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22/07/99 Toespraak van mr. Pieter van Vollenhoven als voorzitter van de Raad voor de Transportveiligheid en als voorzitter van de International Transportation Safety Association (ITSA) tijdens het International Symposium on Independent Accident Investigation. Tokio, 22 juli 1999, gesproken woord geldt.

Mr Chairman, ladies and gentlemen, Let me start by thanking you for your kind invitation. I am delighted to be here with you today. I cannot deny that this sounds like just another polite opening sentence. But believe me. I mean what I say. For today you have placed the subject of safety in the spotlight. In particular, you will be looking at independent investigations into the causes of accidents and incidents. The subject of independent investigations is very close to my heart, and it has occupied my attention in many different ways for many years. My interest in the subject dates from my national service days. Serving with the Royal Netherlands Air Force as a lawyer and reserve officer, I gained my first experience of investigating accidents. It was with the Air Force too that I trained as a pilot. Since my return to civilian life, it has been my privilege to chair a number of boards concerned with transport safety. This has given me a unique opportunity to learn more about the subject. To start with, I chaired the Dutch Road Safety Board. The Board's main task was to advise the Government on road safety policy. But we also managed to gain some experience of investigating accidents. I chaired the Railway Accident Board. This board was established 43 years ago to carry out independent investigations into the causes of accidents. And the same of course applies to the Dutch Transport Safety Board which was recently established on the first of July 1999. This body is responsible for investigating accidents and incidents occurring anywhere in the transport sector, including pipelines.

Together with the USA, Canada and Sweden, I set up the International Transportation Safety Association - the ITSA - in 1993. The ITSA unites all multi-modal and some single-modal safety bodies. All have one thing in common. They are responsible for carrying out independent inquiries into the causes of accidents and incidents. As chairman of the ITSA it is one of my jobs to promote these independent inquiries worldwide.

As I have already pointed out, safety and independent investigations in particular are subjects that are close to my heart. In fact, I believe that independent investigations are so essential that the public should have the right to them. And this right, I feel, should be included in the Constitution.

Why do I feel so strongly about the subject?
Because an independent inquiry can be of great value to members of the public - both in general, and individually. The subject of safety has long been a very complex subject, in which many - often conflicting - interests play a role. For the general public, independent investigations can safeguard the transparency of our actions, and help democracy to work properly.

For the various interests at stake could be of such a nature that the parties involved are only too pleased if the true causes of an accident are never revealed. For example, experts were issuing warnings for many years that certain tunnels were unsafe ... But these warnings fell on deaf ears. And when an accident finally occurred, the people in charge claimed that the question of unsafe situations had never been raised.

In the Netherlands, a soldier's name was recently cleared after a fifteen-year struggle. It was his task to inform the next-of-kin that their father, husband or son had been killed while demonstrating how to defuse landmines - and that this had been the victim's own fault. The soldier was not convinced that this was the case. He believed that the mine itself was faulty. He lost his job as a result. And it took fifteen years before his name was cleared. Studies showed that this type of landmine was indeed faulty.

In other words, independent investigations can play a very important role in upholding our democratic system. And by giving the public the right to them, governments underscore this importance.

But one thing is essential. Any investigation into the causes of an accident or incident must be kept strictly separate from the investigation that aims to establish who was to blame for it. For it is from the lessons learned from independent investigations that we discover ways of improving or adapting our safety systems.

And though investigations into the causes of an accident or incident and into the parties responsible may be held at the same time, the investigations themselves must be kept separate. For the scope of an inquiry that only aims to establish who was to blame is sometimes limited. The people involved are not obliged to give statements to the police - certainly if they run the risk of incriminating themselves. And this makes it very difficult to find out the exact causes.

Let me give you two examples to illustrate how the two types of inquiry differ.

A motorist once ignored a red traffic light and caused a very serious accident. He too was seriously injured. Every time he was questioned he claimed not to have seen the red light. But witnesses confirmed that the other lights, which the victim of the accident had passed, had been green. In other words, it was fairly obvious who was responsible for causing the accident.
But an independent inquiry conducted later on showed that a wet road surface in combination with a certain fall of light created an optical illusion. And this optical illusion was so strong, that the person who caused the accident was convinced he had never been on that road before.

My second example has to do with a train. Approaching a junction at high speed, this train passed over points that were in the wrong position. Fortunately, the train managed to stay on the tracks, but it could easily have been derailed and crashed. At the time, maintenance work was being done and the points had not been secured according to the instructions. Here too, it was clear who was responsible. The maintenance engineers had ignored the rules. But an independent inquiry showed that for many years engineers had not been sticking to the rules. For if they had worked strictly according to the book, they would only have been able to work on one or two points a day. In practice, they were expected to check six or seven. What is more, they could not let trains wait for them to finish a job. There was, in other words, an enormous difference between theory and practice. And it turned out that those who had written the rules had never discussed matters with the engineers, or vice versa.

Ladies and gentlemen,

I can well imagine that you might feel I am exaggerating when I say that independent investigations should be a right. And I can hear you thinking "all well and good that this gentleman feels so strongly about the subject. But when he talks about the right to independent investigations, does he seriously think that anyone is opposed to them?"

Of course not. No one is opposed to them. For wherever and whenever a serious accident occurs, the media, the general public, the victims and their families, Members of Parliament and the Government immediately call for an independent investigation to establish its causes. In other words, no one questions the need for independent investigations. But just how independent are they in practice?

Since accidents do not occur very frequently, there are few countries that have permanent committees solely responsible for investigating their causes. Not only were such committees regarded as unnecessary, but it was felt that the members would soon lose their expertise through lack of work. In many cases, therefore, "independent" investigations are carried out by government inspectors, who are themselves responsible for either drafting regulations or monitoring compliance. They are, in their own eyes at least, the real experts. Or these same people form a committee, chaired by an independent person, such as a judge.

And governments tolerate this type of dubious independence. Because they have a monopoly on safety, they are not very keen on truly independent investigations. In the wake of industrialisation, safety increasingly became a government responsibility. And now, as I just said, governments have a monopoly on safety. They not only compile the regulations but also monitor compliance with them. As a result, governments now tend to regard truly independent investigations as a threat and a motion of no-confidence, rather than a means of boosting their policies.

And after the investigation has been completed, the general public is often left wondering how the accident could ever have happened, and what the parties concerned are concealing - even where no one has anything to conceal. The slightest suggestion that the investigation was not impartial, or that there has been a conflict of interests is enough to lead to a public outcry. And any recommendations that are made, even if they are wholly correct, will be met with distrust.

In the Netherlands too, the word "independent" was open to many interpretations. After many discussions, we have now chosen the following principles as our guidelines.


1. In doing their work, the members of an Investigation Board are answerable to no one.

2. No single interest may be overrepresented on the Board.
3. The Board may decide on its own authority to investigate an accident or incident.

4. The Board is a permanent body. This safeguards its independence, and enables it to monitor the follow-up to its recommendations, and to investigate incidents.

5. The Board passes on its recommendations directly to the parties concerned.

6. The Board is financially independent.

In other words, safety is the only interest the Board serves. In carrying out its investigations, it has to avoid even the slightest suggestion that any other interest has influenced its conclusions and recommendations.

To be quite honest, I have to say that very few independent investigations in the Netherlands meet all these conditions. At the moment we are checking our investigations with these guidelines! I should now like to look at the various factors that make the subject of safety so complex and I should add that all these factors could in my opinion be the subject of an independent investigation. First, safety and economics.
Safety often takes a back seat when other interests - particularly economic interests - are at stake. This is something the past has taught us. And I am sorry to say that it applies to every sector. Take emergency exits in tunnels - for reasons of cost their numbers are being cut. Or the dangerously overloaded trucks on our roads. And ferry boat operators who, to avoid delays, don't chain cars down in bad weather. Or take yourself. You break speed limits, because you are in a hurry to meet a deadline, or attend a meeting.

The U.S. Federal Aviation Agency even has a black list of twelve countries that are known to ignore international safety regulations. Airlines from these countries are not allowed to land in America or Canada. Or take the Challenger Space Shuttle crash. It had long been known that there were problems with the O-rings. Indeed, according to the report on this accident, I quote:

"We can lower our standards a little bit, because we got away with it last time... you got away with it, but it should not be done over and over again like that."
Emergency procedures are often left untried, because testing is too costly. In short, it's often a question of priorities. And sadly enough, safety is not always a priority. This fact alone, I feel, is enough to justify independent investigations.
Another factor making the subject of safety so complex is what I would call pigeon-holing. As I have already pointed out, safety has slowly but surely become a government responsibility. Not one, but several government departments were made responsible for the many issues that fall under the heading "safety". As a result, each issue began to lead a life of its own, and the wheel was invented many times over. The government not only had a monopoly on safety. But every issue was given its own little pigeon-hole, and thinking on safety was sectoral in the extreme. The result was that independent investigation was for instance completely accepted in one sector, while in other sectors it was a taboo subject. And there are many such examples. Another drawback of this pigeon-holing is that the various safety issues each have their own monitoring systems. In the Netherlands we now have 32 different inspectorates, apart from the regular police force. And we are no exception. These inspectorates compete with each other and have different enforcement regimes. Work frequently gets done twice or not at all.
This means that in practice we are faced with a whole army of inspectors and supervisors responsible for enforcing a whole maze of laws and regulations. And these enforcers seldom know what powers the others have, or what problems they can expect to find. They have no idea when the others will be holding inspections, or what they will inspect. And as to follow-up, they have no idea what that means. Situations like this not only form a breeding-ground for crime, but are a threat to safety in general.
And when it comes to projects - of whatever kind - safety is often overlooked. The Dutch Ministry of the Interior recently discovered that planners were designing tunnels, for instance, without consulting the fire service. This was happening so often that the same ministry is now carrying out trials with Safety Impact Reports. These reports work with a checklist covering all aspects of safety. The aim is to ensure that each is taken into account, and to prevent planners from cutting corners, on, for instance, emergency exits. A third factor that serves to complicate matters is the notion of safety as a shared responsibility. In the past, the government held sole responsibility for safety. However, since the Eightees the government has changed its philosophy. Not only the government, but society too is responsible for ensuring safety. The notion of shared responsibility has its roots in crime prevention. For it is in this field in particular, that government has gradually started to realise that it can no longer bear the sole responsibility of guaranteeing peoples safety.

In the past few years, an increasing number of agreements and covenants have called on the general public to do their share to prevent crime. And now society is expected to invest in its own safety. But I have to say that I am alarmed at the speed with which this notion is spreading to other safety-related fields.

In its report on the TWA 800 crash near New York on 17 July 1996, the White House Commission on Aviation Safety and Security made the following recommendation: "We are proposing that government and industry come together in a new partnership - this new partnership is in fact our first recommendation". I am convinced that public-private partnerships of this kind will leave quite a mark on the way we tackle the whole issue of safety in the future. But we should take great care. Too many arrangements of this kind might lead to confusion, and, in the event of an accident, make it very difficult to establish who was responsible for what.
The final example I should like to give to show how complex the subject of safety is has to do with the regulations themselves, and the difference between theory and practice.
From my experience with public inquiries, I have learned that society is inundated with safety regulations. And they have led to many unworkable situations. On the shop floor people ignore them. And management turns a blind eye, until something goes wrong and an accident occurs. Then, of course, the workers on the shop floor are to blame.
In other words, ladies and gentlemen, taking all these factors into account, I believe that independent investigations serve as democracy's watchdog, making our actions transparent. And incident studies will help us to keep one step ahead of problems that might arise in the future.
For many years, the US National Transportation Safety Board was the only organisation in the world whose investigations were truly independent. Established back in 1967, the NTSB is responsible for investigating accidents in every transport sector - aviation, railways, shipping and roads, as well as pipelines. Its origins are to be found in the ICAO Convention - the Chicago Convention of 1944. In 1951 it was decided that the investigation into the causes of an accident was to be kept strictly separate from the investigation into the party or parties to blame for causing it. The aim was to put the emphasis on the lessons to be learned for the future. I would point out that the ICAO Convention only specified that an investigation had to be carried out. It was not until much later that the word "independent" was added - in 1981. In 1994, the European Union issued Directive 94/56. This went much further than Annex 13, since it specified that a permanent and independent organisation should be responsible for carrying out the investigation.

In short, the NTSB is the godfather of independent investigations. From the start, independence was guaranteed, since it was a permanent, autonomous organisation. It was a unique decision, too, not to limit the NTSB's authority to aviation accidents only, but to make it responsible for investigating all transport accidents and incidents - including those occurring on the roads and with pipelines. In doing so, Congress aimed to put safety firmly in the spotlight. A sector-by-sector approach would have made this far more difficult. What is more, in setting up an independent organisation, Congress wished to avoid any conflicts of interest emerging during investigations.

The American experience has left a very strong mark on further developments in the field. First, the fact that the NTSB is independent means that no one questions the impartiality of its work. What is more, its recommendations have gained greater authority. Eighty percent are now given follow-up. Second, the Americans taught us that every investigation follows the same procedure, whatever the accident.
As a result, Accident Investigation Boards have been set up in Sweden and Finland to investigate accidents in all sectors. Canada, New Zealand, and the Netherlands, for their part, have set up multi-modal Transport Safety Boards.
I would like to mention here that no-one of the existing multi-modal Safety Boards regrets to be intermodal. It is not only a matter of a greater authority. Through the co-operation of the different sectors in one Board or Agency a more integrated way of thinking and uniform method of investigation has developed. Although the investigation will continue to be carried out within each mode, the integrated approach achieves a higher safety level.
Third, a permanent, independent organisation not only guarantees the independence of investigations. It can also ensure that follow-up is given to its recommendations. And, since prevention is better than cure, it can carry out incident studies.
If no one keeps track of the recommendations that have been made they can soon disappear into the bottom of a desk drawer, never to see the light of day again. To prevent this happening, the Americans have introduced the Most Wanted List of recommendations that have not yet been given follow-up.
When it comes to the existing Safety Boards, one thing I feel is very important. Increasingly, their attention is turning to incident studies. By carrying out incident studies, the Safety Boards can act as an Early Warning System on behalf of the public. They can inform us over what is going on in the field of transport safety. In short, the National Transportation Safety Board has taught us many useful lessons.
Ladies and gentlemen, this brings me to my conclusion. For sixteen years, I have campaigned in the Netherlands for the establishment of a Transport Safety Board. My first letter on the matter to the transport minister dates from March 1983. As I said earlier, neither the government nor the sectors involved were very enthusiastic about the idea, to put it mildly.

However, a Dutch Transport Safety Board was set up on the first of July 1999, thanks to a motion put forward by Parliament in November 1993. And what led Parliament to propose this motion? It was a world conference on transport safety, held in 1992, at which members of Parliament were able to meet the members of existing safety boards. It has been an uphill struggle, but I am pleased to say that more and more people and organisations are recognising the importance of truly independent investigations.

There are international debates on this subject in the world of shipping within IMO (International Maritime Organisation) and even in the European Union the issue of independent investigations is raised in the rail- and road sectors.
In the Netherlands, even a survey is being carried out regarding independent investigations in sectors not covered by the Dutch Transport Safety Board. In Japan I have since quite a few years a very good mutual understanding with Professor Seiji Abe. With TASK you started to work in 1993 to establish a professional and independent organisation for investigating railroad accidents. Due to your activities I have heard that the Railway Director of the Japanese Ministry of Transport has the intention to establish an accident investigation board including the railway and aviation sector. Perhaps your activities will also result in establishing a Japanese Transport Safety Board. An organisation of this kind not only makes society safer but boosts public confidence in independent investigations in general.
I wish all of you every success and as chairman of both the Dutch Transport Safety Board and the International Transportation Safety Association I will of course assist you in any way I can. Especially if you look at the long existing ties between Japan and the Netherlands 400 years I would be honoured if we could work together in realising a Japanese Transport Safety Board. It would not only be an important decision for the Asian world but also a great example. As former President of the Dutch Railway Accident Council I keep the warmest memories of our meetings with TASK.
Thank you very much for your attention.

Deel: ' Toespraak Van Vollenhoven op symposium onderzoek ongevallen '




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