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42 Roberts, A.F. (1989, July 1). "A Correlation of Eyewitness trackways in each bore to carry trains in each direction, and Accounts and Results of the Scientific Investigation," The separated by an enclosed central corridor called the gallery. King's Cross Underground Fire: Fire Dynamics and the Organi- The gallery is divided into two chambers; the lower one serves zation of Safety. Papers presented at a Seminar Organized by for pedestrian and maintenance access as well as for distribu- the Environmental Engineering Group of the Institution of tion of various electrical and safety systems, and the topmost Mechanical Engineers, pp. 4148. chamber serves as an air duct for the ventilation system pio- Rogerson, J.H. (1989, July 1). "Safety Auditing," The King's neered by BART. Cross Underground Fire: Fire Dynamics and the Organization BART officials were optimistic about the ventilation sys- of Safety. Papers presented at a Seminar Organized by the tem's design and ability to safely handle a fire under the Bay, Environmental Engineering Group of the Institution of but San Francisco's assistant fire chief had voiced concern that Mechanical Engineers, pp. 7176. fighting a fire in the tunnel would be like entering a 3-mile Simcox, S. & Wilkes, N.S. (1989, July 1). "Computer Simu- (4.8-kilometer)-long high-rise building that was lying on its lation of the Flows of Hot Gases from the Fire at King's Cross side and had no windows. Everyone had agreed that smoke Underground Station," The King's Cross Underground Fire: would be the major problem should a fire occur; they were all Fire Dynamics and the Organization of Safety. Papers pre- correct. sented at a Seminar Organized by the Environmental Engi- A few hours prior to the incident, at 4:45 p.m. on January neering Group of the Institution of Mechanical Engineers, 17, a westbound train had stalled in the tunnel for about 20 pp. 1925 (including diagrams). Also available in Fire Safety minutes. Passengers later reported that there had been sparks, Journal 18 (1992), pp. 4973. explosion-like sounds, and flashes that seemed to warn of a fire. Even closer to the time of the incident, at 5:15 p.m., patrons at the Embarcadero station on the San Francisco side 3.2.11 Bay Area Rapid Transit (BART) of the tunnel reported seeing smoke coming from the west Transbay Tunnel Fire side of the tunnel. Problems prior to the stalling of the 6:06 Location: San Francisco, California p.m. train that caught fire were acknowledged by BART, but Date: January 17, 1979 the system officials said there did not appear to be any con- Incident Category: fire nection between the earlier reports and the incident that Tunnel Length: 3.7-mile (5.9-kilometer) twin-bore closed the tunnel. tunnel with service tunnel Fatalities and Injuries: 1 fatality, 58 injuries (including 19 Analysis of the Incident firefighters) On January 17, 1979, at about 6:00 p.m., a fire occurred in the fifth and sixth cars of a seven-car train (Train No. 117) Synopsis traveling from Oakland to San Francisco in the Transbay Tun- During the evening rush hour on Wednesday, January 17, nel Tube Bore A. The train was stopped, passengers were 1979, a fire broke out in a circuit breaker in the fifth and sixth moved into the forward cars to avoid the fire, and the exhaust cars of a seven-car westbound BART train about two miles fans in both vents located at each end of the tube were acti- (3.2 kilometers) into the Transbay Tunnel. The train was vated to draw the smoke out of the tunnel tube. stopped by the emergency brake and could not be restarted. The last cars of the train were uncoupled from the train, An unsuccessful attempt to disconnect the burning cars but attempts to move the rest of the train were unsuccessful. delayed the evacuation of passengers by about 30 minutes, The NTSB later determined that the uncoupling system mal- during which the tunnel filled with smoke despite activation functioned because of a short in the train's control circuit. At of the ventilation system. Rescue efforts involved taking the the same time, personnel from BART and from both the Oak- passengers out through the service tunnel, although smoke land and San Francisco fire departments entered the tunnel entered both the service and the other main tunnel. to rescue staff and passengers. There were numerous miscommunications almost as soon as the incident began. San Francisco fire department tapes Analysis of Pre-Incident Information and Events showed a call from BART dispatchers at 6:00 p.m., but the dis- BART is a rapid transit district serving the San Francisco patchers stated that they had reached a wrong number and Bay area that includes mainline rail service between San Fran- were disconnected. At 6:09 p.m., BART contacted the Oakland cisco and Oakland via the two-bore Transbay Tunnel tube. fire department, which dispatched one unit of about 10 fire- The tube sections resemble huge binoculars in cross section, fighters. These firefighters proceeded to the Oakland West sta- 24 feet (7.3 meters) high and 48 feet (14.6 meters) wide, with tion to board a special train, while a second unit of firefighters

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43 entered the tunnel walkway on foot. The San Francisco fire The dense smoke limited visibility to almost zero and department was not officially contacted until 6:34 p.m., impeded rescue efforts; it took almost 40 minutes for Oak- 25 minutes after Oakland was notified and 34 minutes after land firefighters to reach the train. By that time, passengers, the first call made to the department was disconnected. many of whom had panicked, had crawled along the train's Indecision about the rescue train led to BART dispatching floor in an effort to escape the fire by entering the more for- an eastbound train filled with rush-hour passengers to act as ward cars. the rescue vehicle. The decision to send a train with passen- Once firefighters were able to reach the passengers, the pas- gers from the Embarcadero station was based on the view sengers were removed via a narrow trackside catwalk through that it would have taken at least 10 minutes to order the emergency doors to the gallery ways between the eastbound approximately 1,000 passengers off the train. When the train and westbound tunnel tubes and onto an eastbound train stopped in the tunnel to pick up the passengers stranded that took them to the West Oakland station. Paramedics from the disabled train, passengers in the rescue train were treated many people at the scene, where ambulances waited told only that they would be stopping for other passengers to take the more seriously injured to hospitals. but were not told that there was a fire in the other tunnel Of the injured people, 24 passengers, 19 firefighters, and tube. The rescue train remained in the adjacent tube for three BART employees were sent to three Oakland hospitals about 45 minutes, during which there were no lights or fresh and one San Francisco hospital. Most, with the exception of air on that train, and some passengers smelled smoke com- the firefighter who died, were treated for smoke inhalation ing from the other tunnel. and noncritical injuries. Because of the thick smoke and the Intense smoke minimized visibility and hampered rescue time it took firefighters to reach the wreck, a number of the efforts. It was later found to contain toxic materials attributed firefighters reported running out of oxygen. Despite the heavy to combustion of the train's polyurethane seats. The material smoke, a few of them were able to make it completely through had previously been identified as a potential fire hazard; the tunnel. Some of the Oakland firefighters walked the entire BART had received a $2.5 million federal grant for replace- length of the tube and emerged at the San Francisco end; they ment with less flammable materials. At the time of the inci- were among the seven firefighters taken to San Francisco dent, BART was preparing to secure bids for replacement General Hospital. seats and had estimated that it would take at least a year for new seats to be obtained and installed. The fire was declared under control at about 10:45 p.m., Damage and Service Restoration although it took more time for the fires in the rear-end cars to be fully extinguished. They were then pulled from the tun- Damage to the gutted BART cars was estimated at $800,000. nel by a diesel engine. Their windows and roofs were missing, No other monetary damage figures were publicized. and they were described as crumpled like pieces of tin foil. Although BART intended to restore service within days About 24 hours after the original incident, Oakland firefight- of the incident, criticism by California Public Utilities Com- ers arrived at BART's storage yard to douse a small fire that mission (PUC) investigators and Oakland and San Francisco flared in the gutted train. fire officials prevented this from occurring. The fire depart- ments criticized BART officials for not giving firefighters what they called "ultimate authority" during the incident. Fatalities and Injuries San Francisco's fire chief announced that his department The single fatality (Oakland firefighter William Elliott, 50, was planning to conduct its own investigation of events who died of a combination of smoke inhalation and flue gas surrounding the fire. poisoning) and the injuries to passengers and firefighters were BART had been running test trains through the fire- caused primarily by gases from the combustion of plastics. damaged tunnel prior to the meeting of the PUC. However, within 3 days of the incident, the PUC ordered BART to keep the Transbay Tunnel closed until a number of safety improve- Fire and Emergency Response ment actions had been taken, including the following: Fire personnel from the San Francisco and Oakland fire departments responded to the incident, which occurred Present sworn testimony that both tunnels were struc- about a mile (1.6 kilometers) from the Oakland end of the turally sound and operationally safe, and have the testi- tunnel tube. The fire started small and was originally recorded mony verified by either Caltrans or the California by the Oakland fire department as a two-alarm fire. Although Department of Industrial Safety. the tunnel's ventilation system was working, it did not expel Develop a plan to keep smoke from a burning train out of smoke quickly enough and allowed smoke to fill the tunnel. the gallery that separates the two tunnel tubes.