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Les enquêtes techniques

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publié le 21 octobre 2005 (modifié le 31 mars 2008)

Final report on the investigation into the November 6th 2002 accident on board the Paris to Munich # 261

This report (format PDF - 1,7 Mo) presents the sequence of events, analyses and recommendations of the technical investigation ordered by the Minister of Transport following the fire in one sleeping-car of the Paris to Munich train on November 6th, 2002, resulting most unfortunately in a particularly heavy death toll of 12 fatalities.

The technical investigation started by clarifying the fire scenario to identify all causes and factors which had an impact on its unfolding and severity. Next the investigation researched the different relevant areas brought to light, to determine preventive measures to be implemented to avoid any repetition.

The origin of the fire was located in the service kitchenette, where a hot plate was heating while in contact with objects and clothes placed on it or in its immediate proximity : these caught fire while the sleeping-car attendant had gone to sleep in his bunk in the corridor.
The sleeping-car atttendant was awoken by the fire in the kitchenette and ran to find the train controller. Neither was able to return to the sleeping-car where the fire had spread quickly and forbade any access.
The train with one sleeping-car on fire then stopped as it exited the Nancy train station, after the alert had been raised by the station staff and the catenary was de-energized.
In spite of a speedy response from the emergency services, 12 passengers perished asphyxiated by smoke and toxic gases, while 8 were able to escape by breaking the window of their compartment using various means.

Numerous causes and elements exacerbated the situation during this fire. The investigation highlighted specifically the following :
-  faulty use of the hot plate and working space, initial cause of the fire ;
-  low level of preparedness of the sleeping-car attendant when faced with emergency situations ;
-  haphazard communication conditions between members of the train crew in case of an emergency ;
-  locking of corridor door which prevented any passenger escape through that corridor, and blocking of access doors with hooks, which delayed rescuers.
-  susceptibility of sleeping-car to fire because of the very nature of certain materials (contributing to the quick development of blaze and the production of smoke and toxic gases) and because of limited anti-fire devices (no fire detectors, no extinguishers near the service area) ;
-  window-breaking hammers not visible enough to enable use of the compartment emergency exits.

Of the 19 suggested recommendations, 17 come from the draft report and 2 further ones were added (R 2b and R 9b).

Recommendations on the role of staff on board sleeping-cars aim at strengthening responses when faced with an emergency situation :
-  by holding a staff meeting at each train departure to know about specific communication and alerting arrangements, as is the case for all SNCF trains with sleeping-cars ;
-  by including emergency situations more specifically in instructions and training for this category of staff, particularly for service providers, and by requiring an acceptable foreign language fluency on international trains.

Concerning rolling stock, the recommendations aim at remediation of all sleeping-car characteristics which work against safety, and which are due most of the time to the outdated design dating back some forty years. Before this type of car is put back in use on the French national railway network, safety features will need to include the following :
-  removal of locking devices non compliant with the UIC regulations and which had been installed on access and corridor doors for security reasons ;
-  upgrading emergency exits and associated devices (window-breaking hammers, windows) as well as extinguishers ;
-  an audit on susceptibility to fire, based on the UIC recommendations, with upgrading in line with findings ;
-  improvement of safety and ergonomics of electrical equipment used for catering.
In addition and in cooperation with the other partner railway undertakings, the SNCF ought to :
-  check that all measures listed here above have been applied to all sleeping-cars used on the French network, since the age of the fleet could make it prone to similar defects ;
-  plan to equip all these sleeper-cars with smoke detectors and a public-address system, by a given date which will be set after studying implementation arrangements ;
-  study the introduction of a secure ventilation system in case of fire, to avoid toxic smoke propagation ;
-  improve means of communication to be used by on-board staff with at the very least an intercom system.

Finally, at the instigation of SNCF and the French Ministry of Transport (through its Land Transport Directorate), all these measures should lead to the up-dating, clarification and reinforcement of the existing construction standards as well as of the interoperability rules being prepared at an international level.