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Mont Blanc Tunnel Fire - Coggle Diagram

- - - - 25 years experience
      - 57 year old Belgian man
      - Time pressure to make delivery
      - Smoker
      - Failure to acknowledge cars flashing lights (Fraser Mitchell & Charters 2005)
    - - Lack of emergency preparedness
      - Preconditioned due to various other small fires. Comfortable assumption it would be much like the others (Fraser Mitchell & Charters 2005)
      - Pumped fresh air into tunnel
        
        Procedural Event Analysis Tool to be completed.
      - Incident Cause and Analysis Method to be completed.
      - Delay in closing the tunnel
    - - Lack of emergency preparedness
      - Preconditioned due to various other small fires. Comfortable assumption it would be much like the others (Fraser Mitchell & Charters 2005)
      - Silenced the alarm system
        
        Human Factors Investigation Tool to be completed.
      - Delay in closing the tunnel
- - - - Smoke enters refuge through ventilation system
      - Second exit to refuge inadequate, escape attempt through under-road ventilation duct
  - - - Cognitive Task Analysis to be completed.
- - - - Created an overly relaxed safety culture