Safety Unit

Assessment of NSA and NIB activities in Belgium

Reference:
Version:
Date:
Status:
Author:

SAF/VIS/10/BE/RE.01
1.0
05/07/2010
Final
JD/RR/PM/BA

SAF/VIS/10/BE/RE.01

Version Control

Document issued by:

European Railway Agency

120, rue Marc Lefrancq
F-59300 Valenciennes
France

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
0.3

ERA
ERA

1.0

ERA

All - integrating internal comments received

BE: FPS, NSA, NIB
All - integrating comments made during the AL, BA, RR, PM, JD
EXIT meeting, and written comments received
afterwards
Integrating internal comments received
See distribution list

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References
N

Description

Reference
Number

/1/

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

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

Reference

Version

Railway
Corrigendum
Safety
Directive
(RSD) or the
Directive

/2/

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1 TABLE OF CONTENT
1
2
3
4

Table of content ............................................................................................................................. 4

Executive summary ....................................................................................................................... 5
Context of this assessment ............................................................................................................ 7
Organisation and resources ........................................................................................................... 8
4.1 Working methods ................................................................................................................... 8
4.2 Resources ................................................................................................................................ 8
4.3 Timeframe .............................................................................................................................. 8
5 Scope and objectives ..................................................................................................................... 9
6 Analysis ....................................................................................................................................... 10
6.1 Introduction .......................................................................................................................... 10
6.2 Responsibility ....................................................................................................................... 10
6.2.1 NSA activities ................................................................................................................ 10
6.2.2 NIB activities ................................................................................................................. 11
6.3 Independence ........................................................................................................................ 11
6.3.1 NSA activities ................................................................................................................ 12
6.3.2 NIB activities ................................................................................................................. 13
6.3.3 Organisational independence NSA/NIB ........................................................................ 14
6.4 Openness/ Participation ........................................................................................................ 14
6.4.1 NSA activities ................................................................................................................ 15
6.4.2 NIB activities ................................................................................................................. 15
6.5 Process organisation ............................................................................................................. 15
6.5.1 NSA activities ................................................................................................................ 15
6.5.2 NIB activities ................................................................................................................. 16
6.5.3 Cooperation between NSA and NIB .............................................................................. 17
6.6 Final conclusions .................................................................................................................. 18
7 Table of annexes.......................................................................................................................... 19

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2 Executive summary
Assessment of NSA and NIB activities in Belgium
Date of communication of the final version: 12/07/2010

1. Context
Following the train collision of two passenger trains in Buizingen (Belgium) on the 15 th February
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. Scope
The 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 the
railway 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 assessment
assessing the powers and resources put in place by the Members State to enable the NSA/NIB
to cover all tasks foreseen by the RSD
assessing 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 conclusion
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. These
activities need to be developed and supported by sufficient resources (staff and financial), as

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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 as
under the ambiguous relationship with the judicial investigations that are run in parallel and
appear to have predominance.
5. Main observations
Concerning the NSA
1. Based on the experience and dedication of its actual staff the tasks of authorising the
placing into service and safety certification/authorisation appear to be adequately
performed to 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 address
this 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 recommendations
issued 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 the
presented 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 systematic
and 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 independent
experts.
4. To be able to perform its tasks continuously in an adequate, consistent and repeatable
manner 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 investigation
in a formal way in the report to the NSA.
6. Reaction/comments by the concerned persons and/or organisations
All pertinent reactions received, verbally during the exit meeting or written afterwards, were
integrated in the text.

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3 Context of this assessment

Following the train collision of two passenger trains in Buizingen (Belgium) on the 15th February
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) to
control 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 regulatory
framework, 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 8 th
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.

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4 Organisation and resources

4.1 Working methods
The 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 Resources
The 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 Timeframe
The 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 to
be communicated (see list in Annex III) on 12/07/2010.

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5 Scope and objectives

The 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 incidents
which 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.

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6 Analysis
6.1 Introduction
The 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 Responsibility
In 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.

6.2.1 NSA activities

6.2.1.1 Entrusted with relevant tasks
In 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 [safety
certificates 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).

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6.2.1.2 Possible transfer of tasks

The 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).

6.2.1.3 Legal powers for tasks

Art.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, via
Article 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.

6.2.2 NIB activities

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

6.2.2.2 Possible transfer of tasks

The 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 provides
this possibility. However, no investigations have yet been completed and reported under the new
provisions.

6.2.2.3 Legal powers for tasks

It 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 Independence
To be able to fulfill their tasks in an adequate way, the NSA and the NIB need to perform their
processes 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
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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.

6.3.1 NSA activities

6.3.1.1 Resources
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.

6.3.1.2 Relationship with stakeholders

6.3.1.2.1 Relationship with SNCB Group
As 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 the
Agencys 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.

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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 of
driver 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 stakeholders
The actual contracts that manage the relationship between the Belgian Government and the
respective 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.

6.3.2 NIB activities

6.3.2.1 Resources
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

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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.).

6.3.2.2 Relationship with stakeholders

6.3.2.2.1 Relationship with SNCB Group
All 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 stakeholders
A 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/NIB

As 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 of
the NSA and the NIB in accordance with Articles 16.1 and 21.1 of the RSD.

6.4 Openness/ Participation

In 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.

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6.4.1 NSA activities

Based 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.

6.4.2 NIB activities

After 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 also
5.5.2)

6.5 Process organisation

To 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.

6.5.1 NSA activities

6.5.1.1 Authorising 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.

6.5.1.2 Safety certification

Exactly 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.

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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 between
the different existing units within the NSA which for the moment give at least the impression to
work in silos.

6.5.1.3 Supervisory activities

Supervision 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 largely
underdeveloped -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.

6.5.2 NIB activities

In 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.

International Liaison Group of Government Railway Inspectorates - an informal platform for contact between the
independent European railway inspectorates and their representatives

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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 for investigations
- a detailed description of the state of technical components and the actions of staff during the
accident scenario
- issuing recommendations in the investigation reports
On 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 safety
management 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 the
different 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 NIB

The 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.

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6.6

Final conclusions

Based 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 as
under 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.

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Safety Unit

7 TABLE OF ANNEXES

Number
I
II
III
IV
V
VI
VII
VIII
IX
X

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List of attendants to the first contact meeting, to the kick-off meeting and to the exit
meeting
List of people interviewed during the visit
Table of communication of the final report

SAF/VIS/10/BE/RE.01

Annex I: List of attendants

Attendant

function

Mrs. Coune
Mr. Forton
Mr. Latruwe
Mr. De Mulder
Mr. Lambermont
Mr. Lermusiaeux
Mrs. Mathues

FPS Transport, President of Board of Directors

FPS Transport, DGTT, Director
NSA, Director
NSA, Head of Unit, Safety
NSA, Head of Unit, Rolling Stock
NSA, Head of Unit, Infrastructure
NIB, investigator in charge

Mr. Decuyper
Mr. Balon

Ministry of Transport, Head of Cabinet

Ministry of Transport, Rail expert

Mr. Verslype
Mr. Lundstrm
Mr. Accou
Mr. Rumping
Mr. Meneses
Ms.Dinimant

ERA, Executive Director

ERA, Head of Unit, Safety Unit
ERA, Head of Sector, Safety Certification
ERA, Project Officer, Reporting Sector
ERA, Project Officer, Office of Head of Unit
ERA, Project Officer, Regulation Sector

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1st contact
07/05/2010
X

Kick-off
25/05/2010
X
X
X
X
X
X

Exit
23/06/2010
X
X
X
X
X
X

X
X

X
X
X

X
X
X

X
X
X
X

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Annex II: List of conducted interviews

interviewee

function

Mrs. Coune
Mr. Forton
Mr. Peeters
Mrs. Wittevrongel

FPS Transport, President of Board of Directors

FPS Transport, DGTT, Director General
FPS Transport, DGTT, Director, Rail
FPS Transport, DGTT, legal adviser, Rail

Mr. Latruwe
Mr. De Mulder
Mr. Lambermont
Mr. Vanheck
Mr. Lermusiaeux
Mr. Francq
Mr. Froidbise

NSA, Director
NSA, Head of Unit, Safety
NSA, Head of Unit, Rolling Stock
NSA, Project Officer, Rolling Stock
NSA, Head of Unit, Infrastructure
NSA, Project Officer, Infrastructure
NSA, Auditor/Inspector, Safety

AL/RR/PM/BA

Mrs. Mathues
Mr. Schouteten
Mr. Fouquet

NIB, investigator in charge

Previous investigator in charge
Senior investigation expert, SNCB-Holding

AL/RR/PM/BA

Mr. Decuyper

Ministry of Transport, Head of Cabinet

Mr. Verdickt
Mr. Vlassenbroeck
Mr. Vansteenkiste
Mrs. Billiau
Mr. Thienpont

SNCB, General Manager

SNCB, Safety Manager
Infrabel, General Director, Dept. Network Access
Infrabel, Head of Unit, Dept. Network Access
Crossrail, Safety & Environmental Manager

(*) ERA team:

Anders Lundstrm
Bart Accou
Rob Rumping
Julie Dinimant
Pedro Meneses

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(*)

15/06/2010
(*)

16/06/2010
(*)
JD/RR/PM/BA
JD/RR/PM/BA

JD/RR/PM/BA
AL/RR/PM/BA
AL/RR/PM/BA
JD/RR/PM/BA

JD/RR/PM/BA
AL/RR/PM/BA
JD/RR/PM/BA
JD/RR/PM/BA
JD/RR/PM/BA
JD/RR/PM/BA

(AL)
(BA)
(RR)
(JD)
(PM)

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Annex III: Communication of the final report

Special Assessment of NSA and NIB activities in Belgium

12/07/2010 (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 the
special 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

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