Ahmedpur Sharqia oil tanker tragedy: Lessons learnt from one of the biggest road accidents in history
Introduction
Major accidents happen in the process industries with relatively low frequencies but extremely severe consequences (Amyotte et al., 2016). Transportation of hazardous material is one of the most risk intensive tasks in the process industry (Torretta et al., 2017; Casal, 2018). Hydrocarbon fuel tanker truck accidents are capable of causing huge catastrophic damage and loss of lives if not managed. The biggest ever road disasters in terms of death toll have nearly all been fuel tanker truck explosions (Khan and Abassi, 1999) and with an exception of the 1978 Las Aflaque disaster in Spain that cost 217 lives (Arturson, 1981), similar disasters have almost exclusively been in developing countries like the recent south Kivu tanker explosion in Congo (230 casualties) and Okibie tanker explosion in Nigeria (121 casualties).
Major industrial disasters such as the Bhopal gas leak have been discussed voluminous times in literature (Amyotte et al., 2016; Broughton, 2005; Chouhan, 2005). The investigations into some similar, but much smaller disasters are also available in literature (Cuchia et al., 2004; Mishra, 2016; Bariha et al., 2016; Landucci et al., 2017) but to date, there has been no study dedicated to the Ahmedpur Sharqia tragedy.
Moreover, federal inquiries into such accidents often focus on identifying the first cause of the accident rather than the whole chain of failures (Newman, 2015). In the modern safe system approach the role of driver, transport companies, vehicle design, road and environment design, post-accident scene management, emergency and medical services all contribute to form a domino effect as described by some authors (Abdolhamidzadeh et al., 2011; Khakzad et al., 2018). This whole picture can also be illustrated by using the Haddon's Matrix approach (Goniewicz et al., 2016).
Many of these factors are covered by local and international regulatory frameworks, such as the United Nations European Agreement Concerning the Transportation of Dangerous Goods by Road (UN-ADR) Standard (United Nations, 2017).(Oil and Gas Regukatory, 2009) The international treaty will be renamed from January 1, 2021 as the term ‘European’ incorrectly gives the impression that the treaty is open for accession only to European states. As of 2020, 54 countries are part of the treaty and it is widely followed by multinational oil marketing companies (OMCs) in their operations globally. It outlines a set of safety standards including requirements concerning the construction and approval of vehicles and requirements for vehicle crews, operation and documentation among others. Pakistan plans to but has not yet acceded to UN-ADR. In 2009 Pakistan adopted similar laws based on UN-ADR 2009 version for the construction of vehicles for transportation of dangerous goods, known as the Oil and Gas Regulatory Authority - Road Transportation Standards (OGRA-RT) (OGRA-RT, 2009) which are binding for all OMCs operating in the country. UN-ADR is more comprehensive and updated but both these standards are very similar(European Commission, 2006). Additionally, there are also regulations limiting the working hours and rest times of drivers such as the EU directive on driving hours and working time (EC 561/2006).
The aim of this work is to study and identify the role of each factor in isolation to develop a better understanding of the system failure in the light of these standards. The knowledge gained could help prevent a tragedy like this from repeating.
This work has only been possible with the corporation of the (National Highway Authority, 1999) Ministry of Communication, Pakistan, National Highway and Motorway Police and Automotive Design and Safety Research, Pakistan which provided all data, reports and photographs related to the accident to the authors. The authors were also board members of the government inquiry committee therefore have firsthand knowledge of the catastrophe.
Section snippets
Initial reports
On 5:07am, June 25, 2017, an oil tanker owned by Marwat Enterprises Ltd. contractors for Shell Pakistan Ltd. carrying 50 KL of petrol off tracked and overturned on 799 North Bound, N5 Highway near the town of Ahmedpur Sharqia, Pakistan. The driver was initially unhurt during the rollover. The front compartment of the tank was punctured and product spillage occurred. People from the nearby villages gathered around the tanker to collect petrol. Police also arrived on the scene 12 min after the
Investigation methodology
An investigation into this mega disaster was a rather complex task. The wreckage was burnt, and the debris scattered due to the explosion. The rescue efforts had further moved evidence from their original position to make way for emergency vehicles. Witnesses of the rollover and the driver had expired due to burn injuries. Some who witnessed the later explosion and survived suffered severe burns and post-traumatic stress disorder (PTSD) to recall the sequence of events clearly.
Two authors were
Wreckage analysis of the vehicle
As shown in Fig. 1. The front and rear bumper had no sign of impact with any other vehicle, and there was no impact on the sides of the vehicle. There was no evidence of collision before the roll over as mentioned in some initial reports. This was evidently a single vehicle collision. The tank had exploded. The vehicle dimensions as measured are mentioned in Table 1.
The vehicle had only four axles in total instead of 6 axles that are usual for these vehicles. That implied that the vehicle was
Wreckage analysis of theTank
The thickness of the tank walls were 4 mm, in compliance with OGRA-RT regulations but less than current UN-ADR regulations of 5 mm. No major signs of corrosions were detected on the tank.
The tank had two compartments of 25 kL each and 4 manholes of 20 inch diameter. None of the manhole covers were open or leaked (Fig. 4). No manhole cover had any sign of tampering for fuel recovery as claimed by some media reports. Manhole C was torn during the explosion, not before it. The latch mechanism was
Highway analysis
N-5 at this section was a divided 4 lane highway with center median width of 1 m. This section of N-5 was major rural arterial with farm land on both sides of the road (Fig. 13). The lane width is 3.65m with outer left shoulder width of 2.5m and an inner right shoulder of 0.6m.
Left shoulder was not a full depth pavement. The road in this area is carried over on earth embankment and height of earth embankment was about 1.5 m. It was a level roadway with clear sight distance.
There were no signs
GPS and call data analysis
The vehicle was fitted with a tracker system. The tracker data was obtained and verified. The vehicle was travelling at approximately 35.5kmph northbound and was on the location at approximately 5:07am when it stopped moving. The driver had taken a breakfast/sehri break about an hour before the accident.
It was unearthed through vehicle GPS and cell phone data that the driver was alone in the vehicle and had been travelling for 17 h. This tragedy occurred one day before Eid when there was
Photographic and VideoEvidence
Several videos and photographs of the accident were circulating on social media. Most were of the destruction after the explosion but there were some videos that were of before the fire. The videos were all cross examined and where possible obtained from the original source via data transfer so the EXIF data remained intact. Exchangeable image file format (EXIF) is a standard metadata format in images that stores GPS location, camera information, timestamp embedded in the images.It can be
Reconstruction and sequence of events
Observations made in during the wreckage found the shaft and axle intact, ruling out the possibility of a mechanical failure as a cause of the crash. Tire failure was also observed not to be a cause as claimed by the driver. The wreckage had no evidence of collision with any other vehicle either. The theory presented in some news reports of the driver ejecting the moving vehicle was also incorrect as the steering wheel was found broken towards the left indicating the driver was inside the
Haddons matrix of the disaster
Empty Cell PRE CRASH CRASH POST CRASH DRIVER Work shifts were not regulated by the company, The driver was overworked and unrested
Driver was alone; most companies transporting HazMat have a two driver policy.
Driver had been driving all night. most companies transporting HazMat have daytime operations onlyHad no knowledge, training or SOP for handling a spillage situation, did not even inform the company or solicit fire brigade. VEHICLE The vehicle was higher than standards (4.2m instead of 4.0m) making it
Conclusion
The investigation reveals that although the first cause of the accident was driver micro-sleep behind the wheel, the whole catastrophe was indeed a full system failure that followed a domino effect. There was a complete lack of safety culture throughout and the event cannot be blamed on one factor alone.
Work shift management policies which prescribe mandatory work and rest periods, mandate at least two fully licensed drivers per vehicle and prohibit nighttime transportation of hazardous
Author statement
Omer Masood Qureshi: Investigation, Writing –Original Draft, Formal analysis. Ahmed Hafeez: Investigation, Formal analysis. Syed Saqib Hussain Kazmi: Investigation Writing –Review and Editing.
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
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