About Safety Investigations

Transport Accident and Incident Investigation Division
Gediminas Avenue 30, LT-01104, Vilnius, Lithuania, e-mail [email protected]

Civil aviation legislation

• Annex 13 of International Civil Aviation Organization
• Regulation (EU) No 996/2010
• Aviation Law of the Republic of Lithuania
• Description of Procedures for Investigating Civil Aviation Accidents and Incidents

Maritime legislation

• Casualty Investigation Code of International Maritime Organization
• Directive 2009/18/EC
• Regulation (EU) No 1286/2011
• Maritime Safety Law of the Republic of Lithuania
• Description of the procedure for drawing up and submission of reports and safety recommendations for safety investigations into maritime accidents and incidents
• Description of the procedure for notification on maritime accidents and incidents

Railway transport legislation

• Directive (EU) 2016/798
• Implementing Regulation (EU) 2020/572
• Law on Railway Transport Traffic Safety of the Republic of Lithuania
• Description of Procedures for Investigating Railway Transport Accidents and Incidents
• Description of Procedures for Classification, Notification and Information Provision on Railway Transport Serious Accidents, Accidents and Incidents

Upon receipt of the notification of the occurrence of an accident or serious incident, Member States of third country has right to appoint accredited representative, therefore most of the safety investigations are international, especially civil aviation and maritime accidents and incidents safety investsigations.

It also participates in the activities, such as an annual meetings, training, etc., organised by the European Maritime Safety Agency (EMSA), the European Union Agency for Railways (ERA) and the European Network of Civil Aviation Safety Investigation Authorities (ENCASIA).

Lists of Safety Investigation Authorities in other countries:

• Civil Aviation Safety Investigation Authorities - here.
• Maritime Safety Investigation Authorities - here.
• Railway Transport Safety Investigation Authorities - here.

Transport Accident and Iincident Investigation Division's Annual Reports:

Annual Report 2021 (Lithuanian)
Annual Report 2020 (Lithuanian)
Annual Report 2019
Annual Report 2018
Annual Report 2017
Annual Report 2016

National Investigation Body Annual Report on Accidents Having Taken Place on the Railway Transport System of the Republic of Lithuania

Annual Report 2011
Annual Report 2010
Annual Report 2009
Annual Report 2008
Annual Report 2007

Safety investigation means a process conducted by a safety investigation authority for the purpose of accident and incident prevention which includes the gathering and analysis of information, the drawing of conclusions, including the determination of cause(s) and/or contributing factors and, when appropriate, the making of safety recommendations.

The safety investigations shall be independent of, separate from and without prejudice to any judicial or administrative proceedings to apportion blame or liability.

Stages of safety investigation

1. Notification of an accident or an incident

The first stage of a safety investigation is a receipt of a notification about an accident or an incident. Any person involved who has knowledge of the occurrence of an accident or incident shall notify without delay the competent safety investigation authority of the State of Occurrence that is accessible 24 hours per day and 7 days per week. Having received a notification about an accident or an incident the safety investigation authority shall classify the accident or the incident having regard to the injuries of people, and the damage incurred to the vehicle, and pass a decision regarding the launching of a safety investigation.

The safety investigation authority shall notify without delay the relevant international organisations, the European Commission, authorities of the European Union, Member States of the European Union and third countries concerned in accordance with the international standards and recommended practices of the occurrence of all accidents and serious incidents of which it has been notified. Having received a notification about an accident or an incident, Member States or third parties shall have a right to appoint accredited representatives.

2. Investigation on the occurrence site

An accident or an incident investigation continues at the site of the occurrence until all the required evidence from the site of the occurrence is collected, all the relevant persons are inquired, and the required information and the entries from related authorities. However, not all investigations of accidents and incidents have this stage, as a safety investigation of less serious incidents may be carried out by means of correspondence.

In an event of an accident or an incident the priority in all cases is given to the search and rescue services whose duty is to help the injured persons, however, the safety investigation authority has a right to participate in the search and rescue operations, in order to preserve, by photographic or other means, any evidence which might be removed, effaced, lost or destroyed. Safe custody shall include protection against further damage, access by unauthorised persons, pilfering and deterioration. Pending the arrival of safety investigators, no person shall modify the state of the site of the accident, take any samples therefrom, undertake any movement of or sampling from the vehicle, its contents or its wreckage, move or remove it, except where such action may be required for safety reasons or to bring assistance to injured persons, or under the express permission of the authorities in control of the site and, when possible, in consultation with the safety investigation authority.

Some evidence is short-lived (ice, liquid leakage, data entries, etc.), therefore they have to be recorded without any delay. However, the collection of evidence may in some cases take longer due to the threats at the site (flammable, explosive, toxic and radioactive materials, hazardous freight, sharp, heavy and hazardous object, etc.).

The safety investigation authority seeks to carry out a safety investigation at the site of an accident or incident, in order to restore the infrastructure, and not to interfere with the provision of services by the service providers. The safety investigation authority shall collect and move the vehicle and/or its wreckage from the occurrence site if that is necessary for the performance of the further expertise.

3. Obtaining the factual information

Once the investigation starts, the authority starts collecting all the evidence and any factual information. Collection of evidence includes inquiries of the witnesses of an accident or incident, autopsy examination of the bodies of the fatally injured person, medical examination of the heavily injured persons, obtaining the necessary information from the owner of the vehicle, its operator, designer, manufacturer, technical maintenance organisation, training organisation, traffic control authority, etc.

Subject to the course of the safety investigation, the collection of evidence and factual information may continue even after the investigation at the occurrence site is completed, require more time and include a more thorough examination of the wreckage, additional inquiry of the witnesses, consultation with the experts, etc.

4. Analysis

An analysis starts after the safety investigation has performed all actions at an accident or incident site, and has collected all the evidence and the factual information.

An analysis includes an expert examination of the vehicle, its wreckage and other evidence, testing of components and laboratory examination, decrypting of self-recording devices and their records, analysis of any relevant documents, results of the autopsies of the bodies of the fatally injured persons, and of medical examination of heavily injured persons, additional inquiries of witnesses, etc. The scope of the analysis shall be established only in the course of the safety investigation, when more information is obtained by virtue of the investigation.

In other words, the course of the occurrence is restored in the course of the analysis on the basis of the collected evidence. The safety investigation seeks to find out how and why an accident or incident had occurred.

A draft report is formed in the course of the analysis. In case an information gap cannot be filled in by facts, and instead the gap is filled by logical extrapolation and reasonable assumptions, those shall be explicitly indicated in the report. In the course of the process it may be useful to establish all probabilities, and reduce them, by way of analysis, to the most probable hypotheses. Safety findings are established having regard to the results of the analysis, if necessary, followed by specific recommendations for removing them. Just like in the cases of every safety investigation, the information on the safety investigation course shall be made public.

5. Consultation

Before publication of the final report, the safety investigation authority shall solicit comments from the authorities concerned, who shall be bound by applicable rules of professional secrecy with regard to the contents of the consultation. In soliciting such comments, the safety investigation authority shall follow the international standards and recommended practices.

6. Submission of the investigation report

Each safety investigation shall be concluded with a report in a form appropriate to the type and seriousness of the accident or serious incident. The report shall protect the anonymity of any individual involved in the accident or serious incident, and shall state that the sole objective of the safety investigation is the prevention of future accidents and incidents without apportioning blame or liability. The safety investigation report is based only on the facts established in the course of the safety investigation. The report shall contain, where appropriate, safety recommendations.

The safety investigation authority shall make public the final report in the shortest possible time and if possible within 12 months of the date of the accident or incident. If the final report cannot be made public within 12 months, the safety investigation authority shall release an interim statement at least at each anniversary of the accident or serious incident, detailing the progress of the investigation and any safety issues raised.

7. Safety recommendations

Safety recommendation means a proposal of a safety investigation authority, based on information derived from a safety investigation or other sources such as safety studies, made with the intention of preventing accidents and incidents. A safety investigation authority may also issue safety recommendations on the basis of studies or analysis of a series of investigations or having collected and analysed any other information related to transport safety.

At any stage of the safety investigation, the safety investigation authority shall recommend in a dated transmittal letter, after appropriate consultation with relevant parties, to the authorities concerned, including those in other Member States or third countries, any preventive action that it considers necessary to be taken promptly to enhance transportation safety.

A safety recommendation shall in no case create a presumption of blame or liability for an accident, serious incident or incident.

Safety vs. judicial or administrative investigation

In a case of an accident or incident, other investigations may be initiated in addition to the safety investigation. Most often, where in the course of an accident or incident any fatal injuries have been incurred, judicial proceeding is initiated with a view to establishing liability or indemnifying the damage incurred as a result.

The safety investigation shall be independent of, separate from and without prejudice to any judicial or administrative proceedings to apportion blame or liability. Any judicial or administrative proceedings shall be completely separated from the safety investigation. The investigation report, and in particular its analysis, conclusions and safety recommendations cannot be used as evidence in a judicial or administrative process seeking to apportion blame or liability, because that was not established in the course of the safety investigation, and it is not compatible with the objective of the safety objective. It should also be noted that a safety investigation authority is not authorised to provide an expert opinion or any judicial or administrative process related to the transport safety. In this view, the authority’s carrying out investigations independent from the safety investigation shall themselves take the required decisions, and shall conduct and complete the investigations without considering the course of the safety investigation.

However, there is only one evidence, therefore the safety investigation, and the pre-trial investigation shall refer to the same evidence. In that case investigation coordination becomes of extreme importance. All authority’s that are likely to be involved in the activities related to the safety investigation, cooperate with each other through advance arrangements. Those arrangements shall respect the independence of the safety investigation authority, and the information collected by the safety investigation authority shall not be published or used for any purposes other than the safety investigation. When a judicial investigation is also instituted, the safety investigation authority shall be notified thereof. Where the judicial authority is entitled to seize any evidence, the safety investigation authority shall have immediate and unlimited access to and use of such evidence.

Where, in the course of the safety investigation, it becomes known or it is suspected that an act of unlawful interference as provided for under national law, such as national law on accident investigations, was involved in the accident or serious incident, the safety investigation authority shall immediately inform the competent authorities thereof.

Sensitive safety information

Any information collected by the safety investigation authority in the course of the safety investigation (all statements taken from persons; the identity of persons who have given evidence; information of particularly sensitive and personal nature; information concerning the health of the individuals; notes, drafts, opinions written by the investigators; opinions expressed in the analysis of information; drafts of preliminary or final reports or interim statements; cockpit voice and image recordings and their transcripts) shall not be made available or used for purposes other than safety investigation.

Leaflets

A practical guide on safety investigations for Air Accident Victims and their Relatives

Integrating Human Factors in European Railways - Incident and accident investigation