(1) Summary
The summary includes a brief description of the accident/incident, when and where it occurred, as well as its consequences.
It presents the direct causes, as well as the factors that contributed to the event and the underlying causes established by the investigation. The main recommendations are indicated, as well as information on their recipients.
(2) Immediate facts of the accident/incident
1. The event:
- date, exact time and place of the accident/incident;
- description of the events and the place of the accident, including the efforts of the rescue and emergency services;
- the decision to launch an investigation, the composition of the team of investigators and the conduct of the investigation.
2. Circumstances of the accident/incident:
- the personnel and contractors involved and other parties and witnesses;
- the trains and their composition, including the registration numbers of the articles of the railway vehicles involved;
- description of the infrastructure and the signaling system - types of rails, tracks, interlocking, signals, train protection;
- ways of communication;
- works carried out at or in the vicinity of the place of the accident/incident;
- triggering the railway emergency plan and its chain of events;
- triggering the emergency plan of the public rescue services, the police and the medical services and its chain of events.
3. Loss of human life, injured persons and material damage:
- travelers and third parties, staff, including contractors;
- cargo, luggage and other goods;
- railway vehicles, infrastructure and environment.
4. External circumstances:
- meteorological, hydrographic, visibility conditions and geographical references.
(3) Registration of investigations and inquiries
1. Summary of testimonies (subject to the protection of the identity of the persons):
- railway staff, including contractors;
- other witnesses.
2. Safety management system:
- the framework organization and the way in which orders are given and carried out;
- staff requirements and their application;
- routines for internal controls and audits, as well as their results;
- the interface between the different actors involved in the infrastructure.
3. Rules and regulations:
- relevant community and national rules and regulations;
- other rules, such as operating rules, local instructions, personnel requirements, maintenance prescriptions and applicable standards.
4. Operation of rolling stock and technical installations:
- signaling and control-command system, including records of automatic data recording devices;
- infrastructure;
- communication equipment;
- railway vehicles, including records of automatic data recording devices.
5. Documentation regarding the operating system:
- measures taken by staff for traffic control and signaling;
- the exchange of verbal messages in connection with the event, including documentation from the records;
- measures taken for the protection and preservation of the accident/incident site.
6. Human-machine-organization interface:
- working time applied to the personnel involved;
- medical and personal circumstances with influence on the accident/incident, including the existence of physical or psychological stress;
- the design of equipment with an impact on the human-machine interface.
7. Previous events of a similar nature
(4) Analysis and conclusions
1. Final description of the chain of events:
- establishing conclusions regarding the event, based on the facts established in point (3).
2. Interpretation and analysis:
- the analysis of the facts established in point (3), with the aim of drawing conclusions regarding the causes of the accident/incident and the performance of the rescue services.
3. Conclusions:
- direct and immediate causes of the accident/incident, including factors that contributed to the event related to the actions taken by the persons involved or the condition of the rolling stock or technical installations;
- underlying causes related to competences, procedures and maintenance;
- primary causes related to the conditions of the regulatory framework and the application of the safety management system.
4. Additional observations:
- deficiencies and gaps found during the investigation, but without relevance for the conclusions regarding the causes.
(5) Measures that have been taken
Recording the measures already taken or adopted as a consequence of the event.
(6) Recommendations