[SystemSafety] controversial Accident Report

[ECHARTE MELLADO JAVIER]

I don't know if you are aware of a great controversy regarding the investigation of the Santiago accident (24/07/2013)-
"A report prepared by the European Railway Agency for the European Commission has slammed the lack of independence and rigour of the Spanish investigation into the 2013 Santiago de Compostela train crash in which 81 people lost their lives and 150 others were injured."
More info can be found here (https://www.thespainreport.com/articles/790-160707195546-european-railway-agency-slams-spanish-investigation-into-2013-santiago-train-crash)
And the report here http://www.era.europa.eu/Document-Register/Documents/ERA-ADV-2015-6%20Investigation%20report-Santiago%20de%20Compostela%20(003)%20(002).pdf

The official report is only in Spanish (http://www.fomento.gob.es/nr/rdonlyres/0ade7f17-84bb-4cbd-9451-c750ede06170/125127/if240713200514ciaf.pdf) , a very big amount of information, but, in my opinion, with some lack of methodology and consistency. Again, in my opinion, the main technical problem of the official report (apart from the independency issues) is the lack of an explicit "cause-consequence-recommendations" analysis. This can be resolved using WBA (or ECFA+) analysis or  ETA, combined with some sort of AcciMaps and ActorMaps (but the investigators probably know nothing at all about these techniques...).  You can imagine, is a very sensitive issue...with a lot of political interferences and judicialization. No one wants to apply "AcciMaps"...due to the judicial issues.

I have looked into other similar reports (Uk, France) , and I think that the problem is the same, the methodology for the "analysis phase" of the investigation is not explicit. In the same way that the ERA (UE) defines a Common Safety Method for risk assessment, a CSM for investigation should be defined.

Any opinions expressed are my own, not necessarily those of my employer.

Javier Echarte
ISA Technical Director
Altran Spain
______________________________________
[Altran]
C/Campezo, 1, Edificio 1
28022 Madrid, Spain
Tel : + 34 91 550 40 95
www.altran.es<http://www.altran.es/>

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