Things that have never happened before happen all the time.

Scott D Sagan The Limits of Safety

Safety Investigation Reports

Lack of safety is much easier to identify than safety.  For our own research and to assist others who wish to selectively research rail accident investigations from around the world, we have collected available safety investigation reports on this site.  The reports are unaltered from the original documents and are freely available for download.  The abstracts on this site include some notes that we have made regarding incidents where communication was a relevant factor.

We appreciate the openness of the various investigating bodies in making their reports available for study and wide distribution.  Should we have included any report inappropriately, please advise us at and we will correct the situation immediately.

Safety Investigations

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Category: Rail Safety Investigation Reports
Number of Subcategories: 13
folder.png Finland - Accident Investigation Board of Finland Files: 74

In Finland the Safety Investigation Authority investigates all major accidents regardless of their nature as well as all aviation, maritime and rail accidents and their incidents.

The purpose of the investigation of accidents is to improve safety and prevent future accidents. The flow of events during the accident, its causes and results as well as the rescue operation are dealt with in the investigation. A report is prepared on the results of the investigation. The report also presents the recommendations, which are based on the conclusions of the investigation. All reports are written in Finnish with English summaries. An English version is prepared from important reports.

In addition the Safety Investigation Authority takes care of the readiness to conduct investigations and of the development of accident investigation methods. The training of investigators, the preparation of guidelines for the process of investigation, publication of the reports and international cooperation are handled by the Board. In Finland the Safety Investigation Authority is located within the Ministry of Justice.

Most of the Finnish rail accident reports are available on this web site and can be searched with the Aitken & Partners search engine.  The Accident Investigation Board of Finland web site has all Finnish Rail Reports and other reports and analysis.

folder.png France - Bureau d'Enquêtes sur les Accidents de Transport Terrestre Files: 26

The Land Transport Accident Investigation Bureau (BEA-TT)’s activities cover a wide variety of areas.  The Bureau deals with railway transport, urban guided transportation systems (underground, tramcars), cable haulage systems, road transport (notably heavy goods vehicles and public transport by coach and bus) as well as navigable waterways. Each of these sectors has its own regulations and its own economic, technical, professional and even cultural logic.

Each investigation will also have to scrutinise the occurrence under a multiplicity of angles, be it infrastructure, operations, rolling stock, staff training, medical aspects, regulations, etc.

This diversity in investigations to be conducted necessitates for the BEA-TT to call upon temporary investigators and experts whenever necessary in order to secure all required competencies.

Finally, the BEA-TT will need to promote among the main players of land transport systems, the circulation of all the knowledge that the Bureau and its partners will have acquired through all the accident investigations or the studies they will have carried out. The BEA-TT will also be entitled to launch studies or research on the subject of accidentology.

BEA-TT reports are published in French, with an summary available in English. The reports in this category are therefore all in French and the English summaries are copied below.  For the original reports and the full set of BEA-TT reports, please see the BEA-TT Web Site.

folder.png Ireland - Railway Accident Investigation Unit Files: 2

The Railway Accident Investigation Unit (RAIU) is the independent accident investigation unit in Ireland. It is responsible for the investigation of accidents or incidents on the national railway, the DART, the LUAS and heritage railways.

The purpose of the RAIU is to improve railway safety by establishing the cause ot causes of an accident or incident with a view to making recommendations for the avoidance of accidents in the future and the improvement of railway safety. It is not the purpose of the RAIU to attribute blame or liability.

The RAIU investigation reports are published on their RAIU Web Site. Most of the reports are also available on the Aitken & Partners web site for your convenience and to facilitate searches through reports from many organisations. (Use the search facility on this page.) To ensure you have the latest information from RAIU you should check their RAIU Web Site.

folder.png Miscellaneous Rail Safety Investigations Files: 6

The NSW Government created Special Commissions of Inquiry for the Waterfall and Glenbrook rail accidents.  Other special commissions have been created from time to time and reports from such investigations are made available in this section.

Changes in government department organisation have sometimes resulted in reports becoming very difficult to find.  Some such reports are available here.

folder.png Netherlands - Dutch Safety Board Files: 19

The Dutch Safety Board performs independent, comprehensive investigations into the causes or probable causes of individual – or categories of – ‘incidents’. An incident is not only defined as the term ‘incidents’ to include not only disasters and accidents but also ‘incidents that could have turned out badly’.

The Dutch Safety Board is an autonomous administrative body set up under a Kingdom Act The Board is authorised to investigate incidents in any conceivable field but in practice is currently active in the following sectors: aviation, shipping, rail transport, road transport, defence, healthcare (human and animal welfare), industry and networks, pipelines, construction and services, water, and crisis management and aid provision.

The reports from the Dutch Safety Board are mainly in Dutch but some are published in English.

For the full set of reports please see the Dutch Safety Board Railway Reports. The available English reports are available here for your convenience.

folder.png New Zealand - Transport Accident Investigation Commision (TAIC) Files: 129

The principal purpose of the Transport Accident Investigation Commission (TAIC) is to determine the circumstances and causes of accidents and incidents with a view to avoiding similar occurrences in future, rather than to ascribe blame to any person. TAIC investigates significant aviation, rail, and marine accidents and incidents. TAIC does not investigate road events except when the circumstances may have significant implications for rail safety, for example. TAIC is a standing Commission of Inquiry and an independent Crown entity.

An inquiry will usually lead to the publication of a report by the Commission which sets out the facts of an event, analyses them, lists the contributing factors, identifies the safety lessons, notes safety actions taken since, and makes recommendations that might help to reduce the chances of a similar event happening again.
Every inquiry has the potential to be systemic and wide-ranging - looking beyond the immediate people, vehicle and environment of the event to consider the likes of human factors, organisational, cultural and other issues within the training, regulatory, traffic control, vehicle design and maintenance, operator, training, industry and other systems or organisations involved.
Please see the NZ TAIC web site for full details.
folder.png Norway - Accident Investigation Board of Norway Files: 9

The Accident Investigation Board Norway (AIBN) is required to be competent, innovative, credible and compassionate.  For more than 20 years, AIBN has been a permanent, independent body of inquiry for transport accidents. AIBN started out investigating aviation accidents in 1989, and has seen its area of authority expand to include railway, road traffic and shipping accidents.

The investigation has as its goal clarification of the sequence of events and causes, as well as discussing other significant conditions that could prevent rail accidents and serious rail incidents in order to improve railway safety. The investigation does not apportion blame and liability.

The AIBN Reports are published on the AIBN web site.  The majority of the railway reports have been added to the Aitken & Partners web site for convenient searching.  Most of the reports are in Norwegian but all the reports published on this site have English summaries.

folder.png UK - Rail Accident Investigation Branch (RAIB) Files: 364

The Rail Accident Investigation Branch (RAIB) is the independent railway accident investigation organisation for the UK. It investigates railway accidents and incidents on the UK's railways to improve safety, not to establish blame.

The RAIB website provides a range of information about acccidents and investigations.  The published reports are made available on this web site for your convenience.  Where we have identified a communication aspect to the report we have added a comment to the summary.  The reports themselves have crown copyright and are exactly as published by the RAIB.

Please check the RAIB web site for further information and the latest reports.

folder.png USA - National Transportation Safety Board (NTSB) Files: 184

The National Transportation Safety Board was established in 1967 to conduct independent investigations of all civil aviation accidents in the United States and major accidents in the other modes of transportation. It is not part of the Department of Transportation, nor organizationally affiliated with any of DOT's modal agencies, including the Federal Aviation Administration. The Safety Board has no regulatory or enforcement powers.

To ensure that Safety Board investigations focus only on improving transportation safety, the Board's analysis of factual information and its determination of probable cause cannot be entered as evidence in a court of law.

The rail investigation reports from the NTSB are available on their website. The majority of the reports are also available from the Aitken & Partners web site. We collate accident investigation reports from many agencies for ease of access and searching. The search engine on this site gives a more targetted search than a general search engine.