Report on fire in a heavy goods vehicle in the Gudvanga tunnel on the E16 road in Aurland on 5 August 2013
English translation now available. On 5 August 2013, an empty Polish-registered heavy goods vehicle caught fire about 8,5 km into the 11.4 km long Gudvanga tunnel. The vehicle caught fire, the smoke from the fire was intence, and a total of 67 persons was forced to evacuate the tunnel.
The road users were in a critical situation due to the smoke, 23 people were seriously injured and 5 severely injured as a result of the incident. The road users got no information in this situation, which was dramatic when they were captured in the smoke. The investigation has uncovered an abcence of safety management in the Gudvanga tunnel, and a lack of equipement and conditions for self-rescue.
Due to a predetermined routine the smoke was directed towards Gudvangen. This action influenced the road users strongly, and the investigation has pointed out a need for reconsidering this strategy. It is pointed out absence of emergency responce-, incident responce plans, inspections and scenario-based drills in the tunnel.
The AIBN proposes six safety recommendations as a result of the investigation.
Safety recommendation ROAD no 2015/02T
The investigation of the fire in the Gudvanga tunnel on 5 August 2013 uncovered weaknesses in the tunnel's design and safety equipment that had a direct bearing on the rescue work and evacuation of road users. They include under-dimensioned fire extinguishing equipment, a ventilation system with a control fault, a vulnerable communications network without redundancy, inadequate traffic control, monitoring and overview of vehicles in the tunnel, and limited aids for evacuation.
The Accident Investigation Board Norway (AIBN) recommends that the Norwegian Public Roads Administration improve the safety equipment in Gudvanga tunnel in order to ensure its robustness and satisfy the requisite conditions for self-rescue.
Safety recommendation ROAD no 2015/03T
The investigation of the fire in Gudvanga tunnel on 5 August 2013 revealed that road users were not given information that could potentially have helped them in their self-rescue efforts. Information signs and radio alerts were not used. Only those in the immediate vicinity of the fire scene or who realised what was happening at an early stage managed to evacuate before the tunnel filled with smoke. The AIBN believes that giving road users information is essential in order to comply with the self-rescue principle.
The Accident Investigation Board Norway recommends that the Norwegian Public Roads Administration and relevant fire services improve information for road users in the event of a fire in Gudvanga tunnel. Signs, radio alerts and text message notification should be considered, among other things.
Safety recommendation ROAD no 2015/04T
The investigation of the fire in Gudvanga tunnel on 5 August 2013 revealed that five people were severely injured and 23 seriously injured by the smoke. That is much more serious than was first assumed. The smoke injuries are not registered in Statistics Norway's injury statistics for road traffic accidents or in the Norwegian Directorate of Health's register of personal injuries. The AIBN believes that personal injuries in tunnels should be systematically registered, so that this information can be used in connection with preventive work.
The Accident Investigation Board Norway recommends that the Norwegian Public Roads Administration take steps to ensure that Statistics Norway and/or the Directorate of Health include personal injuries as a result of exposure to smoke in connection with tunnel fires in relevant accident statistics.
Safety recommendation ROAD no 2015/05T
In connection with the fire in Gudvanga tunnel on 5 August 2013, the smoke was ventilated from the fire scene towards the tunnel opening in Gudvangen before the road users had a chance to evacuate from the tunnel. This resulted in 67 people becoming trapped in the smoke and 28 people suffering serious smoke injuries. The AIBN believes that the requisite conditions for the self-rescue principle were not met through the pre-defined strategy for fire extinguishing and rescue work as defined in the tunnel's emergency response plan. Corresponding findings were also made in connection with the fire in the Oslofjord tunnel on 23 June 2011.
The Accident Investigation Board Norway recommends that the Directorate for Civil Protection (DSB) and the fire service, in consultation with the Norwegian Public Roads Administration, revise the strategy for fire extinguishing, rescue and smoke control in long single-lane tunnels, so that, as far as possible, the fire ventilation does not come into conflict with the road users possibility of rescuing themselves.
Safety recommendation ROAD no 2015/06T
The investigation of the fire in Gudvanga tunnel on 5 August 2013 shows that the emergency services face challenges as regards notifying, coordinating, leading and cooperating along so many different interfaces in a crisis situation. The cooperation was made even more difficult as a result of the communications network that the emergency services were to use being put out of action and the fire incident commander not being in the command centre. The AIBN has identified a lack of coordination of the emergency services' response plans in the Gudvanga tunnel with respect to ensuring optimal notification, incident site command, information sharing, organisation and dimensioning.
The Accident Investigation Board Norway recommends that the emergency services involved (the fire service, health service, police) in the Gudvanga tunnel coordinate the plans for notification, incident site command, information sharing and for ensuring sufficient resources.
Safety recommendation ROAD no 2015/07T
The investigation of the fire in Gudvanga tunnel on 5 August 2013 has shown that the requisite conditions for self-rescue were not present. The weaknesses are related to inadequate safety follow-up of the tunnel. The tunnel's emergency response plan and the Road Traffic Centre's and fire service's incident response plans/procedures for call-out to the tunnel said little about what was necessary to enable self-rescue and evacuation. Aurland fire service had not prepared an incident response plan for the Gudvanga tunnel. Drills described in HB R511 were not held and the fire service's inspection of the tunnel as a special fire object was inadequate.
The Accident Investigation Board Norway recommends that the Norwegian Public Roads Administration Region West and Aurland fire service cooperate on updating and coordinating the emergency response and incident response plans for Gudvanga tunnel in order to improve the possibility of self-rescue, and carry out inspections and scenario-based drills in Gudvanga tunnel.
|Location||E16 - the Gudvanga tunnel, Aurland in Sogn og Fjordane|
|Accident type||Fire in vehicle|
|Road class||European road|
|County||Sogn og Fjordane|
|Police Disctrict||Sogn og Fjordane|
|Vehicle type||Truck and trailer|
|Type of Transportation||Transfer work/assignment, Freight transport|
|Road region||Western Region|
|Accident category||Ulykke i tunnel|