Environmental Engineering: Incident and Accident Investigation Report

This report provides a thorough incident and accident investigation of the Kaprun fire disaster, which occurred on November 11, 2000, in the Kaprun Tunnel. The report utilizes the Quadrant Model to analyze the behavioral, values, rules, and cultural factors contributing to the tragedy, where 157 lives were lost due to a fire caused by a faulty electric heater. The report details the timeline of events, from the train's departure to the aftermath of the fire, and conducts a Root Cause Analysis to identify critical failures, including design flaws, manufacturing rule violations, and the cultural aspect of skiing. The report also provides a detailed discussion on the hierarchy of controls and offers several recommendations to prevent similar incidents in the future. These recommendations include using the right materials in manufacturing, improving infrastructure accessibility, and implementing effective fire suppression systems. The report also assesses the likelihood of success for these recommendations. The report is a comprehensive analysis of the Kaprun fire disaster, providing valuable insights into the causes, consequences, and preventive measures related to this significant environmental engineering incident.

Running head: INCIDENT AND ACCIDENT INVESTIGATION
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Incident and Accident Investigation
Student PI
Name of Student
Institutional Affiliation
Name of Professor
Date

INCIDENT AND ACCIDENT INVESTIGATION
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Question 1 – Evidence and Timeline
1(a)
The Quadrant Model is normally used to determine the cause of a problem based on the
available evidence and offers the recommendations which should be adopted to avoid the repeat
of the problem. This model also helps to establish a solution to the given problem where
possible. The Quadrant Model is usually based on four distinct quadrants. The four quadrants are
the behavior quadrant, the values quadrant, the rules quadrant, and the culture quadrant.
Most incidences and accidents which occur are always caused by our values, our cultures,
the stipulated rules or our behaviors. In the Kaprun fire disaster which occurred on 11TH
November 2000, 157 people lost their lives as a result of fire outbreak when the train entered the
tunnel. The cause of the fire was the failure of one of the electric heaters which were installed in
the compartments of the conductor. The heater was not designed to be used in a moving vehicle.
The heater overheated and ignited a slow leakage of the highly flammable hydraulic oil. This
resulted in the melting of the plastic fluid lines which led to the deadly fire flames and reduced
hydraulic pressure which resulted in the stoppage of the train and failing of the doors (Harris,
2004).
The available evidence about the Kaprun fire disaster can be presented using the
Quadrant model. In this model, the available evidence is presented in the four quadrants of the
Quadrant Model as follows:
The behavior quadrant. This quadrant explains the causes which could have resulted from
the behavior of the people. The skiing behavior of the people lies in this quadrant. All the victims
of the inferno had boarded the train to go for skiing at Austria's ski resorts.

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The values quadrant. This quadrant describes the values, attitudes, principles, and the
beliefs which are different in different people. Values are closely related to behaviors, but they
are not observable to the general public like the behaviors.
The rules quadrant. This is the quadrant which contains all the procedures or the rules
which govern the people in organizations, institutions, countries or other different places. The
use of the wrong electric heater in the train was as a result of going against some rules which
govern the manufacturing company. The companies should be very strict on their rules to make
sure all the materials used in the manufacturing process are the materials which meet the
required standards. Also, on making funicular railways and other types of railways, the safety of
the passengers should be considered by making sure these railways can be easily accessed for
assistance in times of accidents (Allegheny Portage Railroad Reading 1: Riding on the inclined
plane, 2009).
The culture quadrant. This quadrant which describes the customs, totems, artifacts,
attitudes, and other descriptions of a certain group of people. It may also describe the values,
rules, and behaviors which are practiced by the group. Skiing is a common culture in different
communities. Skiing was the main reason why the victims boarded the train only for them to lose
their lives in the deadly inferno.

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The diagrammatic presentation of the Quadrant Model
Internal External
Individual
Groups
In the Quadrant Model, the values and the behaviors apply to individual persons while
the culture and the rules exist in a group of people. It is also good to mention that the values are
internal and can’t be observed by general the public, while the behaviors are external and
observable to the general public.
Values Behaviors
Culture Rules

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1(b)
The values quadrant. This quadrant encompasses the values which could have led to the
Kaprun fire disaster. The entertainment needs of the people which were the root cause of the
tragedy lie in this quadrant. The people who lost their lives in this tragedy were on their way to
Kitzsteinhorn glacier for mountain skiing to entertain themselves. The entertainment needs lie in
this quadrant since entertainment is an internal desire of the people. However, this evidence has a
shortcoming in that we can’t say all the people who lost their lives in this inferno longed for the
entertainment of mountain skiing. We have some small children who lost their lives, and they
didn’t need any entertainment. The many people who lost their lives in this inferno were burnt
completely leaving ashes, and some DNA tests were required to identify the victims (J.Meyer,
December 2003).
The behavior quadrant. This quadrant covers the behavior of the people which led to the
disaster. The recklessness of the driver and other control staff was among the causes of the
disaster. The use of the inappropriate electric heater in the train resulted from recklessness. The
behavior of skiing in groups was also a cause of the disaster. The people of who lost their lives in
this tragedy were heading to skiing at Kitzsteinhorn glacier in a big group. The drivers and other
train operators should always be careful to ensure all the materials used in their trains or other
machines are the right materials which meet the required standards to avoid unnecessary
accidents.
The culture quadrant. This is the quadrant which covers the different cultures of different
people. Skiing is one of the normal cultural practices of different communities and was the main
reason behind the journey which turned to be a tragedy.

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The rules quadrant. This quadrant covers the rules or the procedures which govern
different organizations, schools, countries or other places. The rules which govern the company
which was operating the train were not followed well. The use of the inappropriate electric heater
which was the main cause of the inferno resulted from breaking some manufacturing rules. The
manufacturing rules should always be followed accordingly to avoid such problems. The
funicular nature of the train also contributed to the many deaths which resulted from the accident
(The Kitzsteinhorn tunnel disaster , 2000). The rules governing the construction of railways and
other transport structures should consider the slopes and the conditions of the areas where the
railways are constructed to make sure they are constructed in suitable slopes and places where
the people can be saved easily in case of accidents.
1(c) Evidence and citations provided in parts (a) and (b)
1(d) The timeline of events which led to the fire and the subsequent loss of lives
Time Event Contributory
Factor
The categorization of
the factor in the
Quadrant Model
9:00 a.m. The train left the terminus. To take people to
Kitzsteinhorn
glacier for
skiing/entertainment
Behavior/culture/values
quadrant
Some minutes
after 9:00 a.m.
The electric fan heater caught
fire and overheated. The
conductor tried to communicate
with the control team but failed
to solve the problem as the
situation was worsening.
Manufacturer’s
design fault and
communication
failure
Behavior/Rules
quadrant

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Some minutes
after
overheating of
the electric
heater
The overheated electric heater
heated the ignited the highly
flammable oil which melted the
plastic fluid lines
Manufacturer’s
design problem Rules quadrant
Immediately
after the
ignition of the
highly
flammable oil
The ignited oil resulted in the
flames and reduced pressure
which led to the train stoppage
failure of the doors.
Design problem Rules quadrant
Immediately
after the
deadly flames
began
Severe injuries and many
deaths
The deadly flames
and the toxic fumes
The time the
people saw
some huge
smoke coming
from the tunnel
People tried to access the tunnel
to come and help the victims,
but their efforts failed.
The dangerous toxic
fumes prevented the
people from
accessing the tunnel
Behavior/rules
quadrant
1(e) The solutions given in the previous sections cater for this part.

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Question 2
(a) A Root Cause Analysis
In the construction of a Root Cause Analysis, we consider all the possible causes which
could have led to the accident. These causes are based on the available evidence. We use
a Root Cause Analysis tree to determine the causes of the accident.
The Kaprun Fire Disaster
The cultural/behavior
causes of the
accident
The design causes of
the fire disaster
The rules as causes
of the disaster
The skiing
behavior
Entertainment
needs Wrong
design of
the faulty
heater
Poor
design of
the tunnel
Failure to follow
the correct
manufacturing
rules/procedure
s

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2(b)
From the causal tree, we can identify the root causes of the fire disaster to be the skiing
behavior of people, the entertainment needs of people, the wrong design of the electrical heater,
poor design of the tunnel, and failure of the companies to follow the correct manufacturing rules
and procedures.
2(c) Recommendations and conclusions
The hierarchy of controls are the methods which are used in the implementation of
controls to reduce or eliminate the risks or hazards which may cause loss, damage or injuries in
the implementation sources. The hierarchy of controls normally consists of various control levels
arranged in a hierarchical order to form a special hierarchical pyramid. These levels are the
hazard elimination level, the hazard substitution level, the engineering level, the administrative
level, the behavioral level, and the personal protective equipment level (Hierarchy of Controls,
2017). (See the appendices for the hierarchy of controls pyramid).
Some recommendations should be implemented to avoid the reoccurrence of a similar
tragedy in Kaprun or any other place in the world. These recommendations include the
following:
The companies should make sure they use the right materials in their manufacturing
processes. The main cause of the fire was overheating of an electrical heater which was not
designed to be used in a moving vehicle. The companies should be very strict to ensure such a
mistake will not happen again.

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The countries should always ensure their railways, and the other infrastructure used for
transport is accessible anytime. This will help to offer the necessary assistance in good time in
case of such an incident in the future.
The companies constructing the tunnels should always make sure the tunnels have a good
automatic sprinkler system to put out the flames of fire in case of occurrence of fire accidents in
the tunnels.
The manufacturing companies should also make sure the doors and the windows they
install in trains and other motor vehicles can be opened easily in case of any problem. The reason
for the many deaths of people in this disaster was the failure of the door systems.
In the implementation of these recommendations, it is good to give special consideration
to the hierarchy of controls.
2(d)
The likelihood of the success of the recommendations
The use of the right materials in the manufacturing process can be easily implemented.
The companies should make sure they use the required materials in their manufacturing process.
The workers who fail to use the required qualities and standards of the materials should be
punished severely as they are posing a threat to the lives of the users of the products.
The accessibility of the infrastructure used for transport should be addressed seriously by
the companies which make the tunnels and the other infrastructure. This will help to reduce the

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number of deaths which occur due to some inaccessible tunnels, hilly roads, swamps, and other
unfavorable topographies.
Establishing a good sprinkler system to put out all the flames of fires in cases of accidents
may be a bit challenging especially in very long and wide tunnels. However, the companies
which construct the tunnels should look for some ways which can help to put out the fires which
may occur in the tunnels (Mawhinney, April 2013).
The companies which make trains and other motor vehicles should always make sure the
doors and the windows of the vehicles and the trains can be opened easily in case of any problem
for the safety of the passengers. This can be easily implemented by the manufacturing companies
(Raye, 2013).
2(e) Covered in part 2(c) and 2(d)

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Question 3. The Incident Report
Table of Contents
The Executive Summary...........................................................................................................................13
The details of the investigation team.........................................................................................................14
The details of the incident.........................................................................................................................14
(a) Summary of the incident............................................................................................................14
(b) The summary of the evidence and data......................................................................................15
(i) Direct evidence..........................................................................................................................15
(ii) The supporting documentation...............................................................................................15
(iii) Interview evidence.................................................................................................................15
Details of analysis.....................................................................................................................................16
(a) Methods used.............................................................................................................................16
(b) Output from RCA......................................................................................................................16
(c) Unknowns, Uncertainties, and Controversy...............................................................................16
(d) Conclusions drawn.....................................................................................................................17
Recommendations.....................................................................................................................................17
(a) To prevent the reoccurrence of this type of incident..................................................................17
(b) Expansion..................................................................................................................................18
(i) Management System..................................................................................................................18
(ii) Geography.............................................................................................................................18
(iii) Other jobs..............................................................................................................................19
(iv) Other companies....................................................................................................................19
(v) Other industries......................................................................................................................19
Appendices................................................................................................................................................21