Presentación de la Agencia Europea del Ferrocarril en INNOTRANS – BERLÍN 18/09/2012. Traducción del Texto al final del documento Versión en Inglés

1. Return of experience: learning from accidents
ERA InnoTrans presentation
Berlin, 18/09/2012
Traducciónes a Español al final del
documento

2. Questions?
Questions in German or English language
are appreciated at any time!
18 September 2012 2InnoTrans 2012 Berlin

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 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
18 September 2012 3InnoTrans 2012 Berlin

4. Why accident investigation?
How the
investigation of accidents and incidents
can contribute?
18 September 2012 InnoTrans 2012 Berlin 4

5. Why accident investigation?
• 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
18 September 2012 InnoTrans 2012 Berlin 5

6. 18 September 2012 InnoTrans 2012 Berlin 6
For the railway sector, the
Railway Safety Directive
provides a system approach
for independent accident
investigation
What applies in the railway sector?

7. 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
18 September 2012 7InnoTrans 2012 Berlin

8. 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
18 September 2012 8InnoTrans 2012 Berlin

9. • 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
18 September 2012 9InnoTrans 2012 Berlin
How to perform accident investigation?
The approach of the Railway Safety Directive

10. 18 September 2012 InnoTrans 2012 Berlin 10
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
How to perform accident investigation?
The approach of the Railway Safety Directive

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
18 September 2012 InnoTrans 2012 Berlin 11

12. • 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
18 September 2012 InnoTrans 2012 Berlin 12
How to perform accident investigation?
The approach of the Railway Safety Directive

13. 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.
18 September 2012 InnoTrans 2012 Berlin 13
How to perform accident investigation?
The approach of the Railway Safety Directive

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
 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
18 September 2012 InnoTrans 2012 Berlin 14

15. 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?
18 September 2012 InnoTrans 2012 Berlin 15

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
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
18 September 2012 InnoTrans 2012 Berlin 16

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
18 September 2012 InnoTrans 2012 Berlin 17

18. 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
18 September 2012 InnoTrans 2012 Berlin 18

19. We make the railway system work better for society.
era.europa.eu
20/09/2012 ERA InnoTrans round table discussion 19

20. 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.

21. 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
Why accident investigation?
• 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

22. • 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
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
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
How to perform accident investigation? The approach of the Railway Safety Directive
• The investigation body
o shall investigate serious accidents
o shall at its discretion decide to investigate other accidents and incidents

23. • 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
----------
¿Cómo llevar a cabo la investigación de accidentes? El enfoque de la Directiva de
Seguridad Ferroviaria
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

24. • 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
----------
¿Cómo llevar a cabo la investigación de accidentes? El enfoque de la Directiva de
Seguridad Ferroviaria
• 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

25. 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

26. 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:

27. • 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

28. 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.