Most serious, public transport accidents are investigated to a greater or lesser extent but, with some conspicuous exceptions, particularly with aviation, only a few are done with the aim of improving safety. Many have been investigated with the aim of apportioning blame or liability and although safety recommendations are often made, they frequently fail to identify some of the underlying causes of whatever went wrong. An accident is rarely the result of a single event. More often, it is caused by a combination of unrelated events coming together. In many modes, the human element in this causal chain can be significant. When an accident occurs, it is normally the result of one or more shortcomings in the safety system. People rarely make mistakes deliberately, but will often do things that have serious consequences. Today's accident and incident investigation must focus on improving the safety of the system and aim to answer five questions: (i) What happened? (ii) How did it happen? (iii) Why did it happen? (iv) What can be done to prevent a reoccurrence? (v) What can be done to minimise accident consequences? This report looks at the current situation within the EU and presents the following conclusions and recommendations: 1. Effective accident and incident investigation makes a positive, and long lasting, contribution to the improvement of transport safety. 2. EU legislation needs to ensure that transport accident investigation bodies should be totally independent of the regulatory body, judiciary and operational regime. 3. All accident investigation reports should be published and made public without restriction. 4. The marine and rail sectors require binding, EU legislation for independent accident investigation along the lines already adopted in Council Directive (94/56/EC) for civil aviation. 5. Adequate resources should be made available to suitably experienced, accredited accident investigators to ensure they can carry out their work effectively. 6. The lessons learned from accident investigations and the safety recommendations that follow should be shared freely between Member States, through centralised European databases. 7. Procedures should be established by the EU and Member States to ensure a timely response to safety recommendations, to monitor the progress of the implementation of safety recommendations, including actions taken and, in due course, the effectiveness or otherwise of such actions. 8. In view of the large numbers of road deaths across the EU, the application of independent accident investigation techniques to representative samples of road crashes is particularly important. A co-ordinated independent European road accident investigation strategy should be developed with new systematic in-depth injury and accident causation data systems. 9. EU financial support for in-depth accident investigation studies should be conditional on those conducting and managing them not having a stake in the financial consequences of the study. 10. Event recorders should be fitted progressively to all vehicles transporting passengers and goods with procedures laid down to establish appropriate access to data. 11. If new European safety regulatory authorities are established for any of the modes, separate arrangements should be made for the establishment and maintenance of EU databases and for the monitoring of safety performance. 12. Further co-operation in accident investigation between different Member States should be encouraged. (A)
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