Experiencia acumulada en accidentes ferroviarios: Aprendiendo de los accidentes

Return of experience: learning from accidents

ERA InnoTrans presentation

Berlin, 18/09/2012

Xose Manuel

Texto tecleado

Traducciónes a Español al final del documento

Questions?

Questions in German or English language are appreciated at any time!

18 September 2012 2 InnoTrans 2012 Berlin

Migration strategy towards a single certificate

The Agency’s Recommendation on a migration strategy towards a single certificate states 2 preconditions to be met before the move to a single EU safety certificate:

• RUs/IMs take forward their full responsibility under Article 4(3) of the Railway Safety Directive for managing, controlling and monitoring risks of their operation

• There is harmonised decision making for the assessment and supervision of the safety of the rail system by the national safety authorities (NSAs) which takes forward their tasks under Articles 16(2) (e) and (f) of the Railway Safety Directive


Why accident investigation?

How the investigation of accidents and incidents

can contribute?

18 September 2012 InnoTrans 2012 Berlin 4


• Any accident and incident is an indicator that there might be an

issue with

• the management of safety by the responsible actors

• the way the supervision authorities perform their tasks

• the regulatory framework

• In a wide range of industries independent accident investigation has proven as successful tool to increase safety by learning from accidents and incidents



For the railway sector, the Railway Safety Directive

provides a system approach for independent accident

investigation

What applies in the railway sector?

Why accident investigation? The approach of the Railway Safety Directive

• Serious accidents on the railway are rare, but • can have disastrous consequences • may raise concern among the public about

the safety of the railway system

• Accidents should be investigated • to avoid recurrence • to prevent accidents • to improve railway safety

• The objective is prevention by learning from accidents and incidents


How to perform accident investigation? The approach of the Railway Safety Directive

• The Member States must establish a permanent body for accident investigation, independent from • infrastructure managers • railway undertakings • any other party whose interests could conflict with

the tasks of the investigating body

• The investigation body must obtain sufficient resources


• The investigation body

• shall investigate serious accidents

• shall at its discretion decide to investigate other accidents and incidents

• The investigation may not be concerned with apportioning blame or liability

• The investigation body must perform its investigations independently of juridical investigation




The investigation should identify

• direct and immediate causes relating to

actions taken by persons involved the condition of rolling stock or technical installations

• underlying causes relating to

skills procedures maintenance

• root causes relating to

the regulatory framework conditions the application of the safety management system



• The investigation shall be carried out with openness

• Infrastructure managers, railway undertakings, the safety authority, and other involved and interested parties shall be regularly informed of the investigation and its progress

• They should be given an opportunity to submit their opinions and views


• Any investigation shall be the subject of a final report

• The report must be published

• The reports may contain safety recommendations

• Usually, safety recommendations shall be addressed to the NSA, because only the NSA as supervisory body has • the overview on the national railway sector

• the power to enforce measures and to withdraw a safety authorisation/safety certificate

• the power to promote and, enforce and develop the safety regulatory framework

• The addressee of the safety recommendation shall report back on actions taken or planned



Conclusion

• The Railway Safety Directive provides a system approach for independent and transparent railway accident investigation with the objective of learning from accidents and incidents for the improvement of safety

• This objective can only be achieved, if

The Member states have transposed the Railway Safety Directive correctly into national legislation

The investigation bodies apply the system approach by investigating also into the root-cause level

• With this scope, accident investigation can be a valuable tool for monitoring the actual state of safety management at all levels in the railway system and help in assessing the fulfillment of both preconditions to move to a single EU safety certificate.



How this system approach works in practise?

• There is a broad variety of the safety culture maturity amongst the Member States which also applies to accident investigation

• Several Member States are still governed by a “blame-culture”

• In some Member States, independent accident investigation is estimated as potential threat for government, authorities and railway industry

• The majority of the investigations

is limited to the identification of direct and underlying causes

is focussing mainly on technical issues

doesn’t include the investigation of safety management and organisational issues


42%

2% 1%

48%

1% 6%

Direct

Direct/Underlying

Direct/Root

Underlying

Underlying/Root

Root

Analysis of the safety recommendations of investigation reports:

The broad majority of the recommendations is aiming on the direct and underlying causes

How does this system approach work in practise?


Conclusion

To improve safety by learning of accidents and incidents, the investigations need to look deeper into underlying and root causes:

• Railway undertakings/infrastructure managers/entities in charge of maintenance

with their safety management system (SMS)

with monitoring their safety performance

• The National Safety Authority (NSA)

safety certification and authorisation

supervision activities

authorisation to place into service

• The regulator

with the regulatory framework


How can the Agency contribute?

Several actions already taken or planned:

• Guidance on accident investigation

• Training of the investigators

• Systematic evaluation of investigation reports on SMS issues, including feedback to the investigation body

• Assessment of the investigation bodies

All actions are carried out in co-operation with the network of investigation bodies


Summary

• Two preconditions before the move to a single EU safety certificate:

• RUs/IMs take forward their full responsibility for managing, controlling and monitoring risks

• Harmonised decision making for assessment and supervision by the NSAs

• Independent accident investigation proven tool in all industries

• For the railway sector, the Railway Safety Directive provides the framework for safety-oriented accident investigation

• Today, investigations limited to direct causes and technical issues

• The investigations need to look deeper into the root causes

• Then, accident investigation can be a valuable tool for monitoring the actual state of safety management at all levels in the railway system and help in assessing the fulfillment of both preconditions

• The Agency has taken actions to support the investigation bodies


We make the railway system work better for society.

era.europa.eu

20/09/2012 ERA InnoTrans round table discussion 19

TRADUCCIÓN PRESENTACIÓN AGENCIA EUROPEA DEL FERROCARRIL EN INNOTRANS – BERLÍN 18/09/2012 Diapositiva 1

European Railway Agency Return of experience: learning from accidents ERA InnoTrans presentation Berlin, 18/09/2012 ---------- Agencia Europea del Ferrocarril Experiencia acumulada: Aprendiendo de los accidentes Presentación ERA InnoTrans Berlín, 18/09/2012 Diapositiva 2

Questions? Questions in German or English language are appreciated at any time! ---------- ¿Preguntas? ¡Preguntas en idiomas Alemán o Inglés serán bien recibidas en cualquier momento! Diapositiva 3

Migration strategy towards a single certificate The Agency’s Recommendation on a migration strategy towards a single certificate states 2 preconditions to be met before the move to a single EU safety certificate:

• RUs/IMs (Railway Undertakings/Infraestructures Manager) take forward their full responsibility under Article 4(3) of the Railway Safety Directive for managing, controlling and monitoring risks of their operation.

• There is harmonised decision making for the assessment and supervision of the safety of the rail system by the national safety authorities (NSAs) which takes forward their tasks under Articles 16(2) (e) and (f) of the Railway Safety Directive

---------- Estrategia de migración hacia un solo certificado La Recomendación de la Agencia sobre la estrategia de migración hacia un solo certificado se basa en 2 precondiciones que deben darse antes de hacer el cambio a un único certificado de Seguridad de la UE:

• Las empresas ferroviarias y los gestores de infraestructuras, según el artículo 4(3) de la Directiva de Seguridad Ferroviaria, asumen su total responsabilidad para avanzar en la gestión, el control y la monitorización de los riesgos de sus operaciones.

• Hay una toma de decisión armonizada para la evaluación y supervisión de la Seguridad del sistema ferroviario por las Autoridades Nacionales de Seguridad (Dirección General de Ferrocarriles, en el caso de España), las cuales asumen sus tareas según los Artículos 16(2) (e) y (f) de la Directiva del Sistema Ferroviario.

Diapositiva 4

Why accident investigation? How the investigation of accidents and incidents can contribute? ---------- ¿Por qué investigación de accidentes? ¿Cómo puede ayudar la investigación de los accidentes e incidentes?

Diapositiva 5


• Any accident and incident is an indicator that there might be an issue with o the management of safety by the responsible actors o the way the supervision authorities perform their tasks o the regulatory framework

• In a wide range of industries independent accident investigation has proven as successful tool to increase safety by learning from accidents and incidents

---------- ¿Por qué investigación de accidentes?

• Cualquier accidente e incidente es un indicador de que podría

haber un problema con:

o La gestión de la Seguridad por los actores responsables

o La manera en que las autoridades de supervisión llevan a cabo

sus tareas

o El marco normativo

• En una amplia gama de sectores la investigación de accidentes

independiente se ha demostrado que es una herramienta exitosa

para incrementar la Seguridad derivada del aprendizaje de los

accidentes e incidentes

Diapositiva 6

What applies in the railway sector? For the railway sector, the Railway Safety Directive provides a system approach for independent accident investigation ---------- ¿Qué aplica en el sector ferroviario?

Para el sector ferroviario, la Directiva de Seguridad Ferroviaria proporciona

un enfoque del sistema para la investigación de accidentes

independiente

Diapositiva 7

Why accident investigation? The approach of the Railway Safety Directive

• Serious accidents on the railway are rare, but o can have disastrous consequences o may raise concern among the public about the safety of the railway system

• Accidents should be investigated o to avoid recurrence o to prevent accidents o to improve railway safety

• The objective is prevention by learning from accidents and incidents ---------- ¿Por qué investigación de accidentes? El enfoque de la Directiva de Seguridad Ferroviaria

• Los accidentes graves son escasos, pero: o Pueden tener consecuencias desastrosas o Puede suponer una preocupación para el público sobre la Seguridad del

sistema ferroviario

• Los accidentes deberían ser investigados:

o Para evitar su repetición

o Para prevenir accidentes

o Para mejorar la Seguridad ferroviaria • El objetivo es la prevención por el aprendizaje derivado de los accidentes e

incidentes Diapositiva 8


• The Member States must establish a permanent body for accident investigation, independent from o infrastructure managers o railway undertakings o any other party whose interests could conflict with the tasks of the

investigating body

• The investigation body must obtain sufficient resources ---------- ¿Cómo llevar a cabo la investigación de accidentes? El enfoque de la Directiva de Seguridad Ferroviaria

• Los Estados Miembros deben establecer un organismo

permanente para la investigación de accidentes, independiente

de:

o Los gestores de infraestructuras

o Las empresas ferroviarias

o Cualquier otra parte cuyos intereses podrían entrar en conflicto

con las tareas del organismo de investigación • El organismo de investigación debe contar con suficientes recursos

Diapositiva 9


• The investigation body o shall investigate serious accidents o shall at its discretion decide to investigate other accidents and incidents

• The investigation may not be concerned with apportioning blame or liability

• The investigation body must perform its investigations independently of juridical investigation

---------- ¿Cómo llevar a cabo la investigación de accidentes? El enfoque de la Directiva de Seguridad Ferroviaria

• El organismo de investigación: o Deberá investigar los accidentes graves o Deberá decidir a su criterio si investigar otros accidentes e incidentes

• A la investigación puede no interesarle asignar culpa o responsabilidad

• El organismo de investigación debe llevar a cabo sus

investigaciones independientemente de la investigación judicial

Diapositiva 10 How to perform accident investigation? The approach of the Railway Safety Directive The investigation should identify

• direct and immediate causes relating to o actions taken by persons involved o the condition of rolling stock or technical installations

• underlying causes relating to o skills o procedures o maintenance

• root causes relating to o the regulatory framework conditions o the application of the safety management system


La investigación debería identificar:

• Las causas directas e inmediatas relativas a:

o Las actuaciones desarrolladas por las personas implicadas

o El estado del material rodante o de las instalaciones técnicas

• Las causas subyacentes (básicas) relativas a:

o Conocimientos o habilidades

o Procedimientos

o Mantenimiento

• Las causas raíz relativas a

o Las condiciones del marco normativo

o La aplicación del sistema de gestión de la Seguridad

Diapositiva 11 How to perform accident investigation? The approach of the Railway Safety Directive

• The investigation shall be carried out with openness

• Infrastructure managers, railway undertakings, the safety authority, and other involved and interested parties shall be regularly informed of the investigation and its progress

• They should be given an opportunity to submit their opinions and views ---------- ¿Cómo llevar a cabo la investigación de accidentes? El enfoque de la Directiva de Seguridad Ferroviaria

• La investigación deberá ser desarrollada con transparencia

• Los gestores de infraestructuras, empresas ferroviarias, la

autoridad de Seguridad, y otras partes implicadas e interesadas

deberán ser regularmente informadas de la investigación y su

avance

• Debería darse a los anteriormente citados una oportunidad para

remitir sus opiniones y puntos de vista

Diapositiva 12 How to perform accident investigation? The approach of the Railway Safety Directive

• Any investigation shall be the subject of a final report

• The report must be published

• The reports may contain safety recommendations

• Usually, safety recommendations shall be addressed to the NSA, because only the NSA as supervisory body has o the overview on the national railway sector o the power to enforce measures and to withdraw a safety

authorisation/safety certificate o the power to promote and, enforce and develop the safety regulatory

framework

• The addressee of the safety recommendation shall report back on actions taken or planned


• Cualquier investigación deberá ser objeto de un informe final

• El informe debe ser publicado

• Los informes pueden contener recomendaciones de Seguridad

• Normalmente, las recomendaciones de Seguridad deberán ser dirigidas a la DGF (Dirección General de Ferrocarriles - autoridad nacional de Seguridad), porque sólo la DGF como organismo supervisor tiene: o La visión de conjunto sobre el sector ferroviario nacional o El poder para imponer medidas y para retirar la autorización o certificado

de Seguridad o El poder para promocionar y, hacer cumplir y desarrollar el marco

normativo de Seguridad

• El destinatario de las recomendaciones de Seguridad deberá informar a su vez sobre las acciones tomadas o planificadas

Diapositiva 13 How to perform accident investigation? The approach of the Railway Safety Directive Conclusion

• The Railway Safety Directive provides a system approach for independent and transparent railway accident investigation with the objective of learning from accidents and incidents for the improvement of safety

• This objective can only be achieved, if o The Member states have transposed the Railway Safety Directive

correctly into national legislation o The investigation bodies apply the system approach by investigating

also into the root-cause level

• With this scope, accident investigation can be a valuable tool for monitoring the actual state of safety management at all levels in the railway system and help in assessing the fulfillment of both preconditions to move to a single EU safety certificate.

---------- ¿Cómo llevar a cabo la investigación de accidentes? El enfoque de la Directiva de Seguridad Ferroviaria Conclusión

• La Directiva de Seguridad Ferroviaria proporciona un enfoque de

sistema para la investigación independiente y transparente de

accidentes ferroviarios con el objetivo de aprender de los

accidentes e incidentes para la mejora de la Seguridad

• Este objetivo puede sólo ser alcanzado, si: o Los Estados Miembros han transpuesto correctamente la Directiva de

Seguridad Ferroviaria a la legislación nacional

o Los organismos de investigación apliquen el enfoque de

sistema mediante la investigación también hasta el nivel de

causas raíz • Con este alcance, la investigación de accidentes puede ser una valiosa

herramienta para monitorizar el estado real de la gestión de la Seguridad a todos los niveles en el sistema ferroviario y ayudar en la evaluación del cumplimiento de las dos precondiciones para cambiar a un único certificado de Seguridad UE

Diapositiva 14 How this system approach works in practise?

• There is a broad variety of the safety culture maturity amongst the Member States which also applies to accident investigation

• Several Member States are still governed by a “blame-culture”

• In some Member States, independent accident investigation is estimated as potential threat for government, authorities and railway industry

• The majority of the investigations o is limited to the identification of direct and underlying causes o is focussing mainly on technical issues

o doesn’t include the investigation of safety management and organisational issues.

---------- ¿Cómo funciona en la práctica este enfoque de sistema?

• Hay una gran variedad en términos de madurez en cultura de la Seguridad entre los Estados Miembros lo cual aplica también a la investigación de accidentes

• Algunos Estados Miembros están aún gobernados por una “cultura de culpabilización”

• En algunos Estados Miembros, la investigación de accidentes independiente es vista como una potencial amenaza para el gobierno, las autoridades y la industria ferroviaria

• La mayoría de las investigaciones: o Están limitadas a la identificación de causas directas (inmediatas) y

subyacentes (básicas) o Están focalizadas principalmente en aspectos técnicos o No incluyen la investigación de la gestión de la Seguridad y los aspectos

organizacionales Diapositiva 15 How this system approach works in practise? Analysis of the safety recommendations of investigation reports:

• Direct 42%

• Direct/Underlying. 2%

• Direct/Root. 1%

• Underlying. 48%

• Underlying/Root. 1%

• Root 6% The broad majority of the recommendations is aiming on the direct and underlying causes ---------- ¿Cómo funciona en la práctica este enfoque de sistema? Análisis de las recomendaciones de Seguridad de los informes de investigación:

• Directas (inmediatas) 42%

• Directas (inmediatas)/Subyacentes (básicas). 2%

• Directas (inmediatas)/Raíz. 1%

• Subyacentes (básicas). 48%

• Subyacentes (básicas)/Raíz. 1%

• Raíz 6% La gran mayoría de las recomendaciones tienen como objetivo las causas directas (inmediatas) o subyacentes (básicas) Diapositiva 16 Conclusion To improve safety by learning of accidents and incidents, the investigations need to look deeper into underlying and root causes:

• Railway undertakings/infrastructure managers/entities in charge of maintenance o with their safety management system (SMS) o with monitoring their safety performance

• The National Safety Authority (NSA) o safety certification and authorisation o supervision activities o authorisation to place into service

• The regulator o with the regulatory framework

---------- Conclusión

Para mejorar la Seguridad por el aprendizaje obtenido de los accidentes

e incidentes, las investigaciones necesitan analizar más a fondo las

causas subyacentes (básicas) y raíz:

• Empresas ferroviarias/gestores de infraestructuras/entidades a

cargo del mantenimiento

o Con sus sistemas de gestión de la Seguridad (SMS)

o Con la monitorización de su desempeño en Seguridad • La Dirección General de Ferrocarriles (Autoridad Nacional de Seguridad en

España) o Certificación de Seguridad y autorización o Actividades de supervisión o Autorización de puesta en servicio

• El regulador o Con el marco normativo

Diapositiva 17 How can the Agency contribute? Several actions already taken or planned:

• Guidance on accident investigation

• Training of the investigators

• Systematic evaluation of investigation reports on SMS issues, including feedback to the investigation body

• Assessment of the investigation bodies All actions are carried out in co-operation with the network of investigation bodies ---------- ¿Cómo puede contribuir la Agencia? Algunas acciones ya tomadas o planificadas:

• Guía en investigación de accidentes • Formación a los investigadores

• Evaluación de los informes de investigación sobre asuntos del

sistema de gestión de la Seguridad, incluyendo los comentarios al

organismo de investigación

• Evaluación de los organismos de investigación

Todas las acciones son llevadas a cabo en cooperación con la red de organismos de investigación Diapositiva 18 Summary

• Two preconditions before the move to a single EU safety certificate: o RUs/IMs take forward their full responsibility for managing, controlling and

monitoring risks o Harmonised decision making for assessment and supervision by the NSAs

• Independent accident investigation proven tool in all industries

• For the railway sector, the Railway Safety Directive provides the framework for safety-oriented accident investigation

• Today, investigations limited to direct causes and technical issues

• The investigations need to look deeper into the root causes

• Then, accident investigation can be a valuable tool for monitoring the actual state of safety management at all levels in the railway system and help in assessing the fulfillment of both preconditions

• The Agency has taken actions to support the investigation bodies ---------- Resumen

• Dos precondiciones antes de hacer el cambio a un único certificado de Seguridad UE: o Empresas ferroviarias/gestores de infraestructuras asumen su total

responsabilidad para avanzar en la gestión, el control y la monitorización de los riesgos.

o Toma de decisión armonizada para la evaluación y supervisión por las Autoridades Nacionales de Seguridad

• Investigación de accidentes independiente, herramienta probada en todos los sectores

• Para el sector del ferrocarril, la Directiva de Seguridad Ferroviaria proporciona el marco para una investigación de accidentes orientada a la Seguridad

• Hoy, investigaciones limitadas a causas directas (inmediatas) y aspectos técnicos

• La investigación necesita analizar más a fondo las causas raíz • Entonces, la investigación de accidentes puede ser una valiosa herramienta

para la monitorización del estado real de la gestión de la Seguridad a todos los niveles en el sistema ferroviario y una ayuda en la evaluación del cumplimiento de las dos precondiciones

• La Agencia ha adoptado acciones para dar soporte a los organismos de investigación

Diapositiva 19

We make the railway system work better for society. ---------- Hacemos que el sistema ferroviario funciones mejor para la sociedad.

Presentations & Public Speaking

Experiencia acumulada en accidentes ferroviarios: Aprendiendo de los accidentes