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HFI- Mont Blanc Tunnel Fire (2.0 WORKPLACES (2.1 Equipment design…
HFI- Mont Blanc Tunnel Fire
2.0 WORKPLACES
2.1 Equipment design
Ventilation systems were outdated.
Taproot
Emergency phones would work for couple of seconds then crash.
Fishbone Analysis
Italian control room turned their sensor off because of false reading prior to the accident.
Taproot Analysis
Smoke detection system didn't pick up the first round of smoke.
Smoke was to thin
Taproot Analysis
2.2 Workplace environment
Tunnel had a small area due to its enclosed built and two lanes
Smoke quickly filled the tunnel giving poor lighting and visibility.
People in the tunnel couldn't see what was going on due to poor visibility.
Incident cause Analysis
Control rooms could not see the situation as smoke blocked CCTV.
Incident Cause Analysis
Operators closed boom gates
Tunnel became congested with cars and people. Smoke killed engines and tyres started to exploded
Congestion and smoke made it hard for emergency crews to access tunnel
Incident Cause Analysis
2.3 Workplace factors
Safety features within the tunnel were LTA
Safety shelters were not built to withstand heat for more than 2 hours.
Taproot
Smoke started to come through the ventilation system in the safe shelters.
Shelters would have little oxygen
Taproot
Fresh air was pumped into the tunnel from the Italian end.
Air fuelled the fire even more and increased the spread of smoke towards French end.
Incident Cause Analysis
1.0 People
1.1 Individual factors
Driver did not follow emergency procedures
Driver did not contact anyone on the situation
Driver stop truck in middle of tunnel & ran away
Procedural Event Analysis
Truck driver continued driving after seeing smoke coming from the truck
Under pressure to make required delivery time schedule
Procedural Event Analysis
Operators complacency affected their judgement
Inappropriate safety measures carried out
Operator pump fresh fresh air into tunnel
TRACE Analysis
French operators ignore indicators because couldn't see the threat on CCTV
TRACE Analysis
Communication between controls rooms were poor
Operators having difficulties understanding what each control room was saying
Fishbone Analysis
Operators were under pressure to resolve situation
Not well trained in carrying out emergency response in fire situation
Poor decisions were made
TRACE Analysis
1.0 Management
1.2 Job Design
No supervision over control operators decisions
Decisions were made based on the individual knowledge and experience
Incident Cause Analysis
Roles of operators weren't clear
Confusion over what their task and requirements are during emergency situations
Poor decisions being made
TRACE Analysis
1.3 Information transfer
Communication line between operators was faulty
Communication became unclear and operators on both sides were unsure what each other were reporting
Fishbone Analysis
1.1 Organisational system factors
Emergency and tunnel systems were LTA
Could not withstand smoke and heat
Tripod Analysis
Emergency procedures did not cover all possible scenarios & steps that should be taken in such an event.
Tripod Analysis
Operating procedures were not appropriate for the tunnel activities and systems.
Tripod Analysis
Life cycle
Drilling occurred on the Italian side for a few hundred metres in 1946
French and Italian governments agreed and signed plan for the construction of the tunnel in 1947
French and Italian government officially launch the start of drilling on 30th May 1959
French and Italian drilling workers met each other in the tunnel on the 4th August 1962
The tunnel was officially opened to the traffic on the 19th July 1965
Surveillance cameras were installed and capacity of air supply increased in 1978
Video equipment, safety shelter & sprinkler system were installed. Emergency phone, emergency equipment & generators were replaced in 1990
In 1997 fire detection system was installed
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