Emergency procedure instructions were "forgotten, incorrectly applied, applied too late or applied in the wrong order", the report from the Channel Tunnel Safety Authority said. It blamed the poor response on the company's complicated emergency procedures and poor staff training.
"The incident was more serious than it should have been because the emergency procedures were too complex and demanding and the staff on duty had not been adequately trained to carry them out," said Roderick Allison, chairman of the safety authority.
The findings also pointed out that there were "errors and delays" dealing with the blaze and there was early confusion about the seriousness of the fire.
The authority made 36 recommendations to ensure there would be no repetition of the incident, which led to 30 lorry drivers requiring hospital treatment after being trapped in a fume-filled carriage.
One of the most damaging revelations was that Eurotunnel's system for handling a fire alert was revealed to be deficient in a major emergency exercise eight days before November's blaze. The report points out that five of the first six fire detectors inside the tunnel only gave unconfirmed alarms, even though four security guards saw flames up to six feet high on the doomed goods train before it entered the tunnel.
It also says staff failed to halt other trains in the tunnel to prevent smoke and fumes building up and that Eurotunnel managers failed to act on a July 1996 staff-performance audit that revealed "many areas of concern" in the rail control centre.
Despite the report's tone, it did not recommend that Eurotunnel change its open lattice-sided wagons which carry freight lorries and have been criticised by experts who believe the design fanned flames as the train raced through the tunnel.
This theory was supported by the Fire Brigades Union, which called for the wagons to be banned. Mike Fordham, the secretary, said the fire was "a disaster waiting to happen that happened."
Eurotunnel disagreed, and has more than 70 similar wagons on order. "We welcome the safety authority's contribution and accept its criticism," said a spokesman for Eurotunnel.
Among the report's recommendations was a requirement that Eurotunnel abandon the present policy of drivers taking a train through the tunnel in the event of a fire so the blaze could be tackled more easily on the outside. It said the "drive-through" strategy failed on this occasion after an alarm caused the driver to stop and then the overhead power supply was lost.
The safety authority added that Eurotunnel should improve training of all staff involved in emergencies, with special training called for control- centre operators.
The authority said its report did not give a "green light" for Eurotunnel to restart freight shuttle services, which have been halted since the fire. The company, however, claim it will be able to resume goods services next month.
The authority said it would be advising the Anglo-French Intergovernmental Commission separately about Eurotunnel's proposals to restart.
Jeremy Beech, Kent's chief fire officer, who sits on the safety authority, said the criticisms expressed by the authority "do not immediately render the entire system dangerous or unsuitable. As a fire officer I would prefer to see Eurotunnel using a closed design for its freight shuttle wagons," he said, adding that he had no doubt the existing freight shuttles would "eventually be phased out".
John Prescott, Deputy Prime Minister, called for a clear timetable for implementing the recommendations of the CTSA's report, which he described as "an indictment of poor operating procedures and practices by Eurotunnel.
"Its recommendations for the future are addressed to Eurotunnel and I expect the company to implement them promptly and in full."
Eurotunnel must abandon its "drive-through" policy, which allows burning trains to continue through the tunnel.
All rolling stock must be tested to ensure it does not "leak" smoke into the interior.
Eurotunnel staff to be retrained to cope with emergencies.
Any member of staff failing a competence assessment should be removed from duty, re-tested and re-trained.
All control-centre procedures to be reviewed and simplified.
Staff must be tested regularly in order to maintain levels of competence.Reuse content