Procedure
The primary goal of the Board’s work is to prevent future incidents and to limit the after-effects of the ones that do occur. The Board’s investigation uncovers both the actual causes of incidents and the underlying causes, an approach intended to reveal any shortcomings in the system(s) being used. If systematic safety shortfalls are uncovered then the Board may publish recommendations to put right these shortcomings.
The Board would like to emphasise that it is no part of its remit to try to establish the blame, responsibility or liability attaching to any party. Information gathered during the course of an investigation – including statements provided by the Board, information that the Board has compiled, results of technical research and analyses and drafted documents (including the published report) – cannot be used as evidence in criminal, disciplinary or civil law proceedings. However, it is still possible that a (criminal) inquiry to apportion blame could be started up, although any such inquiry would be quite separate from the Board’s own investigation.
Note that for less serious incidents, there may be official bodies other than the Board – such as inspectorates and judicial authorities – who are carrying out their own investigation on the basis of their statutory remit. Such investigations are quite separate from any investigation the Board may be carrying out.
The Board’s investigative competence does not cover public order disturbances, law enforcement by competent authorities or the conduct of the armed forces in armed conflicts or during operations to enforce international law (peace missions). Note, however, that this does not prevent the investigation by the Board of incidents that occur during armed conflicts or during peace missions but do not appear to have been caused by an act of war.
The investigation process itself can be broken down into a number of phases: after an incident, the first stage is always to set in motion an exploratory investigation – which will take no longer than a few months – in order to establish whether there is a systematic safety shortcoming worthy of a full investigation by the Board. Note too that the occurrence of a series of incidents may be reason enough to launch an investigation. In the next phase, a plan of action is drawn up. The investigation itself will result in a (draft) final report that after viewing will be approved and published.
Viewing procedure
The Dutch Safety Board has instituted a viewing procedure, the aim of which is to keep errors to a minimum and to give stakeholders the chance to make use of their right to hear and be heard. Under this procedure, copies of the draft report – which at this stage does not yet have its guiding foreword or recommendations – are given to the stakeholders with a request to submit any comments within four weeks. Any stakeholders located abroad – for instance in connection with an aviation incident – will be given 60 days for this. If the Board agrees with the comments then it will incorporate them into the definitive version of the report. If the Board feels that a comment does not necessitate changes to the report then this will be stated in the definitive report, usually in an appendix to the report that also contains the justification for the investigation.
Once the report has been published and sent to those who are the subject of its recommendations, these stakeholders will be given a maximum of six months (in the case of government institutions) or twelve months (in the case of private individuals) to respond. The response has to be sent to the minister responsible for the relevant operational sector. A copy of this response must be sent simultaneously to the chairman of the Dutch Safety Board and to the Minister of the Interior and Kingdom Relations. In this way, the appropriate ministry can monitor the follow-up action taken in the light of the recommendations. In contrast to its predecessor (the Transport Safety Board), the Dutch Safety Board now has the legal authority itself to check up on the actual action taken in the light of its recommendations.
Assessment framework
The Board has its own assessment framework that it uses alongside the existing legislation, regulations and specific standards for the branch of industry in question. Amongst other things, this framework sets out the way in which – in the Board’s opinion – the parties involved should have acted in accordance with their own responsibilities in connection with an incident. The Board’s framework is based on widely accepted and implemented standards and norms, as well as on national and international legislation and regulations.
The Kingdom Act recognises a number of operational sectors where international obligations mean that in all cases the Board has to carry out an independent investigation. This applies in particular to the aviation industry, but is also true for rail transport and accidents involving the release of hazardous substances. For the rest, the Board decides for itself which individual or series of incidents should be investigated, based on its own social responsibilities.
