects

NR/L2/EBM/STP001 Network Rail Standards Management – Process requirements

NR/L2/OPS/035 Dissemination of Urgent Operating Advice

NR/CS/FIR/100 Company Fire Safety Handbook

NR/L2/OCS/041 Operations Manual

NR/SP/CTM/032 Training, Competency and Assessment in Accident and Incident Investigation

NR/L3/INV/3001 Reporting and Investigation Manual

SMIS Event Matrix

Disclaimer

In issuing this document for its stated purpose, Network Rail makes no warranties, express or implied, that compliance with all or any documents it issues is sufficient on its own to ensure safe systems of work or operation. Users are reminded of their own duties under health and safety legislation.

Supply

Copies of documents are available electronically, within Network Rail’s organisation. Hard copies of this document may be available to Network Rail people on request to the relevant controlled publication distributor. Other organisations may obtain copies of this document from IHS. Tel: 01344 328039.


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Contents

1 Purpose 6

2 Scope 6

3 Definitions 7

4 Principles 9

5 Review 10


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1 Purpose

The purpose of this Network Rail standard and the processes within the Reporting and Investigation Manual is:

a) To provide a consistent, comprehensive and structured process:

• for the reporting of accidents and incidents;

• for the investigation of accidents and incidents in order to prevent, or reduce the risk of, their recurrence, without apportioning blame or liability;

• that enables information obtained from investigations to be shared with, and used by, organisations with a direct responsibility for maintaining, or improving railway safety.

b) So that:

• the requirements of Railway Group Standards GO/RT3119 and GE/RT8047 are met;

• accurate information is provided to the safety management information system (SMIS);

• action plans from investigation reports are accepted by the responsible designated competent person (DCP) for managing their implementation, tracking and closure once complete;

• recommendations from investigation reports, including those carried out by other parties, are systematically considered, implemented where appropriate, and tracked to completion;

c) To assist in:

• assessing safety risks;

• monitoring safety performance and compliance with Network Rail’s Health and Safety Management System (HSMS).

2 Scope

2.1 This standard and the processes within the Reporting and Investigation Manual apply to:

a) Events occurring on Network Rail Managed Infrastructure (NRMI);

b) Events that do not occur on NRMI but which cause, or have the potential to cause, an increase in risk on NRMI;

c) Events occurring on Network Rail managed stations;

d) Events involving rail vehicles operated by Network Rail;

e) Accidents and assaults involving Network Rail employees whilst on duty, including whilst travelling in road vehicles (whether owned, hired or leased by Network Rail);

f) Occupational ill health affecting Network Rail employees;


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g) Accidents and assaults involving employees of contractors whilst undertaking work for Network Rail;

h) Accidents to members of the public occurring on NRMI or Network Rail managed stations, including cases of suicide, suspected suicide and attempted suicide;

i) Enforcement action taken by the Office of Rail Regulation (ORR) or other enforcing authority concerning issues relating to operations or activities on or affecting NRMI and Network Rail managed stations;

j) Judicial Inquiries, RAIB Investigations, Network Rail led Local and Formal Investigations, and investigations led by other Railway Group members.

2.2 This Network Rail standard and the processes within the Reporting and Investigation Manual are applicable to all business units and functions.

2.3 This standard and the processes within the Reporting and Investigation Manual do not apply to the initial reporting of an event (for example, information given by a signaller) as detailed in the Rule Book and the Working Manual for Rail Staff.

3 Definitions

Accident – An unwanted or unintended sudden event or a specific chain of such events which have harmful consequences; for example, accidents include the following: collisions, derailments, vehicles struck at level-crossings, persons struck by trains, fires and others.

Assault – Any event in which a person is:

a) physically assaulted,

b) subjected to verbal abuse or has been threatened with violence, whether or not there is physical injury.

All assaults shall be dealt with in the same manner as an accident.

Contractor – A person undertaking work under contract for Network Rail; this includes a person sub-contracted to undertake work for Network Rail.

This includes a self-employed person and staff of agencies used by Network Rail or its contractors.

Designated competent person (DCP) – The person identified by the lead organisation as responsible for supervising/managing the investigation process.

Event – Where this term is used, it means occurrences resulting in an accident or incident.

Enforcement action – For the purposes of this specification, this means Improvement Notices (except Improvement Notices served under the Fire Precautions Act 1971), Prohibition Notices and prosecutions by the ORR, Health and Safety Executive (HSE), Environment Agency or other enforcing authority.


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Incident – An unplanned, uncontrolled event that under different circumstances may have resulted in an accident (includes, and may also be referred to as, a ‘Near miss’ or ‘Close call’).

Line manager or project manager – This includes, for the purposes of this specification:

a) persons with the competence and responsibility within their function for:

the safe operation of the railway and organisation of train services;

briefing the reporting or investigation process to employees;

managing or supporting the reporting or investigation process.

b) persons responsible for managing, administering and delivering contracts either for major or minor works schemes, e.g. project managers.

Local action – A response directed at line management due to the application of an existing control measure not being followed (e.g. not following a rule, regulation or process).

Member of the public – This definition applies to persons who are not:

a) employees of Network Rail and its contractors whilst on duty;

b) the employees of other Railway Group members and their contractors whilst on duty.

The definition includes:

c) passengers;

d) railway neighbours, i.e. persons who may be affected by Network Rail activities, including users of level crossing;

e) persons on business or with legitimate reasons for being on Network Rail property (e.g. HM Railway Inspectors and others with statutory powers to enter onto Network Rail property);

f) trespassers.

Network Rail Managed Infrastructure (NRMI) – Network Rail Managed Infrastructure is the infrastructure that falls within the geographic boundaries of Network Rail’s operational railway, including the permanent way and land within the lineside fence, and plant used for signalling or exclusively for supplying electricity for traction purposes to Network Rail’s operational railway.

It does not include stations (whether or not these are managed by Network Rail), nor does it include depots, yards or sidings owned by, or leased to, other parties. However, it does include permanent way at stations and plant within these locations used for signalling Network Rail’s operational railway or exclusively for supplying electricity for operational purposes to the operational railway.

Structures such as tunnels, bridges, viaducts, underpasses, etc, are deemed to form part of NRMI only in relation to their potential to transfer risk onto, or from, the operational railway.


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Occupational ill health – Any case of ill-health that is suspected or known to have resulted from the affected person’s work environment or work activity, other than ill-health caused by personal accident or assault.

NOTE 1 This term only applies to cases of occupational ill-health diagnosed or certified by a medical practitioner and includes cases of reportable disease.

Recommendation – A proposal made following an inquiry or investigation to:

a) change an existing control measure, or

b) define a new control measure

to eliminate or mitigate a risk derived from the cause(s) or contributor(s) of an event, as described in an inquiry or investigation report.

Reporting and Investigation Manual – A Network Rail produced manual comprising the company’s processes, and supporting guidance, for accident and incident reporting and investigation.

4 Principles

4.1 Reporting and Investigation Manual

4.1.1 The Reporting and Investigation Manual is mandated by this Network Rail standard and shall provide a set of procedures to apply to accident and incident reporting and investigation activities within Network Rail.

4.1.2 The Reporting and Investigation Manual shall specify a set of minimum requirements for:

a) accident and incident reporting activities;

b) accident and incident investigation activities;

c) management of recommendations and local actions arising from inquiries and investigations to facilitate their implementation where appropriate;

4.1.3 The Head of Corporate Assurance and Accident Investigation (HoCAAI) shall have arrangements in place to maintain the Reporting and Investigation Manual that shall include within it a process for proposing and approving changes to its contents, including arrangements for obtaining the consent of the HoCAAI if there is any change resulting from a change in relevant legislation, Railway Group standards or Technical Specifications for Interoperability (TSI), or other Network Rail company standards.

NOTE 2 Such process will enable the HoCAAI to regularly review and update the processes within NR/L3/INV/3001 and in accordance with NR/L2/EBM/STP001.

4.1.4 Where Functions/Business Units identify proposed changes to the Reporting and Investigation Manual such proposals shall be submitted to the HoCAAI in accordance with the process shown in NR/L3/INV/3001.

4.2 Training and competency and awareness of requirements

4.2.1 The HoCAAI shall have arrangements in place to approve courses and the competence requirements for investigation management within Network Rail.


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4.2.2 The competencies for Network Rail staff are contained in NR/SP/CTM/032.

4.2.3 Functional/Business Unit Directors shall:

a) arrange for staff to be made aware of the requirements and their responsibilities in respect of this standard and the processes contained within the Reporting and Investigation Manual;

b) have arrangements in place with contractors for the reporting of events in accordance with the processes contained within the Reporting and Investigation Manual;

4.3 Designated competent persons

4.3.1 Functional/Business Unit Directors shall identify the need for Designated Competent Person(s) to be appointed to manage the investigation processes within the Function/Business Unit.

4.3.2 Where such need is identified the Functional/Business Unit Director shall arrange to:

a) determine the most appropriate level of post within the Function/Business Unit to undertake the role of Designated Competent Person, taking account of the competence requirements contained in NR/SP/CTM/032, and

b) inform the HoCAAI of:

1) the posts within the Function/Business Unit that will undertake the role of Designated Competent Person and

2) the names of the person undertaking the role.

4.3.3 Functional/Business Unit Directors shall arrange to notify the HoCAAI of any changes to the information provided in accordance with 4.3.2(b).

4.4 Single point of contact

The HoCAAI shall act as the Single Point of Contact for Network Rail between the Rail Accident Investigation Branch (RAIB), the Office of Rail Regulation (ORR) and RSSB for the purposes of accident investigation.

5 Review

The HoCAAI shall arrange for compliance with the processes within the Reporting and Investigation Manual to be assessed regularly.

25/05/2010 - Version 1

Standards Briefing Note

Ref: NR/L2/INV/002 Issue: 13 Title: Accident and Incident Reporting and Investigation Publication Date: 03/12/2011 Compliance Date: 03/03/2012 Standard Owner: Head Of Corporate Assurance & Accident Investigation Non-Compliance rep (NRNC): Head Of Corporate Assurance & Accident Investigation Further information contact: Steve Hudson, Senior Investigator Tel: 085 82637 Purpose: The purpose of this Network Rail standard is to mandate the use of the Reporting and Investigation Manual: a) To provide a consistent, comprehensive and structured process:

• for the reporting of accidents and incidents; • for the investigation of accidents and incidents in order to

prevent, or reduce the risk of, their recurrence, without apportioning blame or liability;

• that enables information obtained from investigations to be shared with, and used by, organisations with a direct responsibility for maintaining, or improving railway safety.

b) So that: • the requirements of Railway Group Standards

GO/RT3119 and GE/RT8047 are met; • accurate information is provided to the safety

management information system (SMIS); • action plans from investigation reports are accepted by

the responsible designated competent person (DCP) for managing their implementation, tracking and closure once complete;

• recommendations from investigation reports, including those carried out by other parties, are systematically considered, implemented where appropriate, and tracked to completion;

c) To assist in: • assessing safety risks;

• monitoring safety performance and compliance with Network Rail’s Health and Safety Management System (HSMS).

Scope: This standard and the processes within the Reporting and Investigation Manual apply to: a) Events occurring on Network Rail Managed Infrastructure (NRMI); b) Events that do not occur on NRMI but which cause, or have the potential to cause, an increase in risk on NRMI; c) Events occurring on Network Rail managed stations; d) Events involving rail vehicles operated by Network Rail; e) Accidents and assaults involving Network Rail employees whilst on duty, including whilst travelling in road vehicles (whether owned, hired or leased by Network Rail); f) Occupational ill health affecting Network Rail employees; g) Accidents and assaults involving employees of contractors whilst undertaking work for Network Rail; h) Accidents to members of the public occurring on NRMI or Network Rail managed stations; i) Enforcement action taken by the Office of Rail Regulation (ORR) or other enforcing authority concerning issues relating to operations or activities on or affecting NRMI and Network Rail managed stations; j) Judicial Inquiries, RAIB Investigations, Network Rail led Local and Formal Investigations, and investigations led by other Railway Group members. This Network Rail standard is applicable to all business units and functions. This standard and the processes within the Reporting and Investigation Manual do not apply to the initial reporting of an event (for example, information given by a signaller) as detailed in the Rule Book and the Working Manual for Rail Staff.

What’s New/ What’s Changed and Why: The standard has been revised to take account of the conversion of the suite of Level 3 standards forming the Reporting and Investigation Manual (RIM) to modules (Level3), with a new Level 3 standard (NR/L3/INV/3001 – see separate Briefing Note) authorising the RIM. This has resulted in some requirements in NR/L2/INV/002 Issue 12 being: Transferred to the relevant RIM module (this includes the ‘Definitions’), or Removed to avoid duplicating requirements in the relevant RIM module, or Deleted as they were considered no longer appropriate or necessary. The ‘Scope’ and ‘Purpose’ have been revised to better reflect the processes within the RIM. The following new requirements have been added: Clause 4 – the need for Functional/Business Unit Directors to specify which posts shall undertake the role of Designated Competent Person(s) to manage the investigation processes within the Function/Business Unit and for this information to be passed to the Head Of Corporate Assurance & Accident Investigation (note that this currently happens but had not been documented in NR/L2/INV/002 previously). Account has been taken of (a) organisational changes resulting from ‘devolution’ and (b) the Red-Amber-Green classification (see details inside the front cover).

Affected documents:

Reference

NR/L2/INV/002 ISSUE 12

Impact

Superseded

Briefing requirements: Where Technical briefing (T) is required, the specific Post title is indicated. These posts have specific responsibilities within this standard and receive briefing as part of the Implementation Programme. For Awareness briefing (A) the Post title is not mandatory.

Please see http://ccms2.hiav.networkrail.co.uk/webtop/drl/objectId/09013b5b804504da for guidance.

http://ccms2.hiav.networkrail.co.uk/webtop/drl/objectId/09013b5b804504da

25/05/2010 - Version 1

Briefing (A-Awareness/

T-Technical)

Post Team

Function

A Functional/Business Unit Directors All All

A Head of Corporate Assurance & Accident Investigation

Safety and Sustainable Development


A Senior Investigators Safety and Sustainable Development


*NOTE: Contractors are responsible for arranging and undertaking their own Technical and Awareness Briefings in accordance with their own processes and procedure

Documents

Ref: NR/L2/INV/002 Issue: 13 Date: 3 December 2011 ... · Ref: NR/L2/INV/002 Issue: 13 Date: 3 December 2011 Compliance date: 3 March 2012 Page 2 of 10 User information This Network