BEA-TT RAIB - Rail Accident Investigation Branch

168 Pages·2010·3.98 MB·English

BEA-TT RAIB
Bureau d’enquêtes sur les Accidents Rail Accident
de transport terrestre Investigation Branch
Technical Investigation Report
concerning the Fire
on Eurotunnel Freight Shuttle 7412
on 11 september 2008
This document is a translation of the French original report
November 2010
BEA-TT -- RAIB

Conseil général de Department for
l’Environnement et du Transport

Développement durable
Bureau d’enquêtes sur les Rail Accident
accidents de transport Investigation Branch

terrestre

Affaire n° BEATT-2008-015

Technical Investigation Report
concerning the Fire on
Eurotunnel Freight Shuttle 7412
on 11 September 2008

(translation of French original)

BEA-TT – Bureau d'enquêtes sur les Accidents RAIB – Rail accident investigation branch
de transport terrestre
Tour Pascal B – 92055 La Défense cedex The Wharf – Stores Road – Derby DE21 4BA
Tél : [phone] Tél : [phone]
Fax : [phone] Fax : [phone]
mél : [email protected] e-mail : [email protected]
www.bea-tt.developpement-durable.gouv.fr http://www.raib.gov.uk

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Notice
The technical investigation covered by this report was
performed by collaboration between the competent
French and UK organizations in charge of railway
accidents investigations.

In France, the investigation was performed by the Bureau
d’Enquêtes sur les Accidents de Transport Terrestre
(BEA-TT) according to Section III of Law No. 2002-3 of
3 January 2002 as amended, and Decree No. 2004-85 of
26 January 2004 as amended, relating in particular to
technical investigations following an accident or incident
involving land transport facilities.

In the United Kingdom, the investigation was performed
by the Rail Accident Investigation Branch (RAIB)
according to the “Railways and Transport Safety Act
2003” and the “Railways (Accident Investigation and
Reporting Regulations) 2005”.

In accordance with French and UK legislation, the sole
purpose of this report is to prevent future accidents, by
determining the circumstances and causes of the event
analysed, and drawing up the relevant safety
recommendations. It is not intended to determine
responsibility.

As a result, the use of this report for any purposes other
than prevention could lead to its incorrect interpretation.

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Contents

Glossary.....................................................................................................................9
Summary.................................................................................................................11
1 Immediate findings and opening of the investigation.................................13
1.1 Circumstances of the fire.......................................................................................13
1.2 Loss of human life, injuries and damage to equipment.........................................13
1.3 Traffic measures taken after the fire......................................................................13
1.4 Opening of the investigation.................................................................................13
2 Organisation of the investigation .................................................................15
2.1 Cooperation between BEA-TT and RAIB............................................................15
2.2 Investigations carried out......................................................................................15
2.3 Preparation of the report........................................................................................16
3 Context............................................................................................................17
3.1 Eurotunnel concession...........................................................................................17
3.2 The Folkestone – Coquelles section of the line.....................................................17
3.3 Rail Control Centre (RCC)....................................................................................30
3.4 Road terminals.......................................................................................................34
3.5 Fire safety..............................................................................................................34
3.6 Rolling stock..........................................................................................................40
3.7 Train formation......................................................................................................46
3.8 Dangerous goods...................................................................................................48
3.9 Loading of road vehicles.......................................................................................49
3.10 Departure of the train............................................................................................50
3.11 Role of crew members on board the train while it is travelling............................50
3.12 Role of the crew in the event of an evacuation.....................................................50
3.13 Organisation of rescue operations in the event of a fire...................................51
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3.14 Eurotunnel’s safety management system...............................................................56
4 The investigation.............................................................................................59
4.1 Summary of witness statements.............................................................................59
4.2 Summary of the information recorded by the investigators...................................70
4.3 Conditions for resuming running...........................................................................88
4.4 Safety management................................................................................................89
4.5 Previous events of a similar nature........................................................................92
4.6 Measures taken by Eurotunnel after the fire of 11 September 2008......................92
5 Final report on the chain of events...............................................................93
5.1 Events prior to the detection of the fire.................................................................93
5.2 Detection of the fire and stopping of mission 7412...............................................94
5.3 Notice to the emergency services..........................................................................97
5.4 Evacuation of mission 7412 to the service tunnel.................................................97
5.5 Management of the shuttle evacuation by the Rail Control Centre.....................101
5.6 Exit of other missions..........................................................................................101
5.7 Evacuation of passengers and crew to the French terminal.................................103
5.8 Organisation of rescue.........................................................................................103
5.9 Management and operation of tunnel installations..............................................104
5.10 Resumption of traffic...........................................................................................110
6 Analysis and recommendations for preventative measures.....................111
6.1 Evacuation of people...........................................................................................111
6.2 Fire-fighting.........................................................................................................112
6.3 Rolling stock........................................................................................................116
6.4 Fixed installations................................................................................................117
6.5 Telecommunications............................................................................................119
6.6 RCC work, procedures and tools.........................................................................120
6.7 Organization in the event of a bi-national emergency.........................................125
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6.8 Strategy in the event of a fire on board a freight shuttle.....................................125
6.9 Prevention of fires on the vehicles transported...................................................127
6.10 Safety management system.................................................................................127
7 Conclusions...................................................................................................133
7.1 Cause of the fire..................................................................................................133
7.2 Negative factors...................................................................................................133
7.3 Organisational factors..........................................................................................133
7.4 Safety management system.................................................................................134
7.5 Recap of the recommendations...........................................................................134
ANNEXES.............................................................................................................139
Annex No. 1: Decision to open an investigation in France..........................................141
Annex No. 2: Protocol between BEA-TT and RAIB...................................................142
Annex No. 4: Speed table.............................................................................................152
Annex No. 5 : Recommendations following the fire of 1996.......................................153
Annex No. 6 : Recommendations following the fire of 2006.......................................157
Annex No. 7 : Main outstanding points........................................................................159
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Glossary
(cid:153) BEA-TT: Bureau d’Enquêtes sur les Accidents de Transport Terrestre – Land
Transport Accident Investigation Bureau
(cid:153) BINAT: Bi-national emergency plan
(cid:153) BINAT POSS: Message warning of the impending implementation of the BINAT plan
(cid:153) BINAT GO: Message triggering the implementation of the BINAT plan
(cid:153) CP: Cross-passage
(cid:153) Crossover: Installation allowing trains to pass from one tunnel to the other.
(cid:153) DOS: Directeur des Opérations de Secours (French Republic) – Director of
Emergency Operations
(cid:153) EMS: Engineering Management System
(cid:153) FD (Controller): Fire Detection (Controller)
(cid:153) FEMC: Fire Equipment Management Centre (Eurotunnel)
(cid:153) FLOR: First Line of Response (fire-fighters)
(cid:153) IGC: Inter-Governmental Commission
(cid:153) ICC: Incident Coordination Centre (located in the United Kingdom)
(cid:153) ISIS: Integrated Staff Information System
(cid:153) KFRS: Kent Fire and Rescue Service
(cid:153) Mission: Eurotunnel train movement
(cid:153) NVS: Normal Ventilation System
(cid:153) PCO: Poste de Commandement Opérationnel = Incident Coordination Centre (located
in France)
(cid:153) PK: Point Kilométrique – Kilometric Point
(cid:153) PRD: Piston Relief Duct
(cid:153) RAIB: Rail Accident Investigation Branch
(cid:153) RCC: Rail Control Centre
(cid:153) REX: Return on Experience
(cid:153) RTM : Rail Traffic Management
(cid:153) SDIS : French fire and rescue service
(cid:153) SEL: Elementary Section
(cid:153) SLOR: Second Line of Response
(cid:153) STTS: Service Tunnel Transport System
(cid:153) SVS: Supplementary Ventilation System
(cid:153) TCC: Terminal Control Centre
(cid:153) TVM: Transmission Voie-Machine – track-to-train transmission system
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