Abbreviations
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ALARP BS EN CCTV kV |
As Low As Reasonably Practicable British Standard European Norm Closed Circuit Television kiloVolt |
Table of Contents
4. Reading and Research material
5. Question 1 – Direct cause of fire and severity
6. Question 2 – Direct causes, Potential root causes and Justification
7. Question 3 – Risk reduction measures that may have avoided or reduced the number of casualties
1. Introduction
1.1. On the 11th November 2000, the Gletscherbahn Kaprun 2 Funicular in Austria was the scene of a disaster that claimed the lives of 155 people. Only 12 survivors escaped from the scene of the fire.
1.2. The Kaprun 2 Funicular ran between the Kaprun valley and the Kitzsteinhorn Glacier, safely transporting millions of skiers and tourists since 1974.
1.3. Kaprun 2 received significant modernisation during 1993 and was hailed as the Pride of Austria’s ski resorts.
2. The Funicular
2.1. The Funicular was pulled between the Kaprun valley and the reception centre at the Kitzsteinhorn Glacier by a motorized winch and cable system.
2.2. There were no engines, fuel tanks or drivers; however, the train did have low voltage electrical systems and 160 litre hydraulic reservoir tanks holding hydraulic fluid for the braking system. A conductor operated the hydraulic carriage doors and was located at the front or rear of the train dependent on direction of travel.
3. The Fire
3.1. An electric fan heater designed for domestic use had been situated in the control console within the rear conductor cab. The electric fan heater overheated and caught fire causing plastic pipework to melt, releasing hydraulic fluid from the braking system.
3.2. The flammable hydraulic fluid escaping from the melted plastic pipework ignited spreading the fire. The loss of hydraulic fluid also led to a loss of pressure causing the hydraulic braking system to operate bringing the train to a halt approximately 500 metres into the tunnel during its ascent.
3.3. The fire increased in intensity due to the tunnel acting as a giant chimney which sent toxic fumes, smoke and towards the Alpen centre damaging a 16 kiloVolt (kV) power cable running alongside the track resulting in a total power outage across the resort.
3.4. The fire claimed the loss of 155 lives through a combination of asphyxiation and burns. The fire increased in its ferocity as a result of an emergency escape door been left open in the Alpen centre following an escape by workers there. The open door increased the chimney effect within the tunnel increasing the intensity of the fire.
4. Reading and Research material
4.1. There is a limited amount of research material available detailing the Kaprun 2 disaster. Research into the disaster was limited to the end of module brief along with press articles and online videos describing possible events. Press articles and online videos cannot accurately be described as factual.
5. Question 1 – Direct cause of fire and severity
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Direct cause of fire |
Severity |
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6. Question 2 – Direct causes, Potential root causes and Justification
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Direct causes |
Potential Root causes |
Justification |
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Train
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Mindset
Design
Human error
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Tunnel
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Alpen centre
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7. Question 3 – Risk reduction measures that may have avoided or reduced the number of casualties
- (A) Use of an approved design heater located away from plastic pipework
- (B) Intercom systems allowing two-way communication between the passenger carriages and the conductor cab
- (C) Internal carriage door override system allowing the passengers to open the doors in the event of an emergency on loss of hydraulic supplies
- (D) Safety Hammers which could have been used to shatter the acrylic carriage windows
- (E) Mobile phone / Wireless network coverage
- (F) Passenger access to portable fire extinguishers
- (G) Signage indicating what to do in the event of an emergency
- (H) Fixed sprinkler systems within the tunnel
- (I) Emergency refuge areas or escape tunnel
- (J) Battery operated emergency lighting
- (K) Fire / Heat detection systems
- (L) Tunnel ventilation system (semi-transverse) which could have been used to remove the toxic fumes / smoke from the tunnel.
- (M) Fixed fire hydrants or Portable fire extinguishers located at set intervals throughout the tunnel
- (N) Training – Staff training combined with external emergency service training
- (O) Segregated electrical power supplies / communication lines (run in the maintenance tunnel instead of alongside the tracks)
- (P) Use of Flame Resistant Hydraulic Fluid
- (Q) Manual fire alarm actuator or Rotary Fire alarm bell located within the passenger carriages
- (R) Closed Circuit Television (CCTV) from the passenger carriages to the conductor cabs
8. Question 4 – Categorisation of Risk reduction measures using the Risk Control Hierarchy model (Step Change in Safety)
- (A) Substitution – Alternative equipment
If a design approved heater had been used and positioned away from the plastic pipes containing hydraulic fluid it’s possible the disaster might never have happened.
- (B) Engineering – Additional equipment
If an intercom system had been fitted between the passenger carriages and the conductor cabs then the passengers would have been able to alert the conductor to the emergency.
- (C) Engineering – Modification
If an internal carriage door override system had been fitted then the passengers might have been able to escape from the fumes / smoke and subsequent fire once the train had stopped and it is possible that many of the casualties could have been avoided.
- (D) Recovery – Rescue equipment
A safety hammer would have given the passengers a means of breaking through the acrylic carriage windows.
- (E) Engineering – Modification / Additional equipment
A modification to the train and tunnel could have been made allowing the use of fibre optic cabling / wireless connectivity allowing a phone signal to be used within the tunnel. This would have allowed passengers to contact the emergency services.
- (F) Recovery – Fire extinguishing systems
If the passengers were able to reach the fire extinguishers located within the conductor cab or if portable fire extinguishers were located within the passenger carriages then the fire might have been contained or possibly extinguished at the outset. All public transport must carry accessible fire-fighting equipment.
It’s possible that the operating company were satisfying Fire Safety regulations by carrying portable fire extinguishers; however, it is also possible that the decision to locate these in the conductor cabs was to prevent inadvertent tampering by the public.
- (G) Improve Personnel Awareness – Signage
The use of signage detailing what to do in an emergency might have meant that fewer passengers died. There was a lack of knowledge which resulted in some of the passengers that escaped from the carriages ascending the tunnel; possibly to avoid the heat from the fire at the rear of train being overcome by toxic fumes and smoke which lead to death by asphyxiation.
- (H) Recovery – Fire extinguishing systems
The addition of a fire sprinkler system to the train would probably have been ruled out if an As Low As Reasonably Practicable (ALARP) study had been undertaken as there was a mindset that a fire could not occur i.e. there were no perceived combustibles or ignition sources, secondly the addition of a sprinkler system to the train would have led to a greater spend on the external motive force system used to pull the train as a train sprinkler system would need a reservoir of extinguishing fluid to be stored on the train. However, a fixed sprinkler system located within the tunnel could have prevented a substantial loss of life and subsequent loss of reputation and revenue.
- (I) Segregate / Separate – Barriers / Guards / Shield / Enclosure
If the tunnel had emergency refuge areas or an escape tunnel that had protection from smoke with a heatproof capability then the escaping passengers might have had a better chance at survival. The maintenance tunnel could have been designed or modified to provide this function.
- (J) Engineering – Extra lighting
Battery fed emergency lighting located within the train or tunnel would have helped illuminate any possible escape route. Most battery fed emergency lighting systems can provide escape lighting for approximately 90 minutes.
- (K) Recovery – Detection and Alarms
The use of a fire detection system on either the train or within the tunnel might have alerted the conductor and the operatives at the Alpen centre allowing any emergency escape procedures to be activated.
- (L) Engineering – Local ventilation
A semi-transverse tunnel ventilation system could have been used to remove the toxic fumes / smoke. Some ventilation systems are certified to give a 2-hour Line of Defence up to 400 degrees Celsius (British Standard European Norm (BS EN) 12101-03:2015).
- (M) Recovery – Fire extinguishing systems
If the tunnel had fire hydrants or portable fire extinguishers located at intervals along the tunnel, the use of these may have prevented or at least reduced the fire from spreading thereby reducing the loss of life.
- (N) Improve Personnel Awareness – More training / Better instructions / Signage / Drills and Exercises
If there had been a structured training regime which combined staff training with an emergency services response it is possible that a significant loss of life could have been avoided.
The response time for manually releasing the doors by the conductor also contributed to the loss of life as passengers were overcome by toxic fumes and smoke within the confines of the carriages. Similarly the workers that fled the Alpen centre left a fire exit door open which contributed to the chimney effect within the tunnel and increased the intensity of the fire.
- (O) Segregate / Separate – By distance
If the 16 kV power supply cable had been separated by distance from the track then it is possible that the resort supplies and communications to the train may have been preserved. Thought should have been given to routing supplies via the maintenance tunnel.
- (P) Substitute – Alternative substance
If the hydraulic fluid used in the braking system had been a Flame Resistant Hydraulic Fluid then it is possible that auto-ignition of the escaping hydraulic fluid might never have occurred.
- (Q) Recovery – Detection / Alarms
If the carriages had been equipped with manual fire alarm actuators or Rotary fire alarm bells it is possible that the conductor would have been made aware of the incident and passenger panic earlier thereby reducing the loss of life.
- (R) Engineering – Additional equipment
If CCTV had been installed throughout the funicular, this would have allowed the conductor to see the panic that had broken out in the rear carriage and if the camera resolution was high enough it’s possible that the smoke would have been seen.
9. Conclusion
9.1. The Kaprun 2 disaster was avoidable.
9.2. The Mindset by the designers and the Kaprun operator that a fire could never happen cost lives.
9.3. If a thorough Safety Assessment including an ALARP review had been undertaken following the modernisation of the train in 1993 it is possible that the electric fan heater would have been found to be unsuitable for use outside of a domestic environment.
9.4. It’s possible that the company believed that they had complied with all regulatory requirements by placing portable fire extinguishers in the conductor cabs.
9.5. A lack of training combined with the lack of risk reduction measures as shown above contributed to the loss of life.
9.6. Twelve passengers survived as a result of one man’s prior training and an understanding of what to do in the event of a tunnel fire.
10. References
- British Standards Institution (2010) Smoke and Heat Control Systems. Specification for powered smoke and heat control ventilators (fans). BS EN 12101-03:2015. British Standards Online [Online]. Available at: https://bsol.bsigroup.com (Accessed: 20 November 2018).
11. Bibliography
- Kaprun disaster www.railsystem.net/kaprun-disaster/
- https://www.independent.co.uk/news/world/europe/how-did-a-train-that-they-called-fire-proof-become-an-inferno-5367116.html
- https://europeforvisitors.com/switzaustria/articles/kaprun_gletscherbahn_fire.html
- Loss of revenue https://transops.s3.amazonaws.com/uploaded_files/nchrp_rpt_525v12.pdf
- https://theguardian.com/travel/2001/jan/28/austria.wintersportsholidays.wintersports
- Management of dead bodies in disaster situations www.who.int/hac/techguidance/management_of_dead_bodies.pdf
- Train disaster at Kaprun https://www.youtube.com/watch?v=GGYTAQxwHy8
- https://m.youtube.com/watch?v=K9L1Cx47oU
- Fire safety risk assessment (transport premises and facilities) 12/02/2007 ISBN 9781851128259
- FIRING UP RAIL TUNNEL SAFETY [railway-technology.com] https://www.railway.technology.com/features/featurefiring-uprail-tunnel-safety/
- [Technische Universitat Graz] https://lampx.tugraz.at/ntunnel2018/history/Tunnel_2004_CD/pdf/36/inokuma.pdf
- [The causes effects and control of real tunnel fires] https://www.ditzingen.net/fileadmin/Datein/Datein/Fuerwehr/Downloads/Einsatz_und_unfael
- https://core.ac.uk/download/pdf/10834350.pdf
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