Report on fire in heavy goods vehicle in the Oslofjord tunnel on national road 23 on 5 May 2017
Vei rapport 2018/04 eng
English version now available. The Accident Investigation Board Norway (AIBN) has investigated a fire in a foreign heavy goods vehicle consisting of a tractor unit and semi-trailer. No persons sustained serious injuries in the incident, but response and rescue personnel had to evacuate two road users who sought refuge in one of the tunnel’s emergency shelters. The investigation has revealed several similarities with the vehicles that caught fire in the Oslofjord tunnel in 2017 and 2011.
The heavy goods vehicle was loaded with toilet paper, and the vehicle caught fire inside the tunnel when driving up a slope towards Drøbak. The AIBN’s investigation has shown that this fire, like the fire in 2011, occurred as a result of engine failure. The fire escalated quickly, and within a short time the heavy goods vehicle was ablaze.
Whilst the tunnel was in the process of being closed there were some delays in the lowering of the barriers at the tunnel entrances, and several vehicles managed to drive into the tunnel before and whilst the barriers were going down. Among these were two heavy goods vehicles that continued driving all the way to the scene of the fire before stopping.
The heavy goods vehicle, including its load, was completely burnt out. There were also incipient fires in the two heavy goods vehicles that stopped behind the burning vehicle. The fire service’s good and coordinated extinguishing effort was decisive to the fire being extinguished and limited to only one vehicle in this situation.
The investigation has focused on the cause of the engine failure. Technical findings and video material from the tunnel have helped explain the cause of the fire. The contributory factors to the fire can be related to overloading of the engine, and the investigation has revealed indications of inadequate maintenance. An animation illustrating the engine failure has been created and is available for download.
The investigation has also focused on the safety follow-up of the Oslofjord tunnel, and several safety problems have been identified:
a) There is no comprehensive nonconformity system where faults and deviations in the tunnel’s safety equipment can be reported and technical operational statuses can be monitored and followed up.
b) Several faults and deviations in the tunnel’s safety equipment were not revealed at periodic inspections.
c) It has not been the Norwegian Public Roads Administration’s practice to follow the internal guidelines in manual R511 for safety approval of tunnels in operation.
d) The Norwegian Public Roads Administration as the tunnel manager has not kept the emergency response plan for the Oslofjord tunnel up to date in accordance with the requirements of the Tunnel Safety Regulations.
e) The Norwegian Public Roads Administration as the tunnel manager has not organised regular drills in the Oslofjord tunnel in accordance with the requirements of the Tunnel Safety Regulations.
The AIBN has issued four safety recommendations on the basis of this investigation.
Sikkerhetstilråding
Sikkerhetstilråding VEI nr. 2018/05T
Undersøkelsen av brannen i Oslofjordtunnelen 5. mai 2017 har avdekket at det var flere tekniske avvik i tunnelens sikkerhetsutrustning. Flere avvik var kjent for Statens vegvesen i forkant av brannen, og i tillegg ble nye ukjente avvik avdekket under brannen. Undersøkelsen har vist at det ikke foreligger et felles internt avvikshåndteringssystem for tunnelens sikkerhetsutrustning som gir tunnelforvalter mulighet til å overvåke den sikkerhetstekniske driftsstatusen fortløpende.
Statens havarikommisjon for transport tilrår at Statens vegvesen etablerer et helhetlig avvikshåndteringssystem for loggføring, håndtering og oppfølging av feil og avvik med sikkerhetsutrustningen i Oslofjordtunnelen.
Sikkerhetstilråding VEI nr. 2018/06T
Undersøkelsen av brannen i Oslofjordtunnelen 5. mai 2017 har avdekket at periodiske inspeksjoner ikke har vært tilstrekkelige for å avdekke feil og avvik i tunnelens sikkerhetsutrustning. Statens vegvesen har også fraveket egne håndbokskrav om fornyet sikkerhetsgodkjenning av tunneler i drift ved å endre praksis uten at dette er begrunnet nærmere. Undersøkelsen av denne hendelsen har påvist behovet for å følge opp sikkerhetsnivået i Oslofjordtunnelen med jevnlige inspeksjoner og godkjenning.
Statens havarikommisjon for transport tilrår at Statens vegvesen fastholder håndbokskravet om å sikkerhetsgodkjenne tunneler i drift gjennom jevnlige helhetlige inspeksjoner.
Sikkerhetstilråding VEI nr. 2018/07T
Undersøkelsen av brannen i Oslofjordtunnelen 5. mai 2017 har avdekket at beredskapsplanen som var gjeldende under brannen var datert 16. juli 2012. Denne var utarbeidet med foreldede tall for trafikkmengde. Undersøkelsen har også avdekket at det var flere feil med den tekniske sikkerhetsutrustningen i tunnelen under hendelsen, og at beredskapsplanen ikke omhandlet korrektive tiltak ved svikt i teknisk utstyr.
Statens havarikommisjon for transport tilrår at Statens vegvesen ajourfører beredskapsplanen i henhold til forskriftskrav, samt krav og retningslinjer i håndbøker.
Sikkerhetstilråding VEI nr. 2018/08T
Undersøkelsen av brannen i Oslofjordtunnelen 5. mai 2017 har avdekket at Statens vegvesen som tunnelforvalter ikke har gjennomført jevnlige øvelser i Oslofjordtunnelen i henhold til krav i tunnelsikkerhetsforskriften. Siste fullskalaøvelse i tunnelen ble gjennomført 31. mai 2012, fem år før brannen inntraff.
Statens havarikommisjon for transport tilrår at Statens vegvesen, i samarbeid med utrykningsetatene, planlegger og gjennomfører jevnlige øvelser i Oslofjordtunnelen under så realistiske forhold som mulig.
Fakta
| Sted | The Oslofjord tunnel |
| Hendelsesdato | 05.05.2017 |
| Ulykkestype | Brann i kjøretøy |
| Veitype | Riksvei |
| Fylke | Akershus |
| Politidistrikt | Follo |
| Kjøretøy/trafikant | Vogntog semitilhenger |
| Type transport | Godstransport |
| Veiregion | Region øst |
| Ulykkeskategori | Ulykke i tunnel |