The Dutch Safety Board: Prioritising learning, not blame

The OVV has a mandate to initiate investigations across a range of different sectors

The Onderzoeksraad voor Veiligheid (OVV) is an independent administrative body in the Netherlands, established under the 2005 Dutch Safety Board Act. It is tasked with investigating incidents and accidents that threaten public safety across a range of sectors. Crucially its remit is not to attribute fault or legal liability – as is often the case for public inquiries in the UK – but is instead focused on understanding the underlying causes and identifying lessons to prevent future incidents.

The OVV has a statutory duty to investigate incidents in four specific sectors: aviation, shipping, industry and rail. These constitute the bulk of its work. Investigations can be requested by ministers, mayors or even individual citizens, h owever, as an independent body the decision to initiate investigations in areas outside of its statutory duty is at the Board’s discretion. It recently used public surveys to gather ideas to inform its investigation agenda, subsequently introducing new focus areas including ecological safety, digital security and social safety alongside its core work.

Many of its investigations are for small individual incidents but the OVV also conducts high-profile inquiries, including into the Netherland’s handling of the Covid pandemic. This was conducted as a multi-phase, thematic investigation, focusing on lessons for future crises. ¹⁶ The Dutch Parliament is also currently conducting an inquiry into the coronavirus pandemic. This inquiry is focusing on decision making in government and the role and functioning of the House of Representatives. It is expected to take three years to complete. www.houseofrepresentatives.nl/members_of_parliament/committees/pec

• Part 1 focused on the actions taken by the government in its initial response to the pandemic. ¹⁷ Dutch Safety Board, Approach to COVID-19 crisis, https://onderzoeksraad.nl/en/onderzoek/approach-to-covid-19-crisis/  This was initiated in response to a request from the cabinet in the Dutch government. The investigation took 21 months to complete (it started on 7 May 2020 and the report was published on 16 February 2022).
• Part 2 focused on the effectiveness of four measures introduced by the government in the period between September 2020 and July 2021 – vaccination, mask wearing, school closure and curfews – to combat the spread of the pandemic. ¹⁸ Dutch Safety Board, Approach to COVID-19 crisis – Part 2: September 2020 - July 2021, https://onderzoeksraad.nl/en/onderzoek/approach-to-covid-19-crisis-part-2-september-2020-july-2021/  That investigation took 18 months (20 April 2021 to 12 October 2022).
• Part 3 focused on the government’s handling of the risks to public health across the whole crisis period from January 2020 to September 2022. This report made recommendations that provide broader lessons for crises and pandemic preparedness in government. This took 19 months to complete (8 March 2022 to 25 October 2023).

Each report includes recommendations for the cabinet, the relevant minister and other bodies. The focus on learning lessons rather than finding fault, or correcting the historical record of events meant that the OVV was able to complete several rounds of targeted, thematic inquiries quickly.

When deciding whether to launch an investigation the OVV uses an assessment framework that considers factors including the level of public interest, whether new lessons be learned, whether there a suspicion of structural safety shortages in a sector, and if there another organisation that could conduct the research in question.

This flexible, responsive approach allows the Board to remain relevant to emerging risks and public concerns – and is something the UK, which is often slower to establish inquiries, could benefit from.

The OVV can also conduct investigations abroad if there is Dutch involvement in the incident. For example, the OVV led the investigation into the downing of flight MH17 – as the Malaysia Airlines flight had departed from Amsterdam before being shot down over Ukraine in 2014. A separate criminal investigation was conducted by an international Joint Investigation Team, with the OVV focusing on safety and operational lessons. Its report included recommendations for managing the risks of commercial flights over conflict zones – which extended beyond the Dutch context and influenced international aviation protocols.

The investigative approach focuses on lesson learning, in the shortest possible time

The OVV’s purpose is clearly defined in law as ‘preventing future occurrences or limiting their consequence’. Investigations focus on analysis of the root causes of incidents and take a systemic approach, typically examining organisation structures, decision making, information flows and cultural factors, rather just technical and operational errors.

The law also requires that investigations are conducted within the shortest possible time. In 2022, the OVV launched a ‘Turnaround Times’ project to further streamline its processes, ²² Dutch Safety Board, Quality and efficiency of investigations https://onderzoeksraad.nl/jaarverslagen/en/jaarverslag/2022/23003.html  recommending improvements in project planning, progress monitoring and use of project management tools – all aimed at concluding investigations within a year without compromising on quality and rigour.

Unlike in the UK, investigations are conducted in private as explicitly included in the legislation to protect participants and ensure they can participate freely. All information collected by the OVV for an investigation is held privately, and is not subject to a ‘Woo request’ (similar to a Freedom of Information request). However, the final reports, and their official responses, are publicly available on the OVV website.

Statutory backing gives the OVV teeth and mandates compliance with investigations

The OVV is governed by a board of between three and five members, currently including individuals with experience in politics, science, health and public administration. ²³ Dutch Safety Board, About the Dutch Safety Board, Board members, https://onderzoeksraad.nl/en/home/about-the-dutch-safety-board/board-members/  It is primarily funded by the Dutch government, but its operational independence is guaranteed by law. This independence extends to its ability to select cases, initiate investigations, and publish findings without political or commercial interference from the government, regulatory agencies or businesses.

To carry out its work the OVV is granted statutory powers, backed up the Dutch Criminal Code, including immediate access to incident sites, the right to collect evidence and interview witnesses and the authority to inspect facilities and documentation. The maximum prison sentence for anyone refusing to cooperate is three months, or a second category fine (up to €4,100). These powers enable rapid, comprehensive data collection and are key to the OVV's ability to report swiftly and authoritatively.

Independence, credibility and public trust ensure the OVV’s work has impact

Through its independent investigations, the OVV has influenced both national legislation and operational procedures across multiple sectors, including aviation, healthcare, transportation, and industrial safety. The OVV has also contributed to raising public awareness and transparency in how the Dutch state and other organisations handle crises. Its reports are made fully public, are often covered extensively in the media, and are written in a way that is accessible to both experts and the general public.

Its recommendations, although not legally binding, are taken seriously by policy makers, regulators and industry leaders. While it does not have the power to implement its own recommendations, it does have the legal mandate to oversee adherence to them and affected organisations are expected to report on progress. In 2023 the OVV published 23 follow-up reports assessing the status of earlier recommendations. ²⁴ Dutch Safety Board, Committed and with impact, Annual report 2023, https://onderzoeksraad.nl/wp-content/uploads/2024/06/Annual-report-2023-Committed-and-with-impact.pdf

The OVV’s long standing presence within the regulatory landscape enables it to revisit issues over time, providing a recursive, thematic approach to oversight and policy improvement. It also conducts thematic reviews across investigations to identify recurring patterns and systemic issues. This is another way it diverges from the UK, where public inquiries are ad hoc, time limited and often disbanded once the report is published with no formal mechanisms to track implementation.

What lessons can the UK learn from the Dutch example?

The Dutch Safety Board provides a compelling model for how the UK might strengthen its approach to public inquiries and systemic learning – for some topics, at least. This approach is not suitable for all topics of inquiry but could be part of a suite of options to be considered alongside full statutory public inquiries.

A key strength of the OVV is it is a permanent, statutory investigatory body that operates independently from government. This status enables it to respond quickly, and consistently to incidents, without the delays associated with establishing individual inquiries in the UK. The ability to provide ongoing oversight also creates a helpful feedback loop that reinforces accountability and encourages continuous improvement, even after public attention has faded.

A second strength is that OVV investigations are non-adversarial, focusing on understanding what went wrong and how similar incidents can be prevented. UK public inquiries, in contrast often have a strong legalistic and adversarial character, which can prolong timelines. While accountability remains important, for some topics, a greater emphasis on learning and prevention could lead to more timely and constructive outcomes.