Report on fire in a heavy goods vehicle in the Gudvanga tunnel on the E16 road in Aurland on 5 August 2013

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. 

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.

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.

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. 

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.

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.