The 2017 Ahmedpur Sharqia oil tanker explosion and fire, costing 219 lives, is one of the biggest ever road transportation disasters in history. This paper presents a detailed investigation and analysis of the accident circumstances and the series of events that contributed to the calamity. The investigation follows a holistic approach that examines the whole system including driver management, vehicle design, road design, and police management of the spillage scene.

The analysis shows that although the first cause was driver dozing off behind the wheel, it was a complete system failure which created a domino effect. If all safety systems were in place, there would have not been any serious consequences of that first error. The investigation revealed that there were serious lapses in the design and fabrication of the vessel and truck in violation of UN-ADR safety standards and Pakistan's OGRA-RT standards andno proper protocols or SOPs were followed for driver workload and shift management by Shell Pakistan Ltd. and its contractors. Mismanagement of the post crash scenario by local law enforcement agencies was also a major serial failure. The study provides crucial lessons on the domino nature of such disasters.

2017年的Ahmedpur Sharqia油轮爆炸和大火造成219人丧生，是历史上最大的公路运输灾难之一。本文对事故情况和造成灾难的一系列事件进行了详细的调查和分析。该调查采用整体方法，对整个系统进行了检查，包括驾驶员管理，车辆设计，道路设计以及溢出现场的警察管理。

分析表明，尽管首要原因是驾驶员在方向盘后打do睡，但这是一个完全的系统故障，造成了多米诺骨牌效应。如果所有安全系统均已到位，则该第一次错误不会有任何严重后果。调查显示，该船和卡车的设计和制造存在严重失误，违反了UN-ADR安全标准和巴基斯坦的OGRA-RT标准，壳牌巴基斯坦有限公司未遵循适当的协议或SOP进行驾驶员工作量和班次管理。及其承包商。地方执法机构对撞车后场景的管理不善也是一个重大的连续失败。该研究提供了有关此类灾难的多米诺骨牌性质的重要课程。