Regulations on Public Investigations of Railway Accidents and Serious Railway Incidents etc. (Railway Investigation Regulations)

(This translation is for information purposes only)

Laid down by the Ministry of Transport and Communications on 31 March 2006 in pursuance of Act No. 34 of 3 June 2005 on notification, reporting and investigation of railway accidents and railway incidents etc. (Railway Investigation Act) sections 2, 3, 4, 5, 6, 7, 10, 11, 16, 19, 20 and 21. Cf. EEA Agreement annex III point 42e (Directive 2004/49/EC).

Chapter I  Introductory provisions

Section 1 Scope

These regulations apply to railway accidents and serious railway incidents on railways encompassed by the Railways Act.

Funicular railways are not regarded as railways under the Railways  Investigation Act.

Section 2 Competent authorities

The following authorities are assigned authority/tasks under these regulations:

a) The Norwegian Accident Investigation Board for transport is the investigating authority.

b) The Norwegian Railway Inspectorate is the supervisory authority.

c) The Ministry of Transport and Communications is the ministry.

Section 3 Definitions

In these regulations:

a) ‘investigation’ means a process conducted after a railway accident or serious railway incident for the purpose of accident and incident prevention which includes the gathering and analysis of information, the drawing of conclusions, including the determination of causes and, when appropriate, the making of safety recommendations

b) ‘causes’ means actions, omissions, events or conditions, or a combination thereof, which led to the railway accident or incident.

Section 4 The term railway accident and serious railway incident

Under section 5 of the Railway Investigation Act the term railway accident includes the definitions in Directive 2004/49/EC Article 3 paragraph (k) and (l).

Under section 5 of the Railway Investigation Act the term serious railway incident also includes technical faults in the structural subsystems or in interoperability components in the trans-European railway systems for high-speed or conventional trains.

Section 5 The investigating authority’s task and purpose

The investigating authority’s task is to investigate railway accidents and serious railway incidents for the purpose of improving railway safety and preventing railway accidents.

Section 6 Obligation to investigate and extent of the investigation

The investigating authority shall investigate railway accidents and serious railway incidents. 

The extent of investigations and the procedure to be followed in carrying out such investigations shall be determined by the investigating authority, taking into account the principles and the objectives of the Railway Investigation Act and these regulations, and the lessons that the investigation is expected to provide for the improvement of safety.  

In deciding whether or not to carry out a full investigation the investigating authority shall inter alia take into account:  

a) the seriousness of the railway accident or railway incident,

b) whether the railway accident or railway incident forms part of a series of accidents or incidents relevant to the railway system as a whole,

c) the impact of the railway accident or railway incident on railway safety on an EEA level,

d) requests from infrastructure managers, railway undertakings, other railway operations, as well as from supervisory and safety authorities or EEA states.

Chapter II.    Notification and start-up of investigation of railway accidents and serious railway incidents  

Section 7 Notification of railway accident and serious railway incident to the investigating authority

The investigating authority receives notification of railway accidents and serious railway incidents in accordance with the notification and reporting regulations. The investigating authority notifies the supervisory authority.  

Section 8 Start-up of investigations

When notification of a railway accident or serious railway incident has been received by the investigating authority, the latter shall make the necessary arrangements to start the investigation immediately and no later than one week after receipt of notification concerning the accident or incident.  

Chapter III. Information and notification to affected parties and authorities etc.  

Section 9 Rights of affected parties

The investigating authority determines how information on an investigation under the Railway Investigation Act section 16 shall be given. Affected parties mentioned in the Railway Investigation Act section 16 shall be apprised of their rights and that they can request to be given a draft report for comment in accordance with the Railway Investigation Act section 20.  

Section 10 Notification to the supervisory authority

The investigating authority notifies the supervisory authority when its starts investigations of railway accidents or serious railway incidents.  

Section 11 Information to the European Railway Agency (ERA)

Within one week after the decision to open an investigation the investigating authority shall inform the European Railway Agency (ERA) thereof. The notification shall indicate the date, time and place of the railway accident or railway incident as well as its type and its consequences as regards fatalities, injuries and material damage.  

Chapter IV.  Reports         

Section 12 Investigation report

When the investigating authority has investigated a railway accident or serious railway incident, it shall prepare a report explaining the course of events and containing the investigating authority’s statement on the causes. The report shall state the objectives of the investigation, cf. section 5, and contain, where appropriate, safety recommendations in accordance with the Railway Investigation Act section 19 first paragraph.  

The report’s form and content shall be appropriate to the type and seriousness of the railway accident or railway incident and the relevance of the investigation findings. The report shall as closely as possible follow the reporting structure laid down in Annex 1 to these regulations.  

The report shall not contain references to the name or address of individuals.  

Section 13 Safety recommendations

A safety recommendation prepared by the investigating authority shall in no case create a presumption of blame or liability for a railway accident or serious railway incident.  

Safety recommendations shall be addressed to the supervisory authority and, where needed by the reason of the character of the recommendation, to other bodies or authorities in Norway or to other EEA states.  

Section 14 Treatment of a draft investigation report barred from the public domain

Before the investigating authority finalises the report, a draft version of the report shall be made available to the affected parties mentioned in the Railway Investigation Act section 16 first paragraph giving them a reasonable deadline for comments, unless special conditions indicate that this should not be done. Moreover, a draft report shall be made available to the supervisory authority, giving it a reasonable deadline for comments. The right under the first sentence applies only to those parts of the report that the party concerned, because of his connection with the case or investigation, is particularly qualified to comment on.  

The investigating authority’s draft report is not public, cf. the Railway Investigation Act section 21.  

Section 15 Publication of the report

The investigating authority shall make public the final report in the shortest possible time and normally not later than 12 months after the date of the railway accident or the serious railway incident. The report, including any safety recommendations, shall be communicated to the relevant parties, including parties and bodies concerned in other EEA states.  

If the report is not ready within 12 months, the investigating authority shall issue a preliminary report stating the progress of the investigation and the safety issues that the case has brought into focus. The investigating authority decides itself the form in which it wishes to issue a preliminary report, and how it should be made public.  

Section 16 Follow up of reports and safety recommendations

The investigating authority shall send the reports to the ministry which shall take the necessary measures to ensure that the safety recommendations are duly taken into consideration.  

The supervisory authority shall evaluate the reports with a view to identifying and implementing measures able to improve railway safety. The supervisory authority may order whoever is engaged in railway operation under the Railways Act to act on the safety recommendations.  

The supervisory authority and other authorities or bodies or, where appropriate, other EEA states to which the safety recommendations have been addressed shall report back at least twice yearly to the investigating authority on measures that are taken or planned as a consequence of the recommendations. The ministry may task the supervisory authority with coordinating such feedback. The feedback shall be sent via the ministry which shall forward it to the investigating authority.  

Section 17 Annual reports

Each year the investigating authorities shall publish by 30 September a report accounting for the investigations carried out in the preceding year, the safety recommendations that were issued and actions taken in accordance with safety recommendations issued previously.  

Section 18 Forwarding of reports to ERA

The investigating authority shall send to ERA a copy of the final report mentioned in section 15 and of the annual report mentioned in section 17.  

Chapter V. Administrative provisions  

Section 19 Implementation of investigations in the EEA area – assistance etc.

If it is not possible to establish in which EEA state a railway accident or serious railway incident occurred or if it occurred on or close to the border between Norway and Sweden the investigating authorities concerned shall agree which one of them will carry out the investigation or shall agree to carry it out in cooperation. The other investigating authority shall in the first case be invited to participate in the investigation and fully share its results.  

Whenever a railway undertaking established and licensed in another EEA state is involved in a railway accident or serious railway incident in Norway, the investigating authority from that EEA state shall be invited to participate in the investigation.  

The investigating authority may also carry out investigations in cooperation with corresponding authorities in other EEA states in circumstances other than those mentioned in the first and second paragraph.  

Where the investigating authority is responsible for the investigation it shall arrange for the appropriate means, comprising the operational and technical expertise needed to carry out the investigation.  

Section 20 Use of experts and other specialist knowledge

The investigating authority may request information and assistance from other public authorities in connection with investigations, and may utilise such expert assistance as is required by the character of the accident or incident to be investigated.  

The investigating authority may also ask investigating authorities from other EEA states or the ERA to supply expertise or to carry out technical investigations, analyses and evaluations.  

Section 21 Exchange of specialist knowledge

The investigating authority shall conduct an active exchange of views and experience with corresponding investigating authorities in other EEA states for the purpose of developing common investigation methods and common principles for follow-up of safety recommendations and adaptation to the development of technical and scientific progress.  

Section 22 Case handling rules

The rules of the Public Administration Act, including the rules of chapter II on disqualification, apply to the activity of the investigating authority in so far as exceptions are not made in the Railway Investigation Act.  

Chapter VI Final provisions  

Section 23 Other tasks

The ministry may after consultation with the investigating authority assign the investigating authority special tasks with a railway safety objective.  

Section 24 Entry into force

These regulations come into force on 30 April 2006. Regulations on public investigation of railway accidents and serious railway incidents (No. 122 of 29 January 2002) will concurrently be revoked.    

Annex 1. Main content of investigation reports on railway accidents and serious railway incidents  

1. Summary

The summary shall contain a brief description of the accident or incident, when and where it took place and its consequences. It shall state the direct causes as well as contributing factors and underlying causes established by the investigation. The main recommendations shall be quoted and information shall be given on the addressees.  

2. Immediate facts of the accident or incident

1. The accident or incident:

- date, exact time and location of the accident or incident,

- description of the circumstances and the accident site including the efforts of the rescue and emergency services,

- the decision to initiate an investigation, the composition of the team of investigators and the conduct of the investigation.  

2. The background to the accident or incident:

- staff and contractors involved and other parties and witnesses,

- the trains and their composition including the registration numbers of the items of rolling stock involved,

- a description of the infrastructure and signalling system – track types, switches, interlocking, signals, train protection,

- means of communication, - works carried out at or in the vicinity of the site,

- trigger of the railway emergency plan and its chain of events,

- trigger of the emergency plan of the public rescue services, the police and the medical services and its chain of events.  

3. Fatalities, injuries and material damage:

- passengers and third parties, staff, including contractors,

- cargo, luggage and other property,

- rolling stock, infrastructure and the environment.  

4. External circumstances:

- weather conditions and geographical references.  

3. Record of investigations and inquiries

1. Summary of testimonies (subject to the protection of identity of the persons):

- railway staff, including contractors,

- other witnesses.  

2. The safety management system:

- the framework organisation and how orders are given and carried out,

- requirements on staff and how they are enforced,

- routines for internal checks and audits and their results,

- interface between different actors involved with the infrastructure.  

3. Rules and regulations:

- relevant EEA and national rules and regulations,

- other rules such as operating rules, local instructions, staff requirements, maintenance prescriptions and applicable standards.  

4. Functioning of rolling stock and technical installations:

- signalling and control command system, including registration from automatic data recorders, - infrastructure,

- communications equipment,

- rolling stock, including registration from automatic data recorders.  

5. Documentation on the operating system:

- measures taken by staff for traffic control and signalling,

- exchange of verbal messages in connection with the accident or incident, including documentation from recordings,

- measures taken to protect and safeguard the site of the accident or incident.  

6. Man-machine-organisation interface:

- working time applied to the staff involved,

- medical and personal circumstances with influence on the accident or incident, including existence of physical or psychological stress,

- design of equipment with impact on man-machine interface.  

7. Previous accidents or incidents of a similar character.  

4. Analysis and conclusions

1. Final account of the event chain:

- establishing the conclusions on the accident or incident, based on the facts established in heading 3.  

2. Discussion:

- analysis of the facts established in heading 3 with the aim of drawing conclusions as to the causes of the accident or incident and the performance of the rescue services.  

3. Conclusions:

- direct and immediate causes of the accident or incident including contributory factors relating to actions taken by persons involved or the condition of rolling stock or technical installations,

- underlying causes relating to skills, procedures and maintenance,

- root causes relating to the regulatory framework conditions and application of the safety management system.  

4. Additional observations:

- deficiencies and shortcomings established during the investigation, but without relevance to the conclusions on causes.  

5. Measures that have been taken:

- Record of measures already taken or adopted as a consequence of the accident or incident.  

6. Recommendations