Safety Unit. Assessment of NSA and NIB activities in Belgium

Transcription

1 Safety Unit Assessment of NSA and NIB activities in Belgium Reference: SAF/VIS/10/BE/RE.01 Version: 1.0 Date: 05/07/2010 Status: Final Author: JD/RR/PM/BA

2 Version Control Document issued by: Released by: Reviewed by: Authors: European Railway Agency 120, rue Marc Lefrancq F Valenciennes France Marcel Verslype, Executive Director Anders Lundström, Head of Unit, Safety Bart Accou, Rob Rumping, Pedro Meneses, Julie Dinimant Version: 1.0 Date: 05/07/2010 Type of document: Status of document: Visit report Final Amendment records Version Issuer Modified sections Distribution 0.1 ERA New document AL, BA, RR, PM, JD 0.2 ERA All - integrating internal comments received BE: FPS, NSA, NIB 0.3 ERA All - integrating comments made during the AL, BA, RR, PM, JD EXIT meeting, and written comments received afterwards 1.0 ERA Integrating internal comments received See distribution list ERA Version final Page 2/22

3 References N Description Reference Number /1/ Directive 2004/49/EC of the European Parliament and of the Council on safety on the Community s railways and amending Council Directive 95/18/EC on the licensing of railway undertakings and Directive 2001/14/EC on the allocation of railway infrastructure capacity and the levying of charges for the use of railway infrastructure and safety certification /2/ 2004/49/EC Reference Railway Safety Directive (RSD) or the Directive Version Corrigendum ERA Version final Page 3/22

4 1 TABLE OF CONTENT 1 Table of content Executive summary Context of this assessment Organisation and resources Working methods Resources Timeframe Scope and objectives Analysis Introduction Responsibility NSA activities NIB activities Independence NSA activities NIB activities Organisational independence NSA/NIB Openness/ Participation NSA activities NIB activities Process organisation NSA activities NIB activities Cooperation between NSA and NIB Final conclusions Table of annexes ERA Version final Page 4/22

5 2 Executive summary SAF/VIS/10/BE/RE.01 Assessment of NSA and NIB activities in Belgium Date of communication of the final version: 12/07/ Context Following the train collision of two passenger trains in Buizingen (Belgium) on the 15 th February 2010, causing 19 fatalities, the Belgian Parliament decided to establish a Special Commission to investigate the safety of the Belgian railway system. The Agency was invited by this Special Parliamentary Commission to give a presentation at its afternoon session on 31st March. This presentation highlighted the roles and responsibilities of the different players in the railway system, as foreseen by the Railway Safety Directive 2004/49/EC (RSD) see also 2. Scope. After this presentation, the Special Parliamentary Commission accepted the proposal of the Agency to assess the effectiveness of the implementation of the RSD in Belgium and more precisely the functioning of the National Safety Authority (NSA) and the National Investigating Body (NIB). 2. Scope The European Railway Agency strongly believes that only a correct application of the regulatory framework as foreseen by the RSD, whereby all concerned organisations (railway undertakings (RUs), Infrastructure Manager (IM), NSA, NIB, Government) recognise and accept their and each other s role and responsibility, can guarantee a sustainable and safe development of the railway system. This assessment aims at evaluating the role and authority of the NSA and NIB within the Belgian railway system ( passengers transported daily and several thousands of operational staff involved), and their capacity to fulfil the requirements and tasks set out in the RSD and to identify possible topics for improvement. 3. Objectives of the assessment assessing the powers and resources put in place by the Members State to enable the NSA/NIB to cover all tasks foreseen by the RSD assessing the capability of the processes and decision making principles put in place by the NSA/NIB identifying possible issues faced by the NSA/NIB when applying the requirements of the EU legislation verifying the practical awareness that stakeholders have of the NSA/NIB activity 4. Overall conclusion The authority of the NSA appears to be acknowledged and respected for the tasks related to the authorisation of placing into service and the issuing of safety certificates and authorisations; activities that are adequately performed by the NSA. This is however not the case for all supervisory activities the NSA should undertake, which are largely underdeveloped. These activities need to be developed and supported by sufficient resources (staff and financial), as ERA Version final Page 5/22

6 foreseen in recent legislation. In addition, the possible role of the IM in controlling the safety of the railway system needs to be clarified, since this is a potential threat for the authority of the NSA. Although clearly stated in the legislation, recognition of the role and authority of the NIB is suffering under the ongoing but still premature state of development of the NIB itself as well as under the ambiguous relationship with the judicial investigations that are run in parallel and appear to have predominance. 5. Main observations Concerning the NSA 1. Based on the experience and dedication of its actual staff the tasks of authorising the placing into service and safety certification/authorisation appear to be adequately performed to ensure that these tasks will be performed continuously in an adequate and repeatable manner the NSA needs to formally establish and consistently manage the processes that support these tasks. 2. The NSA is not adequately performing the necessary supervisory activities to address this issue the NSA needs to start monitoring in a continuous way the safety level of the railway system and the effectiveness of the safety regulatory framework, taking into account all available sources of information, and use this knowledge to target its promoting, active monitoring and enforcing activities, in a structured way and based on an overview of the main risks within the railway system. 3. The NSA needs to fulfill its responsibility to ensure that the safety recommendations issued by the NIB are duly taken into consideration, and, where appropriate, acted upon. Concerning the NIB: 1. The actual staffing level of the NIB is insufficient to perform its tasks adequately the presented staff extension plan needs to be completed as quickly as possible to address this. 2. The actual relationship between the NIB and the judicial services is unclear a systematic and structured cooperation in the field of railway accident investigations needs to be agreed upon and formalised. 3. Until the end of 2009 all NIB accident investigations were performed by SNCB-Holding, under supervision of the NIB, which at least created a perception of dependence to enable the NIB not to be too dependent on expertise from the SNCB Group the competence of its staff needs to be assured as well as the availability of independent experts. 4. To be able to perform its tasks continuously in an adequate, consistent and repeatable manner the NIB needs to formally establish and consistently manage its process, taking into account recognised good practice and the requirements of the RSD. 5. The NIB needs to address the recommendations that result from its accident investigation in a formal way in the report to the NSA. 6. Reaction/comments by the concerned persons and/or organisations All pertinent reactions received, verbally during the exit meeting or written afterwards, were integrated in the text. ERA Version final Page 6/22

7 3 Context of this assessment SAF/VIS/10/BE/RE.01 Following the train collision of two passenger trains in Buizingen (Belgium) on the 15 th February 2010, causing 19 fatalities, the Belgian Parliament decided to establish a Special Commission to investigate the safety of the Belgian railway system. The Agency - like the European Commission (EC) - was invited by this Special Parliamentary Commission to give a presentation at its afternoon session on 31st March. Inspired by the finding that the Belgian National Safety Authority (NSA) had reported an increasing number of signals passed at danger in its annual reports, concerns about a possible lack of recognition by stakeholders of the investigation undertaken by the National Investigating Body (NIB) and the fact that the entire public debate was (wrongly) focussing on the absence of an automatic train protection system, the Agency decided to build its presentation round the following basic elements of the Railway Safety Directive 2004/49/EC (RSD): a) the responsibility of railway undertakings (RUs) and infrastructure managers (IMs) to control the risks of all their activities, under all circumstances, through the implementation of an adequate safety management system (SMS) b) the important role of the NSA and the NIB in a member state (MS) to make the regulatory framework, as foreseen by the RSD, work As logic conclusion to this presentation and in line with already existing work streams within the Agency, it was proposed to assess the effectiveness of the implementation of the RSD in Belgium and more precisely the functioning of the NSA and the NIB. This proposal was accepted by the Special Parliamentary Commission, who formalised this request by mail, sent to the Agency on 8 th April. It should be stressed that this assessment is not checking the correct transposition of the RSD in the Belgian national legislation; which is of the sole authority of the EC. All eventual findings that might indicate a problem in this area will therefore not be explored in detail nor commented in this report, but addressed to the EC. ERA Version final Page 7/22

8 4 Organisation and resources 4.1 Working methods The main working methods for this mission consisted of the analysis of relevant documents and the conduct of interviews with contact persons in the NSA and NIB, as well as with some stakeholders. Although the available time for this assessment was limited, the Agency is confident that this approach enables to identify a set of relevant issues and observations concerning the role and authority of the Belgian NSA and NIB within the Belgian railway system. This result would not have been possible without the constructive support of the involved authorities during the preparation and conduct of this mission, the openness of the participants during the interviews and their clear will to learn and improve. It should be stressed, however, that it is not because a topic is not mentioned in the report this could automatically mean there is no more possibility for improvement in relation to it. 4.2 Resources The assessment team was formed by the following staff of the Safety Unit within the European Railway Agency: Anders Lundström, Head of Unit Bart Accou, Head of sector, Safety Certification Rob Rumping, Project Officer, Safety Reporting Pedro Meneses, Project Officer, Office of the Head of Unit Julie Dinimant, Project Officer, Safety Regulation 4.3 Timeframe The mission under report was conducted in three consecutive phases, following the work plan as described below. The planning phase of this mission started with a first contact meeting, held in Lille on 07/05/2010 (see list of attendants in Annex I), to present the purpose of the mission, to exchange information and to agree on first practical arrangements. This formed the basis for the review by the Agency of reference documents already made available and for the exchange of a questionnaire, to be filled in respectively by the NSA and the NIB, reflecting their activities and organisation. This planning phase was then concluded with a kick-off meeting, held in Brussels on 25/05/2010 (see list of attendants in Annex I), to present the further details of the mission and a first set of findings and to agree on the practical arrangements for the visit. The fieldwork phase contained a visit to Brussels on /06/2010, where a set of interviews was conducted with NSA and NIB representatives as well as with stakeholders (see list of interviewees in Annex II), together with the review of relevant on site documentation. The reporting phase of this mission first resulted in a draft report that was distributed on 22/06/2010. Consequently an exit meeting took place in Brussels on 23/06/2010 (See list of attendants in Annex I) to discuss draft findings and comments, and a joint set of written comments from Belgian parties was sent to the Agency on 29/06/2010. This then resulted in the final report to be communicated (see list in Annex III) on 12/07/2010. ERA Version final Page 8/22

9 5 Scope and objectives The Railway Safety Directive 2004/49/EC (RSD) sets out a clear and common regulatory framework for keeping guard over the safety of the railway system. It introduces the set up of a National Safety Authority (NSA), whose role it is to regulate and supervise railway safety in a member state (MS). This task is fulfilled through the authorisation of the placing in service of technical (sub-) systems, the issue, renewal, amendments and revocation of safety certificates for railway undertakings (RUs) and safety authorisations for infrastructure managers (IM) -giving evidence that they have established an adequate safety management system (SMS)- the checking whether the conditions and requirements laid down in these SMSs are met and the monitoring, promoting and, where appropriate, enforcing and developing of the safety regulatory framework, including the system of national safety rules as defined by the MS. It also imposes the establishment of a permanent National Investigation Body (NIB) with the role to carry out a fully independent investigation after serious accidents -or those accidents and incidents which under slightly different conditions might have led to serious accidents- on the railway system, the objective of which is possible improvement of railway safety and the prevention of accidents. It should be stressed however that in the prescribed regulatory framework the responsibility for the safe operation of the railway system and the control of risks associated with it belongs clearly and entirely to the IM and the RUs, obliging them to implement necessary control measures and to apply national safety rules and standards through the mean of an adequate SMS -which forms, as already mentioned above, the basis for granting safety certificates and safety authorisations. The European Railway Agency strongly believes that only a correct application of the regulatory framework as foreseen by the RSD, whereby all concerned organisations (RUs, IM, NSA, NIB, Government) recognise and accept their and each other s role and responsibility, can guarantee a sustainable and safe development of the railway system -the chain is only as strong as its weakest link. This special assessment by the Agency aims at evaluating the role and authority of the NSA and NIB within the Belgian railway system ( passengers transported daily and several thousands of operational staff involved), and their capacity to fulfil the requirements and tasks set out in the RSD and to identify possible topics for improvement. The objectives of this mission are therefore to: assess the powers and resources put in place by the MS to enable the NSA and NIB to cover all tasks foreseen by the RSD; assess the capability of the processes and decision making principles put in place by the NSA and NIB; identify possible issues faced by the NSA and NIB when applying the requirements of the EU legislation; verify the practical awareness that stakeholders have of the NSA/NIB activity. ERA Version final Page 9/22

10 6 Analysis 6.1 Introduction The processes and decision making principles put in place by the NSA and NIB, backed up by the necessary powers and resources as made available by the MS, need to ensure that both NSA and NIB are able to fulfill all tasks foreseen by the RSD in an adequate, consistent and repeatable manner. In this context, the following relevant elements will be discussed generally or for each of the reviewed processes: Responsibility Independence Openness / participation Process organisation 6.2 Responsibility In order to assume the responsibilities assigned to an NSA and NIB under the RSD, a MS needs to nominate or establish the necessary bodies and entrust them with the relevant tasks. In addition, the primary railway legislation needs to provide for authority and the necessary legal powers for the performance of the required tasks. Where this is not undoubtedly the case, the risk is real that the role and authority of NSA and/or NIB will be questioned both operationally and institutionally and that as a consequence they will not be able to fulfill their tasks in an adequate way NSA activities Entrusted with relevant tasks In general, through Art.12 of the Law on Railway Safety (19/12/2006), the NSA is entrusted with the relevant tasks of Art.16 of the RSD. Clarification is however needed on the tasks foreseen in Art.16.2 f): monitoring, promoting, and, where appropriate, enforcing and developing the safety regulatory framework. Although the Belgian legislation unambiguously foresees the Government responsibilities for the development of the safety regulatory framework in Art. 6 of the same Law, the responsibilities for the other supervisory activities are not so clearly stated. These activities should exceed the controls and inspections needed for checking that conditions and requirements laid down in them [safety certificates and safety authorizations] are met and that IMs and RUs are operating under the requirements of Community or national law, as foreseen by Art 16.2 e) of the RSD and covered by Art.12 5 and 7 of the Law on Railway Safety (see also ). Nevertheless, the management of the NSA, the Directorate Rail of the Federal Public Service and the Government representative consider these supervisory activities to be tasks of the NSA, which partly seems to be confirmed by the informative role awarded to the NSA in the Royal Decree of 13/11/2009 on fixing the regulatory framework for national safety rules. The relevance of the observation in the context of this assessment will be made clear when discussing the performed processes by the NSA (see ). ERA Version final Page 10/22

11 Possible transfer of tasks The possibility to transfer tasks of the NSA to other parties is not foreseen in the Belgian law on Railway Safety. Article 27 of the Law on the use of railway infrastructure (04/12/2006) foresees however the possibility for the IM to perform controls and inspections when there are findings that the used rolling stock or the safety personnel endangers the safety of the railway traffic (see ) Legal powers for tasks Art.58 of the Belgian law on Railway Safety foresees the possibility to give NSA staff the status of officer of the judicial police to control and inspect the correct application of the law. By lack of appropriate training, these powers were until now not applied by the staff. Furthermore, the powers and obligations related to this status -i.e. every offence needs to be reported in a formal way- maybe counterproductive when developing the necessary supervisory activities that include inspections and audits (see ), which require a more cooperative approach. Remarkably, the same status of officer of the judicial police has been awarded to the IM, via Article 6 of the Law of 06/05/2009 reviewing the mentioned Art.58 of the Law on Railway Safety, giving him the power to conduct controls and inspections to control the correct application of the Law on railway safety (see ) Another observation concerns the powers to enforce the safety regulatory framework, where the provisions of Art.13 of the Belgian law on Railway Safety refer to the possibility for the NSA to take all necessary measures to fulfill its tasks. Although this appears to be an open door for developing an entire spectrum of enforcement activities, this has never been applied. Nevertheless, the NSA considers the perceived impossibility to enforce its decisions, with only the possibility to revoke authorisations and certificates ( the nuclear option - in application of Art.24 and Art. 30 of the law), as a major issue. Administrative penalties are reported as not yet existing NIB activities Entrusted with relevant tasks It appears that the NIB is entrusted with all relevant tasks in the Belgian legislation Possible transfer of tasks The possibility to transfer the investigations of serious and other accidents to SNCB-Holding, as foreseen in Art.20 of the Belgian law for Railway Safety, was systematically applied before This has changed at the beginning of this year, since the reviewed legislation no longer provides this possibility. However, no investigations have yet been completed and reported under the new provisions Legal powers for tasks It appears that the Belgian legislation foresees the necessary legal powers for the NIB to be able to perform its tasks in an adequate way. 6.3 Independence To be able to fulfill their tasks in an adequate way, the NSA and the NIB need to perform their processes and take the necessary related decision in a completely independent way. Indeed, for both the NSA (Art.16.1) as the NIB (Art.21.1) this is a clear requirement of the RSD. It should be stated ERA Version final Page 11/22

12 however, that exploiting a possible cooperation or synergy with each other or other authorities is not a priori in contradiction with the required need for independence NSA activities Resources The funding principles are approved by law and the funding for the year 2010 (with limited extension) is fixed by Royal decree. Funding for further extension (from 2011) is under discussion in the Government. This transparent way of funding appears to guarantee that the NSA will be able to fulfill its tasks. The interviewed NSA staff members indicate however that the actual staff level is insufficient to fulfill all necessary tasks, which not only include the tasks foreseen by Art.16 of the RSD but also the responsibility to act as the Belgian representative for all aspects of safety and interoperability at the European Commission. This might be resolved once the presented staff extension plan, that will increase the actual staff of 27, is fully completed. It was also indicated that part of the actual NSA activities is driven by the level of competence/area of expertise of the staff. Rather than letting the actual competences of its staff determine its activities, the NSA should foresee the necessary training to ensure that its staff disposes of the required competences and skills to fulfill all the imposed tasks. Additional elements that clearly emphasise the need for an adequate competence management program (including sufficient attractiveness of the functions at the NSA through competitive remuneration and additional social benefits to convince also experienced staff from the railway sector) are the foreseen staff extension and the commitment no longer to transfer staff of the SNCB Group (see ). It is also recommended that the NSA pro-actively tries to find synergies with other authorities (e.g. the aviation regulatory body) and/or Federal Public Services (e.g. FPS Employment, Labour and Social Dialogue) to share knowledge on how to monitor, promote and enforce a safety regulatory framework and eventually even share resources Relationship with stakeholders Relationship with SNCB Group As the result of an infringement procedure by the European Commission, the Belgian Government has committed itself to undertake the necessary steps to assure the independence between the NSA and the SNCB Group, by no longer applying Art. 11 of the Law on Railway Safety, that foresees the transfer of staff from SNCB-Holding to the NSA and back -which clearly forms a potential source of conflicts. Art.14 of the same Law foresees that the NSA can rely on expertise from RUs, the IM or others. This article is however only applied in very exceptional cases (e.g. when assisting the NSA in the Agency s Task Force on Freight Wagon Maintenance) which could be seen as acceptable. The provision of Art.18 of the Law on Railway Safety, foreseeing a role for SNCB-Holding advising on RU s SMS in the safety certification process, which creates at least the perception of dependence, has been changed positively since the review of the legislation in the beginning of ERA Version final Page 12/22

13 The reviewed Art.58 of the Law on Railway Safety provides the necessary power for the IM to conduct controls and inspections to control the correct application of the Law on railway safety (see ). According to Article 27 of the Law on the use of railway infrastructure however, controls and inspections performed by the IM are limited to those cases where there are findings that the used rolling stock or the safety personnel endangers the safety of the railway traffic (see ). Nevertheless, based on figures provided by the FPS, it appears that more than inspections of driver and train crew licenses were performed by the IM in 2009 and more than are planned in This unbalance between the controls performed by the IM and similar activities conducted by the NSA is seriously questioned by the Agency. In addition, the by NSA staff explicitly mentioned interaction problems with the IM (difficult access to onsite information when performing inspections, non-availability of the results of controls performed by the IM, ) only stresses the importance of formalising a possible cooperation in this field to assure the authority of the NSA Relationship with other stakeholders The actual contracts that manage the relationship between the Belgian Government and the respective companies of the SNCB Group are negotiated by the Department of Land Transport within the Federal Public Service of Transport. These contracts focus on productivity as the main objective for these companies. In order to ensure a necessary and sustainable balance between this acute productivity objective and the longer term safety objective, the NSA and the mentioned Department have interest in establishing a structured exchange of views on this topic. As far as not already existing, a similar exchange of views should be established for future developments of the safety regulatory framework by the Department of Land Transport, to actively take into account the experience gained by the NSA through its activities NIB activities Resources The transparent way of funding the NIB, with recent legislation that foresees a limited extension of staff (2-3 persons) appears to be sufficient to fulfill its tasks for The necessary decision however, no longer to rely on SNCB-Holding for the investigation of accidents results in a transitional phase for the NIB, where the actual available number of staff (2 posts, with only 1 occupied) is problematic, not to say insufficient. To be able to fulfill all its tasks, it is indispensable that the foreseen staff extension plan, as presented during the mission, is completed as soon as possible. When recruiting new staff, attention should be paid to cover the most relevant competences that are necessary to conduct a railway accident investigation (i.e. railway technology, accident investigation techniques, human factors, SMS-knowledge, etc.). For those fields not covered by own expertise, it is important to foresee the availability of experts (see also ). An important asset for guaranteeing the independence of the NIB is the training of all NIB staff (eventually including experts), adapted to the development of technical and scientific progress, as an integrated part of an adequate competence management system. It is also recommended that the NIB pro-actively tries to find, or where they already exist better exploit, synergies with other authorities (e.g. the aviation accident investigation body) and/or ERA Version final Page 13/22

14 Federal Public Services (e.g. FPS Employment, Labour and Social Dialogue) to share knowledge on accident investigation methodologies and eventually even share resources (means for onsite intervention, available experts in specific fields like human factors, safety management systems, etc.) Relationship with stakeholders Relationship with SNCB Group All accident investigations that are available in the public database of the Agency for Belgium so far were performed by investigators of SNCB-Holding. Although these reports were delivered under the supervision of the NIB investigator in charge, this way of working creates at least the perception that the investigations are not performed independently from the SNCB Group. This has been changed in the reviewed Art. 20 of the new version of the Law on Railway Safety (see ). A same concern could rise however, when future accident investigations would rely too heavily on expertise from within the SNCB Group. The recent NIB initiative to draw up a list with independent experts for different topics that might be relevant for accident investigations should therefore be continued and maintained Relationship with other stakeholders A major concern is the actual unclear relationship between the NIB and the judicial services that run a parallel investigation and seem to have predominance. Interviewed stakeholders clearly indicated that they fear that NIB findings will be used by the judicial services in their inquiry. It can also be seen as symptomatic that the independent investigation of the NIB after the Buizingen accident was hardly ever publically mentioned by press or concerned parties. The exercise of NIB competences, as foreseen by law, is essential to the safety of railways. The NIB therefore needs to take the necessary initiative to approach the judicial services to agree and formalise, e.g. by signing a memorandum of understanding, on how to organise in a systematic and structured way their cooperation in the field of railway accident investigations (organisation of onsite investigations, availability/exchange of information, ) still guaranteeing the independence of both investigations as foreseen by Art of the RSD Organisational independence NSA/NIB As the result of an infringement procedure by the European Commission, the Belgian Government has committed itself to undertake the necessary steps to assure the organisational independence of the NSA and the NIB in accordance with Articles 16.1 and 21.1 of the RSD. 6.4 Openness/ Participation In general it is the role of the NSA and NIB in a MS to provide its Government (and by doing so, also the public) with the assurance that railway safety is generally maintained and, where reasonably practicable, continuously improved (RSD Art. 4.1). It is logic that in this learning process the NSA and the NIB fulfill their tasks in an open and transparent way, leaving room for the participation of stakeholders. This needs to be taken into account actively in the processes that are put in place by both the NSA and the NIB. ERA Version final Page 14/22

15 6.4.1 NSA activities Based on the received information, confirmed by stakeholders, it appears that the NSA performs the processes for authorising the placing into service (i.e. by means of a «Commission de mise en service») and for safety certification and authorisation in an open and transparent way, leaving room for participation and improvement during the process NIB activities After review of a sample of the accident investigation reports available in the public database of the Agency it appears that the accident investigation process as performed in the past has not adequately given the opportunity for a systematic exchange of views and opinions as foreseen by the RSD (Art. 22.3). No comments or opposite opinions were ever mentioned in the reviewed reports, nor are eventual measures already taken by the involved organisations during the period of the investigation. The risk exists that the same mistake will be repeated in future accident investigations (see also 5.5.2) 6.5 Process organisation To be able to fulfill all tasks foreseen by the RSD in an adequate, consistent and repeatable manner, both the NSA and the NIB need to put in place a set of core processes. The extent, to which each organisation explicitly and consistently performs, manages and establishes its processes (demonstrable and structured) with predictable performance, demonstrating the ability to change, adapt and improve the performance of the processes will determine their capability to continuously meet the requirements of the RSD NSA activities Authorising the placing into service Based on the work products that were reviewed during the mission and the feedback received from stakeholders, it appears that the process of authorising the placing into service is performed in an adequate way, both for rolling stock and other technical (sub-) systems. This performance however, relies entirely on the knowledge and dedication of some very experienced members of the NSA staff. Based on their initiative relevant work products are documented and systematically reviewed during the process. There is however no description of a standard process nor guidance or procedures for staff available, which makes it impossible to ensure a predictable performance. Taking into account the foreseen departure of some of the most senior staff members in the coming years as well as a possible extension with inexperienced staff, this situation can be considered as a serious risk for a consistent performance of these processes in the near future Safety certification Exactly the same comments that were made for the process of authorising the placing into service can be made for the safety certification process, although it should be mentioned that here a first attempt to describe a standard process has been undertaken. ERA Version final Page 15/22

16 When further developing this standard process, the NSA will need to take into account the common safety methods on conformity assessment, recently voted at the Railway Interoperability and Safety Committee and which prescribe guidance for the assessment process and assessment criteria to be used, in replacement of the ILGGRI 1 criteria that are actually in use by the NSA. A further point of attention when establishing standard processes, is to look for synergies between the different existing units within the NSA which for the moment give at least the impression to work in silos Supervisory activities Supervision is an important part of the activities of an NSA. This not only covers checking that RUs and the IM are operating under the legal requirements (including the respect of the relevant essential requirements) and that they meet the conditions and requirements laid down in their SMS. It includes a continuous monitoring of the safety level of the railway system and the effectiveness of the safety regulatory framework, taking into account all available sources of information, like issues noted during the process of granting certificates, recommendations and information resulting from accident investigations performed by the NIB, accident investigation reports and annual reports from RUs and the IM, information from controls, inspections and audits, notification of incidents, etc. This knowledge should then be used to target, in a structured way and based on an overview of the main risks within the railway system, a complete set of NSA processes going from promoting safety and safety culture, over actively performing own monitoring activities (e.g. controls or punctual checks, inspections, specific audits, system based audits) to even enforcing the safety regulatory framework with an adapted gamut of possible measures. Although the NSA performs a considerable number of controls, first attempts are made to take into account the ad hoc information from incident notifications and even a first audit is contracted out, the Agency can only record that the abovementioned set of supervisory activities is still largely underdeveloped -not to say inexistent- and that the NSA is not taking up the full responsibility for the supervisory tasks it should perform. Symptomatic for this, is the way the increasing number of signals passed at danger during the last years has been the subject of correspondence between the NSA, the Minister of Transport and the main RU, with mentioning of an action plan but no evidence of an evaluation of the adequateness of the proposed measures by the NSA nor an active follow up of the implementation. This could of course be an indirect result of the lack of clarity regarding parts of Art.16.2 f) of the RSD in the Belgian legislation (see ). Significant here, is the way the IM reacted repudiate when being asked for a possible enlargement of supervisory activities for the NSA. Combined with the controlling and inspecting role, authorised to the IM under Art.58 of the Law on Railway Safety (see ), this is a potential threat for the authority of the NSA NIB activities In the actual transitional phase of the NIB, with a new investigator in charge and no new investigation reports delivered yet, we can only assume that the investigation process is performed and the desired process outcomes will be achieved. 1 International Liaison Group of Government Railway Inspectorates - an informal platform for contact between the independent European railway inspectorates and their representatives ERA Version final Page 16/22

17 A first attempt has been made to define and document the investigation process. When completing this necessary exercise, attention should be paid to preserve the following strengths identified in previous investigations reports: - a clear motivation of the accident investigation - the use of reconstruction to verify or collect facts - the use of scenario s as a basis for investigations - a detailed description of the state of technical components and the actions of staff during the accident scenario - issuing recommendations in the investigation reports On the other hand, it seems obvious that the following weaknesses that were identified in previous accident investigations reports should be addressed, when further developing the standard investigation process: - inadequate investigation into underlying factors related to safety management and the safety management system, in particular the way risk assessments have been carried out - not or only limited mentioning the legal framework and the role and responsibility of the different concerned organisations - inadequately integrating previous occurrences of a similar nature into the investigation - not mentioning measures already taken by the responsible organisations during the investigation (see also 5.4.2) - in most cases not addressing the recommendations in the final report (see also 5.5.3) Finally the NIB should fully exploit the possibilities offered by the Belgian legislation and develop appropriate criteria to select the incidents and accidents it wants also to investigate on a risk based approach (e.g. an increasing number of signals passed at danger or other near misses). The establishment of a standard process with defined decision criteria can then form a sound basis for a consistent performance and offer the possibility for continuous improvement, not only of the NIB performance but also of the Belgian railway safety system in general Cooperation between NSA and NIB The functional independence between the NIB and the NSA, that is referred to in Art.21.1 of the RSD, cannot be an excuse for the inadequate cooperation between both organisations that was observed. This is mainly reflected in the way safety recommendations that result from accident investigations are handled, whereby the important role to play by the NSA is not sufficiently recognised by both the NSA and the NIB. Although the NSA is systematically informed of the results of the accident investigations performed by the NIB, the recommendations that result from it are not formally addressed in the final report to the NSA as required by Art.25.2 of the RSD. The NSA on the other hand is not aware of the responsibility and the ownership it has to ensure that the safety recommendations issued by the NIB are duly taken into consideration, and, where appropriate, acted upon. It was also confirmed that there is no structured follow-up of the implementation of these recommendations and that there is no exchange of information on measures that are taken or planned as a consequence of the recommendation, as foreseen by Art.25.3 of the RSD. ERA Version final Page 17/22

18 6.6 Final conclusions SAF/VIS/10/BE/RE.01 Based on the observations made during this mission, the Agency reaches the following conclusions on the role and authority of the NSA and NIB in the Belgian railway system. The authority of the NSA appears to be acknowledged and respected for the tasks related to the authorisation of placing into service and the issuing of safety certificates and authorisations; activities that are adequately performed by the NSA. This is however not the case for all supervisory activities the NSA should undertake, which are largely underdeveloped and should form a main focus point of future improvement. These activities need to be developed and supported by sufficient resources (staff and financial), as foreseen in recent legislation. In addition, the possible role of the IM in controlling the safety of the railway system needs to be clarified, since this is a potential threat for the authority of the NSA. Although clearly stated in the legislation, recognition of the role and authority of the NIB is suffering under the ongoing but still premature state of development of the NIB itself as well as under the ambiguous relationship with the judicial investigations that are run in parallel and appears to have predominance. Delivering a high quality investigation report on the Buizingen accident will be crucial for improving the recognition of the NIB by all stakeholders in short term. ERA Version final Page 18/22

19 Safety Unit 7 TABLE OF ANNEXES Number I II III IV V VI VII VIII IX X Description of the Annexes List of attendants to the first contact meeting, to the kick-off meeting and to the exit meeting List of people interviewed during the visit Table of communication of the final report ERA Version 0.1

20 Annex I: List of attendants Attendant function 1st contact 07/05/2010 Kick-off 25/05/2010 Exit 23/06/2010 Mrs. Coune FPS Transport, President of Board of Directors X X X Mr. Forton FPS Transport, DGTT, Director X Mr. Latruwe NSA, Director X Mr. De Mulder NSA, Head of Unit, Safety X X Mr. Lambermont NSA, Head of Unit, Rolling Stock X X Mr. Lermusiaeux NSA, Head of Unit, Infrastructure X X Mrs. Mathues NIB, investigator in charge X X Mr. Decuyper Ministry of Transport, Head of Cabinet X X Mr. Balon Ministry of Transport, Rail expert X Mr. Verslype ERA, Executive Director X Mr. Lundström ERA, Head of Unit, Safety Unit X X Mr. Accou ERA, Head of Sector, Safety Certification X X X Mr. Rumping ERA, Project Officer, Reporting Sector X X X Mr. Meneses ERA, Project Officer, Office of Head of Unit X X Ms.Dinimant ERA, Project Officer, Regulation Sector X ERA Version final Page 20/22

21 Annex II: List of conducted interviews interviewee function 14/06/2010 (*) 15/06/2010 (*) 16/06/2010 (*) Mrs. Coune FPS Transport, President of Board of Directors JD/RR/PM/BA Mr. Forton Mr. Peeters Mrs. Wittevrongel FPS Transport, DGTT, Director General FPS Transport, DGTT, Director, Rail FPS Transport, DGTT, legal adviser, Rail JD/RR/PM/BA Mr. Latruwe NSA, Director AL/RR/PM/BA Mr. De Mulder NSA, Head of Unit, Safety JD/RR/PM/BA Mr. Lambermont NSA, Head of Unit, Rolling Stock AL/RR/PM/BA Mr. Vanheck NSA, Project Officer, Rolling Stock Mr. Lermusiaeux Mr. Francq NSA, Head of Unit, Infrastructure NSA, Project Officer, Infrastructure AL/RR/PM/BA Mr. Froidbise NSA, Auditor/Inspector, Safety JD/RR/PM/BA Mrs. Mathues NIB, investigator in charge AL/RR/PM/BA Mr. Schouteten Previous investigator in charge JD/RR/PM/BA Mr. Fouquet Senior investigation expert, SNCB-Holding AL/RR/PM/BA Mr. Decuyper Ministry of Transport, Head of Cabinet JD/RR/PM/BA Mr. Verdickt Mr. Vlassenbroeck SNCB, General Manager SNCB, Safety Manager Mr. Vansteenkiste Infrabel, General Director, Dept. Network Access Mrs. Billiau Infrabel, Head of Unit, Dept. Network Access Mr. Thienpont Crossrail, Safety & Environmental Manager JD/RR/PM/BA JD/RR/PM/BA JD/RR/PM/BA (*) ERA team: Anders Lundström Bart Accou Rob Rumping Julie Dinimant Pedro Meneses (AL) (BA) (RR) (JD) (PM) ERA Version final Page 21/22

22 Annex III: Communication of the final report Special Assessment of NSA and NIB activities in Belgium 12/07/2010 (date of communication of the final report) The final report was communicated to: - Mr. J. Van Den Bossche, Secretary of the permanent commission Infrastructure and the special commission Railway Safety of the Parliament A copy of the final report has been sent for information to: - Mr. E. Grillo-Pasquarelli, Director of Directorate Land Transport, DG MOVE/D - Mrs. C. Coune, President of the Federal Public Service Mobility and Transport - Mr. A. Latruwe, Director of the Department for Railway Safety and Interoperability - Mrs. L. Mathues, Investigator in Charge, Investigating Body ERA Version final Page 22/22