Abstract
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.
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