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Channel Tunnel at Folkestone on Time (15:36 Hrs1)

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Channel Tunnel at Folkestone on Time (15:36 Hrs1) 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 : +33 (0)1 40 81 21 83 Tél : +44 1332 253000 Fax : +33 (0)1 40 81 21 50 Fax : +44 1332 253001 mél : [email protected] e-mail : [email protected] www.bea-tt.developpement-durable.gouv.fr http://www.raib.gov.uk 1 / 166 BEA-TT -- RAIB 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. 3 / 166 BEA-TT -- RAIB 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 5 / 166 BEA-TT -- RAIB 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 6 / 166 BEA-TT -- RAIB 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 ..................................................
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