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Mont Blanc Tunnel Disaster (Event Sequence (White smoke begins to start…
Mont Blanc Tunnel Disaster
People
Individual factors
Lorry driver
Gilbert Degrave
Saw little amount smoke coming from his trailer but continued to drive on
High complacency and poor competency
Lack of training in emergency situations
Team factors
French and Italian operators
Under pressure to resolve the situation
Italian operator pump oxygen into the tunnel travelling towards french end. fire increase and smoke spread quicker along french end
Cacciabue (2011) discuss Personal traits and external factors are amongst the most important determinants of human behaviour. personal traits are, by their very nature, very hard to consider and prevent, as they are linked to individual characteristic and are therefore impossible to generalise in stereotype constituents
Ignore warning indicators because they could not tell how serious the accident was
cars continued to enter the tunnel
The competency of both sides were poor
High complacency
French and Italian Emergency crews
Sluggish communication between both crews
Poor feedback
Victims and survivors
People on the French side could not see the danger ahead
System Parts
Tunnel
Cameras
Safe rooms
Design mismatch as heat couldn't be resisted for more than 2 hours
Emergency phone lines
LTA heat and smoke Detectors
Operating stations
Road Users
Cars and other Trucks
Flammable materials within
The Lorry that blew up
No indication to alert the driver of the fire building up
Diesel tanks
Previous issue in Lorry fires
Highly combustible and flammable cargo
Air filter was burnt and unwanted particles travelled into the engine starting the fire
Cigarette butt lands on the air filter
A lot of vehicles in the tunnel
Operators
Training
Skills and Knowledge
Qualifications
Operator capabilities
Organisational system/management and regulators
Polices and Procedures
French and Italian accountability
Required training
Cost of system life cycle
Safety of the system
Event Sequence
White smoke begins to start coming from trailer after 2 mins being in the tunnel. Smoke sensor do not pick up the hazard as smoke wasn't dense enough
Fire intensifies and smoke become thicker. Driver notices the smoke but think very little of it and continues driving
Smoke trigger alarms. French operators hears the alarms but is unable to determine the cause. the Italians operator do not hear alarm as they turned there off the previous day due to false alarm. both stations are unable to see the burning Lorry as smoke covers the cameras
40 tonne refrigerated lorry arrives at toll bridge on the french side and heads into the tunnel.
Smoke increase and Degrave stops the lorry and Que of vehicles form behind them
The trailer on the Lorry explodes
Italian operator pumps fresh air towards the french side of the tunnel. pushes more smoke back towards the french side
Road user uses the emergency phone to alert the french operation station of a serious problem. french contact the Italian operation station. they close the tunnel to vehicle on both sides.
Thick smoke fills the tunnel and emergency crew and operators are unable to see the problem
System Life Cycle
Operating
Operator training and requirements
World association Mondiale De La Rout (2011) discusses In order to successfully and efficiently operate and manage a road tunnel, operational tasks and the responsible body for carrying them out, need to be established in order to ensure that all actions required are handled in a consistent and safe way.
Controls
Operators usage
Functions
Allowing all types of vehicles to travel across the alps to reach the french side or Italian side
Maintenance
Spare parts and materials
Upgrading systems
Services/regular system check ups
World association Mondiale De La Rout (2011) discusses structural elements and the technical equipment need regular maintenance whose goal is to ensure safe driving conditions for the public by keeping the tunnel at its designed safety standard.
Availability of maintenance
Skills and experience with specfic system related to the tunnel
Commissioning
Testing & inspecting the safety systems,road,sensors and camera
Heavner (2015) advises look for any Out-of-Specification (OOS) results that occurred during manufacture of faulty batch or product lot.
Price to travel on the bridge
Budget considerations
Maintenance
Responsibilities of the French and Italian owners
Decommissioning
Following appropriate waste and contaminated material removal procedures for the decommissioning of underground tunnels
Construction
Manufacturing
Gries & Blessing (2006) discuss as far as discovering design flaws is concerned, it has been shown that the feedback of those who interact with the physical products in practice- the individual who manufacture, repair, but essentially use the products- play an important role.
Testing structure and safety systems
Materials
Appropriate materials used
Machinery
Organisations
Huge amount of workers
Workplace accidents
Delays construction
Deadline for completion
Rushing the construction process
Concept Design
Quicker route for travelling across the Alps
Available for cars and trucks
Busy roads. More road accident likely to occur
One of the longest underground road tunnel
Attracts tourist
Tourist travelling on an unfamiliar route. Become unaware of hazards
Saves a climb thorough windy roads
Safer travelling route
Workplaces
Workplace Environment
Enclosed underground tunnel
Limited space and access to the tunnel. could only access it through the ends
Dark tunnel. Visibility was limited
Cars filled the tunnel
Harder for emergency crews to access the fire
Equipment design
Safe rooms were not built for this situation
Smoke detection systems were LTA
First sign of smoke wasn't dense enough to set alarms off
Tague (2004) identifies failures are prioritised according to how serious their consequences are, how frequently they occur and how easily they can be detected.
emergency phones were faulty
Workplace factors
Escaping shelters were not able to resist heat for more than 2 hours
Outdated ventilation system
Smoke filled the tunnel
Emergency workers were operating in poor conditions
Operators could not see the Lorry or other cars on cameras
Road users inside the tunnel could not see what was going on
Smoke sensor were turned off on the Italian end so only the french pick up the warning system
Management
Job design
No supervision of actions in operation room
Actions were done in judgement without expert direction
Job requirements and task not clear
Organisational system factors
LTA operating procedures
LTA emergency procedure
System inside the tunnel were not updated
Information transfer
Lack of communication between the french and Italian operators and emergency crews
Faulty communication Line
Poor feedback from both sides
Design flaw
Management/Operations failure
Design Failure
Management/ Organisational failure
Management/Operations- Latent failure
Design Flaw
Precondition
Active failure
Active Failure
Active Failure
Precondition
Managment/organsatinal- Latent failure
Active failure - Design Failure
Management/Organisational failure
Active failure
Precondition
Latent failure