Channel Tunnel Safety Authority/Department of Transport

Channel Tunnel Safety Authority report into Channel Tunnel fire published
_______________________________________________________________

date 13 May 1997
source Channel Tunnel Safety Authority/Department of Transport
type Press release

note CTSA 02/97

The Safety Authority's report on the fire in the Channel Tunnel on 18
November 1996, published today, finds that the incident exposed
fundamental weaknesses in Eurotunnel's management of safety which the
company must recognise and correct at the highest level.

Introducing the Report, Roderick Allison, the Chairman of the Safety
Authority said:

"This was a very serious incident although, thankfully, no-one was
killed or seriously injured. Most of the equipment important for
safety worked as intended and the emergency procedures were broadly
satisfactory. However, the incident was more serious than it should
have been because the emergency procedures were too complex and
demanding and the staff on duty had not been adequately trained to
carry them out. Eurotunnel have already accepted that these
weaknesses must be remedied."

The report sets out in detail the precise sequence of events during
the incident, and describes the casualties and damage which resulted.
It goes on to analyse and comment on the performance of the fixed
equipment, the rolling stock and personnel. The report then sets
out its conclusions and recommendations which number 36. Among the
most significant recommendations are :

Eurotunnel must abandon the present "drive-through policy" (i.e.
the policy that, in the event of a fire, the train would in the
first instance attempt to exit the tunnel so that the fire could be
dealt with in the emergency sidings) and develop a new procedure
taking account of possible failures of rolling stock or fixed
equipment, the risk to following trains from smoke and the risk to
those on the incident train due to the size of the fire at the time
the train stops. (Recommendation 11)

Eurotunnel must carry out thorough tests on all amenity coaches and
locomotives, and correct any faults so as to ensure prevention of the
ingress of smoke. All new rolling stock must meet the same criteria
to prevent the ingress of smoke before they are brought into service.
(Recommendation 12)

Eurotunnel must improve the training of all of their staff in
relation to the management of emergencies and develop a structured
and practically based training programme to cover these needs.
(Recommendation 17)

Eurotunnel's Rail Control Centre Operators' training must be
revised and improved. The additional training programmes must
include training for emergency situations and with in-tunnel
familiarisation visits. Training should be acknowledged with
a certificate which confirms the level of competency attained.
Refresher training should take place periodically. Any member of
staff failing a competence assessment should be removed from duty,
re-trained and retested. (Recommendation 28)

Training by the Rail Control Centre Operators must be reviewed so
that they may acquire 'by heart' knowledge of standard responses
necessary for situations which are uncommon but potentially highly
dangerous, so that the safety of people and the system can be assured
without referring to written documents. Periodic exercises must take
place in order to maintain levels of competence.
(Recommendation 33)

Eurotunnel must fully review Rail Control Centre procedures with a
view to clarifying and simplifying the procedures to make them more
user-friendly. Eurotunnel must allocate sufficient qualified
personnel, in order to complete this task and commit itself to a
time-scale. Eurotunnel must also carry out an analysis of the
tasks of each operator in the Rail Control Centre to ensure that
their tasks are carried out effectively in all circumstances.
(Recommendation 34)

The report makes no recommendation regarding change to the basic
design of the existing HGV rolling stock although a number of
recommendations are made affecting the on-board systems and testing
of the locomotives and amenity coaches. The report recalls that the
Safety Authority considered Eurotunnel's design proposals at great
length in 1992-94 and that an extensive programme of experiments and
tests was necessary, covering in particular :

o fire detection
o rate of fire development

o the ability of the Tunnel ventilation
systems to control air flow

o emergency procedures
o the rail traffic management system

These points constitute key safety criteria for the system and it is
against these criteria that the report examines the system's
performance on the night of 18 November and puts forward its
conclusions and recommendations.

The report does not constitute authorisation for Eurotunnel to
restart HGV services. The Safety Authority will be advising the
Intergovernmental Commission separately about Eurotunnel's proposals
for restart.

NOTES TO EDITORS

1. The Channel Tunnel Safety Authority was established by
Governments under the Treaty of Canterbury in February 1986 to give
independent advice and assistance to the Intergovernmental
Commission on all matters concerning safety of the Channel Tunnel
Fixed Link.

2. Immediately after the incident on 18 November, the Safety
Authority set up a full Inquiry to ascertain the precise course of
events, to examine the performance of the tunnel, fixed equipment
and rolling stock, to analyse the handling of the incidents and to
make recommendations. The Inquiry did not seek to explore the
cause of the fire as this is being investigated by a French Judicial
Inquiry.

3. The co-rapporteurs for the Inquiry were two members of the
Authority, Mr Jeremy Beech, Chief Fire Officer of Kent and M. Pierre
Desfray, Inginieur Divisionnaire des Travaux Publics de l'Etat in
France, assisted by a number of technical experts.

4. The Channel Tunnel Safety Authority's report is published
by The Stationery Office (ISBN: 011 551931 9), priced #35.00 and is
available from:

Stationery Office Bookshops
Accredited agents (see Yellow Pages: Bookshops)
All good booksellers

It can also be ordered by mail order from:

The Stationery Office Publications Centre
PO Box 276
London SW8 5DT

# = pounds sterling

Railhub Archive ::: 1997-05-13 CTS-001