Kaprun Train Incident: An In-Depth Investigation and Analysis Report

This report presents a detailed investigation of the Kaprun train incident, which occurred in a tunnel and resulted in significant loss of life. The report includes an executive summary outlining the investigation's aims and findings. It details the investigation team, the incident summary, and the evidence collected, including direct evidence, supporting documentation, and interview transcripts. The analysis section employs a Quadrant Model and Root Cause Analysis to identify the incident's causes, such as negligence, improper management, and operational failures. The report concludes with recommendations for preventing similar incidents, focusing on restructuring operations, establishing codes of conduct, improving staff proficiency, and automating systems. Appendices with images of physical evidence are also included, providing a comprehensive overview of the incident and its investigation.

Running head: INCIDENT AND ACCIDENT INVESTIGATION
Incident and accident investigation
Name of the Student:
Name of the University:
Author Note:

1INCIDENT AND ACCIDENT INVESTIGATION
Executive summary
The main aim of this report is to provide an in-depth analysis and evaluation of the investigation
of Kaprun train incident. Moreover, it would help to create a better and deeper understand of the
tools and methodology that are required to develop such incident and investigation report. This
report comprise of several valid and rationale findings as well as effectual analysis of the facts
that has generated a reasonable conclusion to acquire a valuable knowledge. Besides that, the
findings of this report is not ultimate and can be explored further for a more profound and
effectual investigation. Thereby, reviewing this report would provide a profound knowledge of
the actual grounds of the incident and the correlations of aspects that are associated with the
incident predominantly.

2INCIDENT AND ACCIDENT INVESTIGATION
Table of Contents
Details of investigation team...........................................................................................................3
Details of incident............................................................................................................................3
Summary of the incident..............................................................................................................3
Summary of evidence and data....................................................................................................3
Direct evidence........................................................................................................................3
Supporting documentation.......................................................................................................4
Interview evidence...................................................................................................................5
Details of Analysis...........................................................................................................................6
Methods used...............................................................................................................................6
Output from RCA........................................................................................................................9
Conclusion.......................................................................................................................................9
Recommendations............................................................................................................................9
Reference list:................................................................................................................................11
Appendices....................................................................................................................................13

3INCIDENT AND ACCIDENT INVESTIGATION
Details of investigation team
The investigation has been conducted by the Decisive Incident Investigation Team (DIIT)
that has been intended to scrutinize every detail of the Kaprun incident to uncover the actual
grounds of the incident. Primarily, a team of four members who are experts in investigation had
visited the scene and initiated in-depth exploration of the disaster effectually. They carry a good
record in terms of quality investigation and cater effectual findings of the incidents.
Details of incident
Summary of the incident
The incident took place at Kaprun while an ascending train was heading to the
Kitzsteinhorn glacier carrying 167-passengers comprising of men, women and children. While
travelling on the route, a sudden fire has caught on the back end of the train while the train was
passing through a 3.2 kilometers tunnel. It has created a massive loss of life resulting in death of
155 people by the fire blaze that has broken out. Besides that, two more people had died due to
the inhalation of toxic smoke in the train. All the passengers who had boarded the train were
mostly skiers, travelling to the glacier mountain with an objective to go for skiing (Ho & Hsu,
2014).
Summary of evidence and data
Direct evidence
Although there are inadequate evidences that would assist to identify the root cause and
the suspects however, there are few evidences that have been found as well as gathered from
considerable sources, and those are as follows:

4INCIDENT AND ACCIDENT INVESTIGATION
 The lower end of the train was fully burnt
 The walls of the tunnel have been damaged by the toxic smoke and it displays
black spots all over
 Ashes of the burnt train’s metal base has been spread all over the tunnel
 Melted rubbers of passengers ski boots found on the rugs of ladder which was for
quick escape purpose
Supporting documentation
Summary of interview: An assortment of interviews has been conducted with the local
people who has eye-witnessed the incident as well as the concerned railway staffs, with an
objective of gathering some amount of information that would be valid in nature (Carattin &
Brannigan, 2014).
According to the interview report of BBC news, the major reason for the incident was due
to a malfunctioning radiator of the funicular train that has sparkled all of a sudden while the train
was passing down the tunnel (Edgar, Sharples & Sidhu, 2016). On the other hand, as stated by
the president of district court of Salzburg to the concerned journalists that a amalgamation of
aspects has led to this dangerous incident. Besides that, with a presentation of report that has
been developed with assistance of five experts has said the ventilator of the heater inside the
cabinet of driver was become jammed or blocked and which caused the blaze (Breiling, 2016).
With support to the statement, he had also added that possibly there must be a leak of hydraulic
oil, which was dripping from a cable into the heater and then spread all over where the blaze then
inflamed heavily (Zia & Mitleton-Kelly, 2013).

5INCIDENT AND ACCIDENT INVESTIGATION
Images of physical evidence: Please refer to Appendices 1, 2 and 3 in the Appendices
section. There, the set of images that has been provided displays the leftover evidences, which
was found within the spot of the incident. This would cater a clear review of the incident that has
occurred during the month of November, dated 11 in the year of 2000.
Interview evidence
More than a few interviews have been carried out with the people living in the
surrounding region as well as with the railway officials. Primarily, the interview was verbal in
nature and no sound recording has been conducted due to security and privacy concerns of
interviewees. However, the findings are significant and which have shed light on the
investigation process effectively. Overall, seven interviews has been conducted that includes five
interviewees are the local natives and two interviewees are the railway officials who were on the
scene when the event has taken place. Below is the interview pattern that has been conducted.
Questions Responses
What is your name? My name is Johannes Judith.
How old are you? Well, I am 32 years old.
What is your occupation? I am a carpenter by profession
What did you saw during the incident? I saw a huge cloud of smoke coming out
constantly from the tunnel and a massive flame
out bursting.
How many casualties have you seen so far? It would be around112 people.
What would be the reason behind this
horrific incident?
I cannot comment on this.

6INCIDENT AND ACCIDENT INVESTIGATION
Details of Analysis
Methods used
Quadrant model
In order to gather considerable evidences, it is significant to apply methodologies and
structure to make it more effective and factual in nature. Concerning to such, a Quadrant Model
has been utilized to analyse the evidences more closely and effectually.
Interior Exterior
Individual
 Negligence of duty
 Improper management
system
 Burnt metal base of the
train
 Blame on the railway
officials
Collective
 Operations of the
management
 Compliance to duty
and responsibilities
 Failure of railway
officials in scrutinizing
the details of the
incident
 Negatives perceptions
of native against the
officials
Fig 1: Quadrant model of Kaprun train incident

7INCIDENT AND ACCIDENT INVESTIGATION
Negligence of duty: It has been noticed as well as observed from the evidences and
findings that there must be any sort of negligence in duty by the railways officials (Carattin &
Brannigan, 2013). It has been placed in the individual and in the interior quadrant as it was
observed and set for first priority.
Improper management system: The ineffectiveness in the management could possibly
lead the incident took place (Lisanti et al., 2015). It has been placed second in the interior
quadrant as it holds significance.
Burnt metal base of the train: The found metal base of the train has brought significant
recognition about the damages (Björck, 2016). Input in the exterior quadrant as it has been
gathered externally.
Blame on the railways officials: The public and the relatives of the victims had blamed
the official for the inappropriateness on their conduct of duty. This event occurred due to the
unanswered questions of the public and failure of finding the reasons behind (Silei, 2014).
Operations of the management: The functionalities of the management of funicular train
are not effective enough, as has lack of responsibility concerns that has made the situation
critical (Ho & Chen, 2015). It has been placed in the collective and exterior quadrant as the
evidence gathered collectively.
Compliance to duty and responsibilities: It has been identified that there must be no
compliance to duty and responsibility by the officials in evaluating the train conditions
effectively (Burns et al., 2013).

8INCIDENT AND ACCIDENT INVESTIGATION
Failure of railway officials in scrutinizing the details of the incident: The official has
failed to scrutinize the details of the incident and upshot to bring a valid reason for the happening
of such incident (Bossong & Hegemann, 2013).
Negative perceptions of natives against the officials: It has been observed by a round of
interviews with the native and relatives of the victims that, they were unsatisfied and unhappy
with the proceedings of their operations. Moreover, they put the blame of such incident on the
railway management totally (Silei, 2014).
Root cause analysis
In order to analyse the actual cause of the incident, the adoption of Root Cause Analysis
(RCA) would be effective in problem solving. Considering such, an effectual RCA has been
performed to scrutinize the aspects that have led to the disaster.
Fig 2: Root Cause Analysis

9INCIDENT AND ACCIDENT INVESTIGATION
Output from RCA
Ineffectiveness of management’s operation: The management of the funicular railway is
ineffective in nature and did not conducted their efficiently. There is no specific structure of the
management’s operation and it way to conduct proficiently.
Incompliance with rules and policies: The occurrence of such incident indicates that there
must be incompliance with rules and regulation of the organisation by the officials
predominantly.
Negligence of duty and responsibility: There must be possibility that the official
neglected their duty of care and responsibility. Concerning to failure of trains radiator and
inattentive response to such malfunctioning indicates such aspect chiefly.
Lack of effectiveness: In the overall, there is a lack of effectiveness in the proceedings of
the railway officials to prevent any sort of futility in the operation.
Conclusion
This is to conclude that the factors of evidence, which have been gathered has assisted to
shed a light on the investigation effectively. Besides that, it has been identified that the aspects
drawn are factual and rationale in terms of reason the causation of such incident precisely.
Recommendations
Prevention of reoccurrence

10INCIDENT AND ACCIDENT INVESTIGATION
It is crucial that effective actions are essential to prevent any such similar occurrence of disaster
in the near future; hence valid recommendation would be of great help in this matter. Below are
some recommendations to avoid such scenarios.
 Restructure of the overall organisation’s operation
 Establishing a valid and rigid code of conduct
 Officials need to be proficient and effective in performing their duties
 Regular monitoring of overall operation required by the top executives
 Technical staffs need to be attentive and ensure smooth functioning of train’s
operation at all times
Expansion
Management system: The management required to hire employees who are experienced
and skilled in this domain to handle responsibilities efficiently.
Automation: The overall railway’s operation system needs to be automated or
computerized proficiently which would help to avoid any sort of accidents or incidents.
Additional staffs: The organization required to employ additional staffs who would
crosscheck every technical detail prior to the journey of funicular train.

11INCIDENT AND ACCIDENT INVESTIGATION
Reference list:
Björck, A. (2016). Crisis Typologies Revisited: An Interdisciplinary Approach. Central European
Business Review, 5(3), 25.
Carattin, E., & Brannigan, V. (2014). Lost in abstraction: the complexity of real environments vs the
assumptions of models. In Fire Evacuation Model. Tech. Conf.
Carattin, E., & Brannigan, V. (2013). Science or science fiction? The use of human behavioral
models in fire safety regulation. Intersci. Comms, 553-558.
Edgar, R. A., Sharples, J. J., & Sidhu, H. S. (2016). Examining the effects of convective intensity on
plume attachment in threedimensional trenches. Chemeca 2016: Chemical Engineering-
Regeneration, Recovery and Reinvention, 613.
Breiling, M. (2016). Tourism Supply Chains and Natural Disasters: The Vulnerability Challenge and
Business Continuity Models for ASEAN Countries.
Zia, K., & Mitleton-Kelly, E. E. (2013). Agent-based modelling of large-scale socio-technical
systems in emergency situations. na.
Lisanti, G., Karaman, S., Pezzatini, D., & Del Bimbo, A. (2015). A multi-camera image processing
and visualization system for train safety assessment. Multimedia Tools and Applications, 1-22.
Silei, G. (2014). Technological hazards, disasters and accidents. In The Basic Environmental
History (pp. 227-253). Springer International Publishing.
Ho, Y. H., & Chen, L. J. (2015). Enhancing robustness of vehicular networks using virtual
frameworks. Telecommunication Systems, 58(4), 329-348.