During the development of independent safety investigations, several main topics have emerged in ITSA, characterizing its search for common grounds and mutual learning. Sometimes, topics originated from the internal needs of safety investigation agencies themselves with respect to the quality and credibility of their performance. Other topics emerged from external changes, forcing the agencies to adapt and provide a flexible response to changes in risk perception and safety assessment in society after major disasters inside as well as outside the transport sector. Sometimes, investigation agencies found themselves in a position as problem owner, due to the absence of existing governmental authorities or allocation of responsibilities within organizations, adding new roles and functions to their mission.
The main objective of ITSA however, has been unchanged. In its Founding Agreement of 22
October 1993, ITSA stated:
• to advocate independent non-judicial investigations of transport accidents in order to contribute to the safety of the traveling public
• to bring together accident investigation agencies in all modes of transportation
• to learn form the experiences of other countries and share safety information.
Over the past 15 years, four main topics can be discriminated, each with a specific focus and timeframe:
• advocating independent investigations and establishing international cooperation between colleagues
• acknowledgement of the role and rights of victims, relatives and family assistance
• deployment of safety investigations outside the transport sector and European harmonization of methods and practices
• building knowledge and expertise networks between practitioners, scientists and policy makers.
However, before the association of independent investigation agencies became a reality, an founding phase preceded the establishment of ITSA.
The concept of independent investigations in to the causes of accidents and the issuing of recommendations to improve the safety of transportation was established in the USA, where in 1967 the National Transportation Safety Board was founded. The NTSB was the first independent investigation agency in the world to cover all modes of transportation; aviation, maritime, railways, roads and pipelines. Despite the rather strict sectoral approaches and differences between the modes of transport, the message came across in Europe after a conference in Amsterdam in 1987. During this conference, the positive experiences regarding joining efforts of all modes of transportation convinced other countries of the usefulness and need to promote this philosophy of independent investigations. In 1990, the concept also became reality in Sweden with the foundation of the Statens Haverikommission and in Canada with the Transport Safety Board of Canada. During the First World Congress on safety of Transportation on the initiative of Delft University of Technology in November 1992, the chairmen of the transportation safety boards of the USA, Canada, Sweden and the Netherlands agreed to start working together on the establishment of an international association.
On October 1993, the same chairmen met again at the Palace Het Loo in Apeldoorn, the Netherlands, to sign an agreement on the foundation of the International Transportation Safety Association ITSA. A small organization was established, consisting of a rotating chairmanship, a small secretariat and contributions by in-kind staff and resources. On an incidental basis, observers were invited to the chairman meetings and topical presentations from outside were discussed.
The objectives of the association were formulated as:
• improve transport safety by learning from each other
• to make information available into the causes of transport accidents, to exchange information on causes, safety studies, recommendations, accident data, investigation methods and techniques
• to share information on implementation of important safety recommendations
• to conduct periodic conferences, to discuss investigation methodologies and techniques, open to all segments of the transportation community.
Topic 1, establishing independence and a multimodal focus
A small number of major transport accidents in aviation and railways in the Netherlands in
1992 and 1993 coincided with the Delft congress and the establishment of ITSA. This offered Mr. Pieter van Vollenhoven -as the Chairman of the Dutch RAIB and the Road safety Council- the opportunity to involve major political decision makers in the Dutch Parliament in his advocacy for independent investigations. This involvement had a major influence on the political decision in 1993 to establish a Transport Safety Board in the Netherlands, modeled after the godfather of the concept, the NTSB in the USA. Eventually, after an international survey of RAND Corporation into existing best practices among safety agencies, in July 1999 the existing Dutch boards merged into the newly formed Dutch Transportation Safety Board. This DTSB was transformed into a multi-sectoral Safety Board in February 2005.
This evolutionary development of the Dutch board may be typical for other countries, in which similar developments took place. An independent safety board for aviation accident investigation was established in Norway in 1989. From 2008 Norway is conducting accident investigations in the four transportation modalities. In 1990, independent safety boards were established in Canada, New Zealand, Sweden, followed by the Interstate Aviation Committee of CIS in 1991 (representing 12 of the former member states of the Soviet Union), Finland (1996), Chinese Taipei (1998), Australia (1999), Korea (2006) and Japan (2008).
At the international level this development into independent, mostly multimodal –and eventually even multisectoral- interest in accident investigations, covering a period of almost 20 years. This also has lead to the expansion of ITSA. New members joined in Stockholm in 1995; the Interstate Aviation Committee of the Commonwealth of Independent States CIS, TAIC of New Zealand and PCIMA of Finland. This Finnish Planning Commission for the Investigation of Major Accidents transformed in 1996 into the present FAIB for each major accident, also outside transport. Gradually, over the years other safety investigation agencies from the United Kingdom, Chinese Taipei, Australia, Norway, Japan and Korea became a member of ITSA. ITSA gradually grew from a small founding father group into an international association of investigation agencies. Some of them have their origin and involvement in a single transport mode, others have been multimodal from their foundation on. Some of them brought with them investigation experiences which stems from the beginning of aviation, such as the AAIB in the UK. Others entered unbroken grounds in domains without an accident investigation tradition.
Their common goal however is to learn from each other’s experiences. By 2008, ITSA has 14 members from across all world regions, in particular with a growth in Asia and Europe. Most of these boards started in aviation, some in the railway sector, frequently merging into a multimodal cooperation. The development of safety investigation agencies is event driven by nature and investigation agencies are embedded in their national, historical, judicial and social environment. Consequently, they cover a wide variety of forms and organizational models. Several agencies took the form of a multi-modal staff organization with a Chief Commissioner or small Board, others organize themselves along lines of a more federal model, interstate cooperation or cover even a continental scope, such as Australia. In the UK, a joint effort between the three investigation branches AAIB, MAIB and RAIB was established to benefit
from mutual learning.
Simultaneously with the development of its safety investigation agency in 1993, the Netherlands took – together with Germany and the United Kingdom – the initiative at the European level to establish the European Transport Safety Council ETSC in Brussels. This ETSC was to serve as an advisory council on transport safety to the European Commission and the European Parliament. The chairman of ITSA, Mr. Pieter van Vollenhoven actively took part in this initiative and became a member of the Board of Directors of the ETSC.
During this period, ITSA served as a repository for common issues among the safety investigation agencies. Several safety boards organized topical conferences, such as the NTSB on Aviation Accident Symposium (March 29-31, 1994), Family & Victim Assistance for Transportation disasters (Sept 28-29, 1998), Transportation Recorders (May 305, 1999) and Transport Safety and the Law (April 25-26, 2000).
In November 1996, ITSA published its Common Concerns, dealing with common issues based on the existing evidence available from investigations in all modes of transportation. These concerns expressed the seriousness and generic nature of the problems each of the members had encountered individually, while several other ITSA members already had identified solutions or even produced recommendations to solve or at least reduce the problems. Developing these Common Concerns however, revealed to the ITSA members that clarifying common issues like Signals Passed At Danger on the railways or fatigue in operator performance in aviation, did not provide an answer in developing a multimodal perspective. It indicated that there was a need for a common methodological basis for the investigation process itself: it put the focus on HOW to investigate, not WHAT to investigate.
This complied on a larger scale with an earlier experience within the NTSB, where in 1968 the
Bureau of Surface Transportation Safety was the first true implementation of an intermodal investigation organization. The Intermodal Group within this Bureau consisted of a Human Factors specialist, an operation researcher, a system safety specialist and a hazardous material specialist. This group provided specialist expert services for investigations in all modes. Facing the differences in investigation practices among the modes, this triggered the notion that a common methodology for all investigations was necessary.
In the following years, several safety investigation agencies took the lead to develop an investigation methodology: the Canadian TSB developed its ‘Integrated Safety Investigation Methodology’ (ISIM 2000). The ATSB elaborated on the notion of ‘cause and proof’ with the report on ‘’Safety Investigation Guidelines (2006)’ and the report on ‘Analysis, Causality and Proof in Safety Investigations’ (2008).
These discussions inspired others to explore the generic applicability of the concept of independent investigation methodology from a multi-sectoral perspective (ESReDA 2005).
Topic 2 expanding the scope, new players appear on the scene
A second phase in the development of ITSA was marked in February 1998 with the organization of the Second World Congress on Safety of Transportation at Delft University of Technology and the ETSC. This congress brought together practitioners from all modes of transportation, staff and members of the investigation board community and scientists from a wide variety of disciplines. It also introduced two new groups of players in the safety of transportation field: victims organizations and high level policy and governance officials.
In the USA, several victim organizations originating from a series of major air crashes, merged into a federation, providing a common voice to aviation passengers and their families. Their needs were recognized by the NTSB, which established a family support office in 1996, now evolved into the Office of Transportation Disaster Assistance.
In the UK, the AAIB policy towards victims words this attitude very simple: ‘We will treat survivors and bereaved families with respect and sensitivity and in a way that we would all wish to be treated if we were subjected to the same tragic circumstances’.
In Scandinavia, in the aftermath of the Estonia capsizing, the Estonia Foundation articulated for the first time the needs and interests of passengers and their relatives involved in a naval
disaster. In road safety, the European Federation of Road Traffic Victims (FEVR) was founded in 1991 in Geneva, now comprising over 20 affiliated organizations from 13 countries.
Simultaneously, major safety concern emerged among leading policy makers throughout the USA, Canada, the European Union, IMO and ICAO, about the institutional concerns that were raised on learning, harmonization and cooperation. The title of the Second World Congress on Safety of Transportation focused on the imbalance between growth and safety. A high level political support emerged for learning across modes of transport, combining a modal orientation with an common learning potential. The importance of prevention in moving towards the 21st Century, was emphasized by the need to develop ‘first time right’, ‘zero defect’ and ‘integral safety’ notions. In order to cope with the forecast of continuing transport growth, the Vice President of the USA Al Gore, as the Chairman of the US Commission on Aviation Safety, called the theme of the congress –Improving safety as we forecast continuing transportation growth- right on target. Innovative ideas and improvements should be shared by everyone, including those in government, academia, industry and the private sector. Together, -he stated- we could reach our common goal of providing transportation, improving the accident rate and implement positive change.
At its 10th Anniversary in March 2004, ITSA commemorated the doctrine of its Chairman
Emeritus Pieter van Vollenhoven that: ’Independent investigation is a right of every citizen and a duty of society’.
Topic 3: European harmonization and a multi-sectoral scope
Harmonizing accident investigation principles and practices has been an issue for a long time. Already in 1961 the British Cairns report examined procedures and processes across the various modes of transportation in order to bring national UK legislation in compliance with the ICAO Annex 13 regulations of 1951. In 1989, the European Commission sponsored the Wilkinson and Rapp report, who had to look at aviation accident investigation practices and principles. Attention was paid to the differences between the either inquisitorial or accusatory traditions within the legal frameworks across the (then 12) member states of the European Union. As a result a European Directive came into force on November 1994, (Council Directive 94/56/EC) dealing with the core regulations in aviation to assure independence and legal status in order to gain the trust of the public and the industry in all member states.
In his European Transport Safety Lecture of 23rd January 2001, the chairman of ITSA advocated the right to independent investigations for all modes of transportation, providing statutory guaranteed for all stakeholders to feel free to tell the truth. Independent investigations should not only be separated from a state interference, but also be free from using the results in legal procedures. Their recommendations, including their timely follow-up, are based on the high quality of the reports, which form the basis for their credibility and acceptance of the recommendations by public and industry. It is no longer a question whether independent investigation boards should be set up, but how they should be organized. In the lecture, the issue is raised whether a national or a single European board should be favored and whether or not all sectors should be incorporated in a single board or represented by a number of sectoral boards. This establishing of sectoral boards has been the case in the USA where the Chemical Safety Board and NIST are modeled after the NTSB for the process industry and construction industry.
In Europe, the Commission’s White paper European transport policy for 2010: time to decide established an ongoing need for proper safety investigation of transport accidents and the extension of relevant legislation to all modes of transport. As a consequence the Commission decided on 11 June 2003, to set up a Group of Experts to advice the Commission on a strategy for dealing with accidents in the transport sector, including oil and gas pipelines. This group consisted of 12 experts, balancing the expertise and experiences from all modes of transportation. Leading officials from the investigation community were present, among which ITSA members from the UK, Finland and the Netherlands. One of the most notable achievements was to develop a common European methodology for safety investigation. The main objective of the Methodology Working Group was to prepare the ground for a decision by the Group of Experts for guidelines on a methodology to be used throughout the transport sectors. By the end of 2006, the Final Report was published, including the Guidelines for this methodology.
Throughout the years, the EU has expanded the concept of the aviation directive on accident investigation to other sectors and has broadened its scope in aviation towards incident analysis (EU Directive 2003/42/EC). In 1999 a Council Directive dealt with mandatory surveys for ro-ro ferries and high speed passenger crafts, in 2002 a Directive was issued on a Community vessel traffic monitoring and information system, while in 2004 a Directive on European Railway Safety followed.
This harmonization however did not stop at the aviation industry, but also involved the maritime transport sector. Several non-European and European investigation agencies, among which the Australian ATSB and the MAIB in the United Kingdom, took the leadership in the establishment of the MAIIF (Marine Accident Investigators’ International Forum) and IMO Investigation Code and its revision.
In an international maritime context, the IMO has adopted in 1997 the Code for the Investigation of Maritime Casualties and Incidents. Preparing this code has seen major input from ITSA members in the maritime sector, among which MAIB, NTSB and ATSB.
In the aviation sector, investigation activities were advocated through the efforts of ISASI (International Society of Air Safety Investigators), ICAO and the AAIB, NTSB and ATSB.
This harmonization towards an investigation methodology was accompanied by an expansion of the scope of some ITSA’s members outside the transportation industry, such as FIAB, SHK and DSB. A series of major accidents in the military, with disco fires, major industrial explosions, in space, health care and construction industry raised the interest of politicians and the public into the value of independent investigations. At several occasions, the expertise and experiences of safety boards was called upon in order to provide a timely transparency in the factual functioning of these complex and public events. Safety investigation agencies were on a case by case basis invited to the role of public safety assessor in order to clarify how public governance authorities, rescue and emergency services dealt with the aftermath of these major events. The investigation into a survivability of major accidents is expanded from a vehicle-bound involvement to other objects and structures without a direct relation with public transport systems.
This new role in conducting an independent investigation in the public governance domain puts new requirements to the skills, expertise and resources of ITSA members. A gradual shift can be observed in the interest of the public and politicians in the outcomes of an investigation. Rather than preventing a similar accident by identifying and subsequently eliminating the technological causes of an accident, the focus in such investigations shift towards an understanding of the systems social and administrative functioning. In debating recommendations, the focus is moving towards responsibilities of the emergency and incident handling in the aftermath of a major event. Vigilance is required to assure that this will not implicitly brings back the issue of blame and accountability in the investigation processes. This requires safeguarding of the demarcation lines between independent and judicial
Topic 4: building and participation in knowledge and expert networks
Although developments can only be assessed fully in retrospect, several trends and patterns are becoming visible which may indicate a next topic for of development for the investigation community. Despite these uncertainties, ITSA and its members are willing to anticipate and to adapt to these future challenges.
Throughout its activities, ITSA has recognized the importance of staff training qualification and certification. In 2000, the NTSB joined efforts with George Washington University establishing the NTSB Safety Academy as a facility for training investigators. In August 2003, the Academy started its courses, housing the TWA 800 B747 fuselage reconstruction for training purposes. Several other boards provide in-house training for their staff and international counterparts from industry and governance, such as Taiwan, Australia and Canada or cooperate with universities such as with Cranfield University (UK) and George Washington University (USA). Each for themselves or in close cooperation with others, ITSA members have developed specific issues such as:
• investigation methodology (Canada and Australia)
• investigator certification (Australia)
• investigation data management systems (Australia and Canada)
• digital data recovery and recording (the Netherlands, Canada, UK, Chinese Taipei)
• organizational and legislation models and methodologies (the Netherlands and ITSA
members’ participation in the EU Group of Experts).
Through personal links communication and information exchange exists with professional investigation organizations like ISASI, MAIIF and the academic community. On specific investigations, safety investigation agencies ask for the support of academic institutes to clarify knowledge deficiencies in the explanation of events.
Several trends emerge which create a sense of urgency to further develop the concept of independent accident investigations. The technological, operating and social environment of the safety investigation community is undergoing rapid changes.
1. Due to the growing scale and complexity of investigations, large-scale introduction of new ICT applications, the high public and political profile of major accidents and the event driven nature of setting priorities, safety investigation agencies have to be very flexible, cost-effective and communicative in managing their own activities. Besides, investigation agencies are challenged to provide transparency not only in the technological and engineering design domain. Due to a role as public safety assessor, also other disciplines are addressed, regarding the human factor, management, organization, and increasingly, governance and control. There is a public appeal to provide a timely insight in the complexity of the sequence of events, a satisfactory explanation and effective measures to enhance the safety of the system under scrutiny. Such an appeal does not restrict itself to the transport sector, but emerges wherever and when a major event has occurred.
2. Due to their accomplishments in achieving a very high level of safety performance, the transportation modes encounter less and less major events which raise public concern as a support for continuous and high safety awareness. Nevertheless, despite such good safety track records, the public may be concerned about transport safety due to occasional high profile incidents, while an absence of perceived lack of safety may induce complacency with other stakeholders. Discussing shared and delegated responsibilities in safety enhancement and changing demarcation lines between stakeholders may cause a loss of transparency. Aggravating the safety debate to higher systems levels may detach the safety debate from the factual and actual functioning of these complex systems and their technological developments. This might introduce a new and artificial distinction between ‘physical safety’ and ‘social safety’.
In 2006, in his inaugural lecture as a professor in risk management at Twente University in the Netherlands, the Chairman Emerites of ITSA professor Pieter van Vollenhoven addressed these issues of demarcation lines, allocation and control of responsibilities and public governance.
3. Finally, safety investigations have gained the interest of the academic community beyond traditional issues and disciplines. This interest is triggered by a small series of major events, such as the Challenger and Columbia shuttle accidents, the Baker report on the BP refinery explosion and the factory explosion in Toulouse. In the academic debate, the analysis is focusing on specific topics such as accident modeling, sacrificial decision-making, safety culture, organizational failure and public governance and control.
Frequently, the reports of safety investigation agencies form the basis for such further analysis and development of new theories and models. In the past, single accident investigations have contributed to generic knowledge development and system deficiency identifications. In the maritime sector, the Titanic provided early lessons in vessel design and self-relianceness of crew and passengers.
Metal fatigue and crack propagation originated as a scientific research domain from the De Havilland Comet investigations, while multiple investigations into technical failures identified engineering design principles such as fail-safe/safe life, damage tolerance or situation awareness. The Tenerife air disaster contributed to the basis for developing the human factors school of thinking.
All together, these challenges put pressure on the competence, performance, quality and credibility of safety investigation agencies in order to enable identification of new knowledge and systemic deficiencies.
Consequently, a new perspective in the development of safety investigation agencies seems to emerge.
Towards a new perspective?
Each for themselves, safety investigation agencies have coped with these challenges by an in- house development in order to satisfy specific needs with respect to developing training methods and techniques, digital data recovery, knowledge and data management, organizational and legislative models and harmonizing investigation methodologies.
Relations in the network have been primarily on a personal and ad-hoc, rather than on an
Being the monopolists in the domain of independent investigations, safety agencies are bound to maintain a careful balance between professional competence, public credibility and quality of the performance. This balance deals with the development of generic investigation methodology and principles and modality specific competences for each sector under its mandate, while maintaining the public confidence in its independence.
A more institutionalized network becomes a prerequisite for a further professional development, sharing of professional expertise and participation in knowledge management. In such a network, ITSA may serve as an internal as well as an external platform for further development of safety investigations:
• by providing a repository for safety information dissemination and common learning
• to serve as a problem provider for knowledge development, system deficiency identification and systems change
• to fulfill a role as public safety assessor and public spokesman beyond and above parties involved.
Safety investigations do not have the option but to render advisory opinions to assist the resolution of disputes affecting life or property.
Safety investigations represent a specific analytic instrument with its own characteristics:
• independent from blame and vested interests of third parties and stakeholders
• a cased based approach, based on a systems perspective
• to provide a timely transparency in the factual functioning of complex systems
• evidence based with respect to its findings and recommendations
• pro-active learning by developing generic principles, notions and knowledge, combined with dissemination of findings and recommendations on domain and sector specific solutions and change strategies.
Cairns Report/Wilkinson & Rapp Report
First World Congress on Safety of Transportation Second World Congress on Safety of Transportation ITSA Common Concerns
NTSB symposium on:
– Aviation Accident Symposium (March 29-31, 1994)
– Family & Victim Assistance for Transportation disasters (Sept 28-29, 1998)
– Transportation Recorders (May 305, 1999)
– Transport Safety and the Law (April 25-26, 2000). Third ETSC Annual Lecture, Brussels (
Main Points Memorandum, Ministry of the Interior, the Netherlands
Final Report of the EU Group of Experts
ISIM, Integrated Safety Investigation Methodology. CTSB 2000
Safety Investigation Guidelines. ATSB 2006
Journal of Hazardous materials, Special Issue on Safety Investigations of Accidents ESReDA book on Shaping public safety investigations of accidents in Europe Inaugural lecture professor Pieter van Vollenhoven, April 2006