How do investigators prepare to investigate a railway accident?

By Janos Rozsa - September 14, 2020

Around 09:40am on Tuesday 12 August 2020 a passenger train (high speed train set comprising a lead power car, four passenger carriages and rear power car), carrying three crew and six passengers, derailed near Carmont (Stonehaven), in Aberdeenshire, Scotland. According to news reports, two of the train crew and a passenger sadly died. This makes this accident the largest loss of life on the UK rail network in 16 years. It is likely that the initial first response and the subsequent investigation were hampered by terrain and weather. The nature of this accident means that it is likely that it will attract high political and media interest. Additionally, other organisations have launched their own independent investigations.

As an investigator, how can you remain calm and professional under these circumstances? As a former Cranfield student, and a former rail accident investigator from Hungary, I can suggest some ideas and good examples. As this is an ongoing investigation, I will not focus specifically on current tragic events but on general examples.

An effective and thorough investigation comprises a sequence of linear and concurrent phases, including pre-deployment, deployment, on-site activities, recovery, detailed investigation and report writing, among others. Let us consider here your pre-deployment preparations.

Have a good plan (fail to plan – plan to fail)

After you receive notification of an accident, keep calm! You have to consider your task and your role. As an accident investigator your primary role is to find the causes of the accident without attributing blame or liability. You need to determine WHAT happened? HOW did it happen? WHY did it happen and what do we need to do to prevent it happening again? Never forget this. If you have a good process, just follow it. So, what will be the first phase?

Following notification, you need to commence pre-deployment planning and preparation. Your pre-deployment preparations are critical to an effective site investigation phase and hence the investigation as a whole. Pre-deployment preparations are based on your individual and organisational experience. At Cranfield, to help aspirant investigators plan their deployments we use the mnemonic IT CRASHED as follows:

Interested parties
Team (who, equipment, health)
Communication (including the media)
Recovery
Accommodation
Site (environment, size, location)
Hazards (and risk management)
Evidence (perishable, critical, plan?)
Deployment (including emergency and repatriation planning)

Interested parties

Who are the interested parties? Let’s make two groups:

1. The railway-related parties

When a railway accident occurs in a European country generally three independent organisations will launch their own investigations: the police, the railway regulator (or safety authority – National Safety Authority (NSA)), and the independent investigating body (National Investigation Body (NIB)). Three different organisations with three different aims and regulations. While the police and NSA look for the causes, including blame and responsibility, the NIB try to find all the causes (direct and indirect) that led to the accident but do not seek to apportion blame or liability. There is also a difference in the outcomes of the investigations. As a result of an investigation, the police and the NSA can prosecute individuals or organisations, but the NIB will formulate and issue safety recommendations with the singular goal of preventing re-occurrence. In the UK for rail, these three organisations are the British Transport Police (BTP), the Office of Rail and Road (ORR) as the NSA, and the Railway Accident Investigation Branch (RAIB) as the NIB. How can these three organisations cooperate? It always depends on the regulations, the current situation and sometimes the individuals involved. Always be cooperative, if it’s possible.

At the accident site you will meet with the representatives of the rail Infrastructure manager, and the railway undertaking(s) as well. They manage their own internal investigations as well and are all interested in a quick recovery to reopen the rail line.

The non-railway-related parties

The media are very interested in gleaning any information about the accident. Never, ever, ignore them! A good media plan (who, what, when) can help you engage with the media, project you and your organisation as professional and competent, and possibly reach out for possible eye or ear witnesses to the event.

Local and national politicians can appear on site at any time. No problem, they are subject to the same rules as anyone else. Always be polite, but strict.

Finally, we have to talk about the victims and their families as well. In my experience this is the most difficult part of any investigation. Training and compassion can help you solve and process this sad and strenuous task. Always be sensitive and honest.

Team (who, equipment, health)

Have a good team. You need to establish an effective team of investigators and/or experts. Most investigating organisations have a duty system, so the team is established automatically. If your organisation does not have one, then you will need to assemble your team. Consider your needs for the investigation – in this case, initial reports from scene indicate a derailment, so first you need a derailment specialist. If you do not have one, you will need to identify a vehicle, and a track specialist as well. As you acquire additional information you can adjust your team to the circumstances. Remember, flexibility is the key.

Communication (including the media)

Communication is a key factor and one of the most important factors on-site. Rail accidents by their nature tend to be linear and can cover considerable distances. Beyond line of sight (BLOS) communication is highly likely. If you can use secure communication devices (e.g. UHF radios or mobile phones) there is no problem communicating with your team. But if the site is remote and there is no mobile coverage, or you can’t use your other devices, the situation can be very much more complex and challenging. Taking into account the circumstances you expect to encounter make a communication plan before you deploy. It has to be included how and when (how often) should the team communicate (inside communication), and who, when and how will the team communicate with other interested parties (outside communication).

Recovery

There is a common misconception that recovery is only relevant after the on-site investigation activities are complete, but this is not true. Emergency services need immediate access to the injured victims, and sometimes the investigators need to move the vehicles and wreckage to collect critical evidence. That is why you have to constantly work with the other interested parties on-site to plan and agree methods of access and recovery to minimise possible destruction of evidence. Of course, you can do this only on-site – as far as possible.

Train pic 1Why has it derailed? We need to move it to find out, but how?

Accommodation

The on-site investigation phase can be complex and protracted. As the accident investigator is a human, you will need to plan for an appropriate area to rest, to eat, and conduct on-site briefings and planning. If the initial notification indicates a protracted on-site investigation phase, your organisation needs to find appropriate accommodation where the team can rest, decompress, reorganise, replan and sleep! Out of necessity this should be close to the accident site.

Site (environment, size, location)

The site– the location, the accessibility and the circumstances. These three factors determine the challenges of the on-site investigation phase. Before you leave your base, you have to collect all the available information about the terrain, the weather, and the recovery possibilities. Many locations on rail networks are not accessible by car, but only on foot. Based on this information you can determine your travel mode, and what kind of personal protection equipment (PPE) and technical equipment you need on-site. You can also plan how and where to access the accident site (in cooperation with other interested parties) and assign the main areas of responsibility to your team. Remember – communicate, communicate, communicate!

Hazards (and risk management)

Never forget that on-site the risk to your physical and mental well-being can be high. There are a lot of risks that you need to be prepared for: fire, damaged or unstable structures, pressurised systems (air pressure for brakes), electric shock (overhead line, third rail, batteries) and biological hazards, among many others. Before you leave your base try to source information about the expected hazards to allow you to generate a generic risk assessment (GRA), based on your knowledge and experience of rail systems. Once on-site you will need to update your initial GRA with the on-site reality and modify your GRA as required. This is a dynamic and ongoing process, hence the term dynamic risk assessment (DRA). With thorough preparation, suitable PPE and a pragmatic and dynamic approach, you can do your job safely. Never take excessive risks, your safety comes first.

Train pic 2Sulphuric acid in the tank – is it leaking?

Evidence (perishable, critical, plan?)

As you have learnt, all investigations must be evidence-based, so you have to safely collect all the evidence. Wreckage, witness marks, data recorders, voice recorders, witness statements and video recordings can all be vital evidence. Based on the initial accident notification, and before you leave your base, you should, as a team, consider what evidence you need to identify, record and harvest. Develop a list or a blank evidence log and start to think about what physical, documentary, digital and people evidence you need collect and how you will safely and securely store them. Remember, perishable and critical evidence must always have priority! Of course, this document won’t be a fixed list, because it can (and must) change, dependent on the evolving investigation.

Train pic 3A fractured rail - is it perishable?

Deployment (including emergency and repatriation planning)

Have a good travel plan! After you have your team you have to decide how you will get to the site. Your mode of travel always depends on the locality and options available to you. Always use your go-kit, if you have one. It should contain, as a minimum:

  • Your personal protection equipment (PPE), because your safety always comes first.
  • Your technical equipment, to help your work (cameras, measuring equipment).
  • Enough food and drink, because an investigation can take a long time.
  • Your identification documents (warrant card).
Train pic 4

Do we have everything?

It sounds simple, but don’t forget you are an investigator, so your mobile will always ring. Your boss, your colleagues, your family, or even journalists will call you. Always be polite but strict, you can always say no to inappropriate or unreasonable requests. If you have to drive your vehicle to the site always keep in your mind: safety is first – you won’t be helping the situation by becoming an accident yourself.

Train pic 5

When you arrive at the site the investigation can start, but that’s a topic for another article.

In summary, I can advise keep calm, always consider your task and role, be honest, polite but strict when appropriate. Your education and experience will always be with you – use it!

There are other aspects to consider in responding to a notification of an accident that we teach during our Fundamentals of Accident Investigation and Applied Rail Accident Investigation courses. Please get in touch via shortcourse@cranfield.ac.uk

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