Commission Implementing Regulation (EU) 2020/572Show full title

4. Analysis of the occurrence, where necessary in respect of individual contributing factors

This part of the report shall analyse the established facts and findings (i.e. performance of operators, rolling stock and/or technical installations) which caused the occurrence. The analysis shall lead to the identification of the safety critical factors that caused or otherwise contributed to the occurrence, including facts identified as precursors. An accident or incident may be caused by causal, systemic and contributing factors which are equally important and should be considered during an investigation.

The analysis may be extended to conditions, feedback mechanisms and/or control mechanisms throughout the entire railway system that were identified as actively influencing the development of similar occurrences. This could comprise the functioning of safety management systems of involved parties and regulatory activities covering certification and supervision.

The following items shall be covered for each of the identified events or factors (causal or contributing) that appear safety critical, in line with the flexibility offered by the structure (see above).

(a) Roles and duties

Without prejudice to Article 20(4) of Directive (EU) 2016/798 this part of the report shall lead to the identification and analysis of roles and duties of individual persons and entities, including if necessary relevant staff and their defined tasks and functions, identified as having been involved in the occurrence in a safety critical manner, or any activity leading to it.

1.	Railway undertaking(s) and/or infrastructure manager(s):	If anonymity is granted to persons or entities please clarify.
2.	The entity/entities in charge of maintenance, the maintenance workshops, and/or any other maintenance suppliers:	If anonymity is granted to persons or entities please clarify.
3.	Manufacturers of rolling stock or other supplier of rail products:	If anonymity is granted to persons or entities please clarify.
4.	National safety authorities and/or the European Union Agency for Railways:	If anonymity is granted to persons or entities please clarify.
5.	Notified bodies, designated bodies and/or risk assessment bodies:	If anonymity is granted to persons or entities please clarify
6.	Certification bodies of entities in charge of maintenance mentioned under 2:	If anonymity is granted to persons or entities please clarify.
7.	Any other person or entity relevant to the occurrence, documented or not in one of the relevant safety management systems or referred to in a register or relevant legal framework:	If anonymity is granted to persons or entities please clarify e.g. keepers of vehicles, terminal providers, loaders or fillers

(b) Rolling stock and technical installations

Causal factors to or the consequences of an occurrence that were identified as relating to the condition of rolling stock or technical installations, including possible contributing factors related to activities and decisions, such as:

1.	Stemming from the design of the rolling stock, railway infrastructure or technical installations:
2.	Stemming from the installation and taking into service of the of rolling stock, railway infrastructure or technical installation:
3.	Laying with the manufacturers or other supplier of rail products:
4.	Stemming from the maintenance and/or the modification of the rolling stock or technical installations:
5.	Laying with the entity in charge of maintenance, the maintenance workshops and other maintenance suppliers:
6.	And any other factors or consequences considered relevant for the purpose of the investigation:

(c) Human factors

Where causal or contributing factors or the consequences of an occurrence were related to human actions, attention shall be paid to the particular circumstances and the manner in which routine activities are performed by staff during normal operations and the human and organisational factors that may influence actions and/or decisions, including:

1.	Human and individual characteristics: (a) training and development, including skills and experience, (b) medical and personal circumstances with influence on the occurrence, including existence of physical or psychological stress, (c) fatigue, (d) motivation and attitude.
2.	Job factors (a) task design, (b) design of equipment with impact on the man-machine interface, (c) the means of communication, (d) practices and processes, (e) operating rules, local instructions, staff requirements, maintenance prescriptions and applicable standards, (f) working time of the staff involved, (g) risk handling practices (h) context, machinery, equipment and instructions shaping work practices.
3.	Organisational factors and assignments: (a) workforce planning and workload, (b) communications, information and team working, (c) recruitment and selection, resources, (d) performance management and supervision, (e) compensation (remuneration), (f) leadership, power issues, (g) organisational culture, (h) legal issues (incl. relevant EU and national rules and regulations), (i) the regulatory framework conditions and the application of the safety management system.
4.	Environmental factors: (a) working conditions (noise, lighting, vibrations, …), (b) weather and geographical conditions, (c) works carried out at or in the vicinity of the site.
5.	And any other factor relevant for the purpose of the investigation in the above points (1),(2),(3),(4):

(d) Feedback and control mechanisms, including risk and safety management as well as monitoring processes

a Implementing Regulation (EU) No 402/2013 of 30 April 2013 on the common safety method for risk evaluation and assessment and repealing Regulation (EC) No 352/2009 (OJ L 121, 3.5.2013, p. 8).
1.	The relevant regulatory framework conditions:
2.	The processes, the methods, the content and the results of risk assessment and monitoring activities, performed by any of the involved actors: railway undertakings, infrastructure managers, entities in charge of maintenance, maintenance workshops, other maintenance providers, manufacturers and any other actors, and the independent assessment reports referred in Article 6 of Implementing Regulation (EU) No 402/2013a:
3.	The safety management system of the involved railway undertaking(s) and infrastructure manager(s) including the basic elements stated in Article 9(3) of Directive (EU) 2016/798 and any EU legal implementing acts:
4.	The management system of the entity/entities in charge of maintenance and maintenance workshops including the functions stated in the Article 14(3) and Annex III of Directive (EU) 2016/798 and any subsequent implementing acts:
5.	The results of supervision performed by the national safety authorities in accordance with Article 17 of Directive (EU) 2016/798:
6.	The authorisations, certificates and assessment reports granted by the Agency, the National Safety Authorities or other conformity assessment bodies: Safety authorisation/safety certificates of the involved infrastructure manager(s) and railway undertaking(s), Authorisations for the placing in service of fixed installations and vehicles authorisations for placing on the market, Entity in charge of maintenance and maintenance workshops (incl. certification).
7.	Other systemic factors:

(e) Previous occurrences of a similar character, if available.