Assessment of NSA and NIB Activities in Belgium En

8/3/2019 Assessment of NSA and NIB Activities in Belgium En

1/22

Safety Unit

Reference: SAF/VIS/10/BE/RE.01Version: 1.0

Date: 05/07/2010

Status: FinalAuthor: JD/RR/PM/BA

Assessment of NSA and NIB activities in Belgium


2/22

SAF/VIS/10/BE/RE.01

ERA Version 1.0 - final Page 2/22

Version Control

Document issued by: European Railway Agency

120, rue Marc Lefrancq

F-59300 ValenciennesFrance

Released by: Marcel Verslype, Executive Director

Reviewed by: Anders Lundstrm, Head of Unit, Safety

Authors: Bart Accou, Rob Rumping, Pedro Meneses, Julie Dinimant

Version: 1.0

Date: 05/07/2010

Type of document: Visit report

Status of document: 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

EXIT meeting, and written comments received

afterwards

AL, BA, RR, PM, JD

1.0 ERA Integrating internal comments received See distribution list


3/22

SAF/VIS/10/BE/RE.01


References

N Description Reference

Number

Reference Version

/1/ Directive 2004/49/EC of the European

Parliament and of the Council on safety

on the Communitys 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

2004/49/EC Railway

Safety

Directive

(RSD) or the

Directive

Corrigendum

/2/


4/22

SAF/VIS/10/BE/RE.01


1 TABLE OF CONTENT1 Table of content ............................................................................................................................. 42 Executive summary ....................................................................................................................... 53 Context of this assessment ............................................................................................................ 74 Organisation and resources ........................................................................................................... 8

4.1 Working methods ................................................................................................................... 84.2 Resources ................................................................................................................................ 84.3 Timeframe .............................................................................................................................. 8

5 Scope and objectives ..................................................................................................................... 96 Analysis ....................................................................................................................................... 10

6.1 Introduction .......................................................................................................................... 106.2 Responsibility ....................................................................................................................... 10

6.2.1 NSA activities ................................................................................................................ 106.2.2 NIB activities ................................................................................................................. 11

6.3 Independence ........................................................................................................................ 116.3.1 NSA activities ................................................................................................................ 126.3.2 NIB activities ................................................................................................................. 136.3.3 Organisational independence NSA/NIB ........................................................................ 14

6.4 Openness/ Participation ........................................................................................................ 146.4.1 NSA activities ................................................................................................................ 156.4.2 NIB activities ................................................................................................................. 15

6.5 Process organisation ............................................................................................................. 156.5.1 NSA activities ................................................................................................................ 156.5.2 NIB activities ................................................................................................................. 166.5.3 Cooperation between NSA and NIB .............................................................................. 176.6 Final conclusions .................................................................................................................. 18

7 Table of annexes .......................................................................................................................... 19


5/22

SAF/VIS/10/BE/RE.01


2 Executive summaryAssessment of NSA and NIB activities in Belgium

Date of communication of the final version: 12/07/2010

1. ContextFollowing the train collision of two passenger trains in Buizingen (Belgium) on the 15

thFebruary

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. ScopeThe 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 others role and responsibility, can guarantee a sustainable and safe development of therailway system.

This assessment aims at evaluating the role and authority of the NSA and NIB within the Belgian

railway system (750.000 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 assessmentassessing the powers and resources put in place by the Members State to enable the NSA/NIB

to cover all tasks foreseen by the RSDassessing 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 conclusionThe 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


6/22

SAF/VIS/10/BE/RE.01


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 asunder the ambiguous relationship with the judicial investigations that are run in parallel and

appear to have predominance.

5. Main observationsConcerning the NSA

1. Based on the experience and dedication of its actual staff the tasks of authorising theplacing into service and safety certification/authorisation appear to be adequately

performedto 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 addressthis 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 recommendationsissued 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 thepresented 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 systematicand 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 independentexperts.

4. To be able to perform its tasks continuously in an adequate, consistent and repeatablemanner 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 investigationin a formal way in the report to the NSA.

6. Reaction/comments by the concerned persons and/or organisationsAll pertinent reactions received, verbally during the exit meeting or written afterwards, wereintegrated in the text.


7/22

SAF/VIS/10/BE/RE.01


3 Context of this assessmentFollowing the train collision of two passenger trains in Buizingen (Belgium) on the 15

thFebruary

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) tocontrol 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 regulatoryframework, 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 8th

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.


8/22

SAF/VIS/10/BE/RE.01


4 Organisation and resources4.1 Working methodsThe 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 ResourcesThe assessment team was formed by the following staff of the Safety Unit within the European

Railway Agency:

Anders Lundstrm, 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 TimeframeThe 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 14-15-16/06/2010, 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 tobe communicated (see list in Annex III) on 12/07/2010.


9/22

SAF/VIS/10/BE/RE.01


5 Scope and objectivesThe 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 incidentswhich 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 others 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 (750.000 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.


10/22

SAF/VIS/10/BE/RE.01


6 Analysis6.1 IntroductionThe 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 ResponsibilityIn 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.

6.2.1NSA activities

6.2.1.1Entrusted with relevant tasksIn 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 [safetycertificates 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 6.5.1.3).

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 6.5.1.3).


11/22

SAF/VIS/10/BE/RE.01


6.2.1.2Possible transfer of tasksThe 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

6.3.1.2.1).

6.2.1.3Legal powers for tasksArt.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 6.5.1.3), which require a more cooperative approach.

Remarkably, the same status of officer of the judicial police has been awarded to the IM, viaArticle 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 6.3.1.2.1)

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.

6.2.2NIB activities6.2.2.1Entrusted with relevant tasks

It appears that the NIB is entrusted with all relevant tasks in the Belgian legislation.

6.2.2.2Possible transfer of tasksThe 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 2010.

This has changed at the beginning of this year, since the reviewed legislation no longer providesthis possibility. However, no investigations have yet been completed and reported under the newprovisions.

6.2.2.3Legal powers for tasksIt 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 IndependenceTo be able to fulfill their tasks in an adequate way, the NSA and the NIB need to perform theirprocesses 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


12/22

SAF/VIS/10/BE/RE.01


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.

6.3.1NSA activities6.3.1.1Resources

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 6.3.1.2.1).

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.

6.3.1.2Relationship with stakeholders6.3.1.2.1 Relationship with SNCB GroupAs 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 theAgencys 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 RUs 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

2010.


13/22

SAF/VIS/10/BE/RE.01


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

6.2.1.3). 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 6.2.1.2).

Nevertheless, based on figures provided by the FPS, it appears that more than 2.000 inspections ofdriver and train crew licenses were performed by the IM in 2009 and more than 4.000 are planned

in 2010. 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.

6.3.1.2.2 Relationship with other stakeholdersThe actual contracts that manage the relationship between the Belgian Government and therespective 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.

6.3.2NIB activities6.3.2.1Resources

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 2010.

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 5.3.2.2.1).

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


14/22

SAF/VIS/10/BE/RE.01


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.).

6.3.2.2Relationship with stakeholders6.3.2.2.1 Relationship with SNCB GroupAll 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 6.2.2.2).

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.

6.3.2.2.2 Relationship with other stakeholdersA 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. 20.3 of the RSD.

6.3.3 Organisational independence NSA/NIBAs 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 ofthe NSA and the NIB in accordance with Articles 16.1 and 21.1 of the RSD.

6.4 Openness/ ParticipationIn 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.


15/22

SAF/VIS/10/BE/RE.01


6.4.1NSA activitiesBased 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.

6.4.2NIB activitiesAfter 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 also5.5.2)

6.5 Process organisationTo 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.

6.5.1NSA activities6.5.1.1Authorising 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.

6.5.1.2Safety certificationExactly 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.


16/22

SAF/VIS/10/BE/RE.01


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 ILGGRI1

criteria that are actually in use by the NSA.

A further point of attention when establishing standard processes, is to look for synergies betweenthe different existing units within the NSA which for the moment give at least the impression to

work in silos.

6.5.1.3Supervisory activitiesSupervision 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 largelyunderdeveloped -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 6.2.1.1). 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 6.3.1.2.1), this is a potential threat for the authority of the NSA.

6.5.2NIB activitiesIn 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.

1International Liaison Group of Government Railway Inspectorates - an informal platform for contact between the

independent European railway inspectorates and their representatives


17/22

SAF/VIS/10/BE/RE.01


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 scenarios as a basis forinvestigations- a detailed description of the state of technical components and the actions of staff during the

accident scenario

- issuing recommendations in the investigation reportsOn 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 safetymanagement 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 thedifferent 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.

6.5.3 Cooperation between NSA and NIBThe 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.


18/22

SAF/VIS/10/BE/RE.01


6.6 Final conclusionsBased 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 asunder 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.


19/22

Safety Unit

ERA Version 0.1

7

TABLE OF ANNEXES

Number Description of the Annexes

I List of attendants to the first contact meeting, to the kick-off meeting and to the exit

meeting

II List of people interviewed during the visit

III Table of communication of the final report

IV

V

VIVII

VIII

IX

X


20/22

SAF/VIS/10/BE/RE.01


Annex I: List of attendants

Attendant function 1st contact07/05/2010

Kick-off25/05/2010

Exit23/06/2010

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. Lundstrm 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


21/22

SAF/VIS/10/BE/RE.01


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

Mr. Vanheck

NSA, Head of Unit, Rolling Stock

NSA, Project Officer, Rolling Stock

AL/RR/PM/BA

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

JD/RR/PM/BA

Mr. Vansteenkiste

Mrs. Billiau

Infrabel, General Director, Dept. Network Access

Infrabel, Head of Unit, Dept. Network Access

JD/RR/PM/BA

Mr. Thienpont Crossrail, Safety & Environmental Manager JD/RR/PM/BA

(*) ERA team:

Anders Lundstrm (AL)

Bart Accou (BA)

Rob Rumping (RR)

Julie Dinimant (JD)

Pedro Meneses (PM)


22/22

SAF/VIS/10/BE/RE.01

Annex III: Communication of the final report

Special Assessment of NSA and NIB activities in Belgium12/07/2010 (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 thespecial 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

Assessment of NSA and NIB Activities in Belgium En

Documents

Transcript of Assessment of NSA and NIB Activities in Belgium En