Titel Swiss Accident Investigation Board SAIB Annual Report 2013 Imprint Swiss Accident Investigation Board SAIB Bundeshaus Nord, Kochergasse 10, 3003 Bern Tel. +41 31 322 33 62 Fax +41 31 324 26 92 www.sust.admin.ch Images Fotolia Edition 150 Published in German, French, Italian and English 10/2014 Art. Nr. 816.002.eng 10.14 150 860325976 Contents 1 Editorial 4 2 Management Summary 5 3 Vision and Strategy of the SAIB 6 4 Management 7 4.1 Achievement of 2013 targets 7 4.2 Finances 8 4.3 Outlook for 2014 8 5 Office 10 5.1 Personnel 10 5.2 Investigation Activity 11 6 Safety Recommendations 12 6.1 Aviation Division 14 6.2 Rail and Navigation Division 22 7 Analyse 26 7.1 Analysis of the statistical data of the Aviation Division 26 7.2 Analysis of the statistical data of the Rail and Navigation Division 30 Annexes Annex 1: List of the final reports of the Aviation Division of the Swiss Accident Investigation Board published in the year 2013 34 Annex 2: List of the final reports of the Rail and Navigation Division of the Swiss Accident Investigation Board published in the year 2013 35 Annex 3: Statistical data for the Aviation Division 36 Annex 4: Statistical data for the Rail and Navigation Division 50 3 1 Editorial The Swiss Accident Investigation Board (SAIB) is the spring of 2013 states that the chosen le- gaining momentum. gal form of an extraparliamentary commission constitutes the appropriate form to meet the On the occasion of the merger of the Aircraft requirements of the institutional, functional Accident Investigation Board (the AAIB) and and personal independence of accident investi- the Investigation Office for Rail and Navigation gations derived from the international and na- (UUS) at the end of 2011, the Federal Council tional legal basis. instructed DETEC to evaluate the organisational form of the SAIB. One specific question was The Federal Council decided in June 2013 that posed: whether the chosen form of the official the SAIB would continue as an extraparliamen- commission should be retained. If necessary, an tary commission. The corresponding inclusion explicit legal basis would have to be created for of a legal basis is envisaged in the context of this purpose. the ongoing second revision of the Aviation Act. The external body mandated to carry out the evaluation came to the conclusion that the This means that the path is clear for the SAIB to independence of the SAIB is the fundamental complete its organisational structuring, which is precondition for the functioning of the inves- already well advanced, and to focus on its con- tigative authority which was being set up. To tribution to improving safety through its safety this end it examined the various aspects of in- investigations. dependence in detail. The report drawn up in André Piller, President of the Executive Board 4 2 Management Summary The evaluation of the Swiss Accident Investi- ers it was thus possible to determine accident gation Board which began in 2012 was com- rates for the years 2007 to 2013 and to define pleted in the reporting year. It showed that the trends. Regarding railway accidents trends of chosen legal form of the SAIB as an extraparlia- the actual event figures of different accident mentary commission is appropriate and in par- categories were analysed. The annual report ticular ensures the independence necessary for also provides detailed insights into the method- a safety investigation authority. Further findings ology of how this analysis was produced. from this analysis were incorporated into the structure of the new organisation and assist in In 2013, a total of 1355 notifications about the continuous improvement of the SAIB’s ac- accidents and dangerous events were received tivities. by the SAIB. An analysis of these notifications led to the opening of 76 safety investigations The present annual report includes for the first which will result in a final report. Seventy-two time a compilation of all the safety recommen- investigations of accidents and serious inci- dations which were issued by the SAIB during dents were able to be concluded and a further 2013. These are provided with a brief introduc- 98 clarifications and summary investigations of tion, as well as the reason why they were for- events of lesser importance were carried out. mulated to the respective supervisory authority. Each of these safety recommendations is also Within the framework of its investigations, the accompanied – where available – by informa- SAIB issued a total of 43 safety recommenda- tion on the implementation status. tions in 2013. On the basis of the statistical data, an analy- sis of meaningful data over a period of several To facilitate readability of the annual report, all years was also undertaken for the first time. statistical data and compilations have been pro- For aircraft with a maximum take-off mass of vided in the form of annexes. less than 5700 kg, for helicopters and for glid- 5 3 Vision and Strategy of the SAIB In the reporting year, the SAIB defined its vision 3. We highlight detected safety deficits and and the strategy which guides all its activity: contribute to remedying them by way of safety recommendations. Vision We are a recognised and reliable partner in 4. We communicate professionally and trans- the national safety system for civil aviation and parently and safeguard the positive percep- public transport and we contribute significantly tion of the SAIB. to maintaining a high safety standard and gen- erating a preventive attitude. 5. We implement international standards and norms and understand our role within a net- Strategy work of national and international partners. 1. We investigate accidents and serious inci- dents in civil aviation and public transporta- 6. We place value on responsible and qualified tion as an independent investigative agency employees and support them with targeted of the federal government. training and professional development. 2. We fulfil our mandate competently and in a timely manner and are a credible partner in the national safety system for civil aviation and public transportation. 6 4 Management 4.1 Achievement petences and responsibilities of the different of 2013 targets agencies. The draft was discussed in the last quarter of 2013 within the management and The Executive Board had laid down the follow- prepared for comment within the Divisions. The ing objectives for the reporting year: ROO will enter into force in the course of 2014. A complete revision of the SAIB Ordinances Implementation and life of the new The General Secretariat of the Department organisation (GS-DETEC) has initiated a complete revision of Management’s concern to organise investiga- the existing SAIB-relevant Ordinances (Aircraft tion procedures and reporting in the Divisions Accident Investigation, Accident Investigation according to uniform standards and quality cri- and Organisation of the SAIB) and of the pos- teria was taken up and given further considera- sibility of unification into a single Ordinance. A tion by the Head of the Office. Standardisation first draft was submitted at the end of 2013 of the core processes is still incomplete and will for comments by the SAIB. In this way the SAIB need to be further developed over the next few management could be fully included in the re- years. vision process. Evaluation of the external evaluation Completion of the management documen- commissioned by the GS-DETEC tation (processes, business rules) In their analysis, in addition to assessing the legal The management decided to adopt Rules of Or- form, the external auditors placed special em- ganisation and Operation (ROO) which describe phasis on the following points: all business processes as well as the tasks, com- 7 Titel – the independence of the SAIB: Anchoring it as 4.3 Outlook for 2014 an ICS process; – organisation of the SAIB: regulation of the de- The key areas for 2014 were derived from the tails falling outside the Ordinances; assessment of the need for action and defined – regulation of communication: Definition of in the targets: competencies for the different management levels; Consolidation of the organisational – collaboration of the Executive Board with the structure Head of the Office: examining the subject With the introduction of the Rules of Organ- matter and demarcation of responsibilities. isation and Operation (ROO), all operational sequences and processes are regulated, as well As a conclusion, it can be stated that the find- as the responsibilities of employees. The overall ings of the auditors were fully integrated into framework for the structures of the SAIB is to the drafting of the ROO, which already incorpo- be confirmed and renewed by extensive partic- rated existing directives regarding finances and ipation in the revision process of the SAIB Or- communications. dinance. The manuals for the investigative activity within 4.2 Finances the Divisions are to be derived from the ROO or adapted appropriately. The Swiss Accident Investigation Board had at its disposal a budget of CHF 10.98 million in the In addition, there are also potential synergies reporting year. CHF 9.496 million were actually for the Divisions in the use of the Central Ser- spent. This amount covers the entire person- vices to be explored. nel and operating expenditure of the SAIB. As is generally customary in other countries, the Positioning of the SAIB through mainte- activities of the safety investigation authority nance of the existing network of relation- are funded almost exclusively by public funds ships and its expansion and constitute a service provided by the State The valuable contacts for the mutual exchange to improve the safety of transportation. Con- of information with the supervisory authorities sequently, all SAIB products, in particular the and with the key companies in the public trans- final reports of investigations, are provided free port sector should continue to be maintained.