Failure Knowledge Database / 100 Selected Cases

The submergence accident at the tunnel of Kokubugawa River diversion channel【Matsudo City, Chiba Prefecture, on September 19th, 1991.】
Masahiko Kunishima, Sachiko Tsukahara (Note1)
On Sep tember 19 th i n 1991, because of th e heavy ra in w ith th e typhoon N o.18, th e m uddy st ream
flowed to the diversion channel tunnel under construction at Matsudo City in Chiba Prefecture, and sevenworkers in it died. Since the temporary cofferdam at pit mouth collapsed, the muddy stream flowed in. Inthe criminal action over this accident, the owner was charged with professional negligence.
1. EventOn Sep tember 19 th i n 1991, because of th e heavy ra in w ith th e typhoon N o.18, th e m uddy st ream
flowed to the diversion channel tunnel under construction which had been constructed for discharging thepart of the water in Kokubugawa R iver (Matsudo City, Chiba Prefecture) to Edo River (via Saka River),and all seven workers in it died. The figure 1 shows the details of the site on the day after the accident.
On t his day, Chiba Prefect ure had h eavy rain, a nd t he w ater w hich overflowed fro m K okubugawa
River and Wanagaya Irrigation Canal, flowed into the entrance of the tunnel. The temporary cofferdam atpit m outh c ollapsed, and t he m uddy stream flowed i n. Th e w ater attacked t he s ite under ex cavation,
which was about 1600 meters away from the pit mouth, and seven workers in the tunnel were confined. 7
workers were found drowned to death consequently.

Figure1: The place of Kokubugawa River diversion channel1

Failure Knowledge Database / 100 Selected Cases

Figure 2 the aspect of the site on the day after the accident (September 20th, 1991)(Source: “Construction Accident" (Nikkei B P)

2. Course (ref. figure 2. in the next page, workers A ～ D are correspondent to the figure.)
After 7 a.m . on Se ptember 19 th in 1991, be cause of the ty phoon, warning of heavy rains and loc al
flooding an d thu nder, strong wind an d h igh surf warning were announced in the nor thwest d istrict in
Chiba Prefecture such as Matsudo City. In Matsudo City, there was rainfall of 31millimeters perhour from 4 p.m. to 5 p.m., just after accident occurred. There was rainfa ll of 2 14 m illimetersfrom the 18th to 5 p.m. on the 19th, and many roads near the construction site were flooded.
In the tunnel in the field, the workers were carrying out the excavation in spite of theheavy rain. While more than a dozen people went up to the ground from the pit after 4 p.m.,the other 5 workers continued to carry out spraying concrete work.
[Around 4:30 p.m.]
The rep ort fr om the c hief of t he c onstruction sec tion of C hiba Pref ecture w hich said " the w ater i n
Kokubugawa River

has exceeded t he tem porary em bankment" cam e to th e fiel d ofTobishima

Construction who was in charge of construction of the main body of the tunnel. He told the site agent ofTobishima Construction Company over the phone that the staffs of S Construction who was in charge ofconstruction of the temporary cofferdam were piling sandbags. The site agent of Tobishima Construction
2Failure Knowledge Database / 100 Selected Cases

directed the employees of the company to escape from the tunnel.
Afterwards, the Kokubugawa River construction section chief of Chiba prefecture told the site agent ofTobishima Construction Company over t he phone that he w ould like the agent to communicate directlywith Shimizu Construction Company, and he offered to start spraying the working face. The construction
chief and the workers (C in the figure) received this direction, and they went down the pit in order to tellof the c hange in i nstructions. The worker C ran farther i nto the tunnel, and he directed the five workers
who were carrying out excavation to leave after the spraying work . At the same time, the construction
chief waited at the bottom of the pit.
[Around 4:45 p.m.]
Since the water level had already reached the height of the entrance of the tunnel when the site agent
and t he w orker of Tobishima Constr uction w ent t o se e h ow it w as going, they di rected the w orkers t oescape from the tunnel. The worker E at the site went down the pit, and he shouted "Come back at once".
[Around 4:50 p.m.]
As received the evacuation directive, the workers (A, B and C) once returned to the bottom of the pit,
and they joined the chief. However, 3 people except for the chief returned again to the back of the pit tocall 3 people who were still working.
[Around 5 p.m.]Moreover, the worker D who had returned from seeing the temporary embankment also went down thepit in order to inform of the danger, and he got past the chief and disappeared into the tunnel.
[Around 5:18 p.m.]
The temporary cofferdam collapsed because of the hydraulic pressure of the muddy stream just after
the worker D ran to the back of the tunnel. The flash flood surged ahead with the muffled thump, and thetunnel was submerged. The total of 7 persons consisted of the 3 persons in the back and the 4 workers (A,B, C and D) were drowned. The construction chief was escaped by clinging to the stair and by climbing
up it, in spite of the fact that he had been soaked up to the neck in the muddy stream.
[After the accident occurred]Though the drainage by the pump from the tunnel started at 9 p.m., the water level in the tunnel did not
drop v ery much, an d res cue w orkers co uld not enter t he tunnel and they wait ed. After midnight whe nabout 7 hours had passed since the accident occurred, a rubber boat and oxygen tanks for di ving searchwere carried in, but the lack of oxygen in the tunnel complicated rescue efforts.
At last, 6 persons were found dead and they were recovered four days after the accident. The remaining
one person was also soon found dead.
3Failure Knowledge Database / 100 Selected Cases

Figure 3 the brief diagram of the temporary cofferdam of the pit mouth(Described by "Construction Accident (Nikkei BP)" and "Asahi Shin bun, dated on September 22nd, 1991")

3. Cause1) The construction director made an error of judgment about how dangerous it was.
In spite of the fact that there was the imminent danger, Chiba Prefecture didn't determined to stop theoperation, but directed to carry out the operation of s praying the working face. Once the director of t hecontractor (the site agent of Tobishima Construction Company) directed the workers to stop the operation,
he could not go against the instruction of the owner, and he directed them to continue the operation.
2) There was a problem in the information system for risk aversion.
Though the indication of the construction director who was the owner might be changed, in spite of thefact that the first news of the overflow of the river had been announced about 45 minutes before the flood,
this information did not re ached t he fi eld dire ctly. Th ough t here w ere tw o t elephones w hich had been
linked with the ground at the back of t he tunnel besides the bottom of the pit, even the nearest one was
300 meters away from the field. Therefore, running to the back was the only way to inform of the danger.
As evidenced by the process of the accident, many people moved in and out within 45 minutes in order toinform of the danger, and the slight difference of their action divided their life-and -death.
And, from another viewpoint, the difference of the contractors between construction of the main bodyof the tunnel (Tobishima Construction in charge) and construction of the temporary cofferdam (ShimizuConstruction in charge) caused the delay of the recognition of the danger and communication.
3) The design of the bolt of the temporary cofferdam differed from the original.
The temporary cofferdam which collapsed in this accident was constructed by putting up the H-shaped
steel frame and horizontal sheathing and by piling the sandbags in front of it. (Ref. Figure 3) The lack ofintensity of the fixing part at the bottom of the H -shaped steel frame caused the washout. Actually, there
4

Failure Knowledge Database / 100 Selected Cases

was a dif ference between the original design of this temporary cofferdam and the result of construction.
Because the staff of the consultant did not understand the situation of the field sufficiently and the design
condition did not match the situation, Shimizu Construction as the owner changed the design by itself.
However, the strength of the bolt became lower than that of the original design. Also, even though thecontractor ask ed th e chi ef o f Kukubugawa River construction sec tion of C hiba Prefect ure to sh ow t hecalculation book of the intensity in the design change, this request was rejected.

Figure 4 the section of the temporary cofferdam（Described by "Construction Accident (Nikkei BP)"）

Figure 5 the fixing part at the bottom of theH-shaped steel frame（Described by "Construction Accident (Nikkei BP)"）4. Immediate Action
In t his accident, th e construction director (the ch ief of K okubugawa c onstruction sect ion of C hibaPrefecture) w as char ged with pr ofessional n egligence, a nd he was giv en prison se ntences of 2
years-imprisonment with a suspended sentence of 3 years. (In May, 1998, the defendant appealed, but theSupreme Court rejected)
Tokyo High Court indicated that the accident was caused by not taking measures to make the workers
evacuate urgently. The court judged that the fault was not directing work continuation, but ignoring theemergency a nd n ot t elling workers to leave the sit e. As there was the ris k of wa shout, the Hi gh C ourt
indicated t hat Chi ba Prefecture ha d a d uty t o m ake peo ple i n t he tu nnel e vacuate urgently and th e
defendant who was in charge of installation and management of temporary cofferdam actually had thisduty.
Tobishima Construction and the site agent of t his company were sent to the public prosecutor's officefor violation of Industrial Safety and H ealth Law, and a fine of 200000 yen was imposed in Se ptember,
1994.

5Failure Knowledge Database / 100 Selected Cases

5. Countermeasure1) The countermeasure to the unusual weather
・ During unus ual we ather s uch as typhoons, a bnormal situations may com e about. I t is necess ary toinstall the system which directs workers to stop work under abnormal situations and to deal with it.
・ When abnormal situations come about, what should be done immediately are pulling the workers off
the s ite and s ecuring their l ives. Eve n t hough the w ork m ust be car ried out, i t sh ould not be d one
until the abnormal situation finishes.
・ The u nusual s ituation w hich m ight oc cur sh ould b e assumed i n advance and the countermeasures
should be examined.
2) Measures to distribute information
・ Measures t o dis tribute i nformation s hould be s ecured b eforehand s o that the fi eld a nd theconstruction director can communicate closely each other in an unusual situation.
・ In ord er t o distribute th e information quickly to the fi eld sin ce th e unusual si tuation is co nfirmed
even when m ultiple co nstruction co ntractors engage in

one c onstruction, t he measures ofcommunication should be confirmed in advance.
3) The consideration in designing・ Though bolts are often used i n the d esign of te mporary structures, t here are many cases tha t t hestructures built temporarily collapse since the actual conditions in the field does not always meet thedesign i ntent (to make it re sist by shear stress) and t he ben ding m oment might b e app lied, if i t isdesigned to resist by shear s tress. The design of t emporary structure such as this cofferdam requires
not only accuracy of calculation process, but prudent consideration for safety on the basis of the site
situation. And, information su ch as

the ca lculation pro cess of designing a nd c onditions forcalculation should be showed all the time.
・ The unusual situation w hich might occur shou ld be a ssumed in a dvance a nd design w ith s afetymargin should be examined.
・ In the case of changing the design condition, when there is a drastic change in the design conditions
and loading conditions in the process of the change should be confirmed.

6．Knowledge
・ In the construction field w hich might be damaged by a natural disaster, the prior investigation andpreparation such as investigations of the flood career of the river and preca utions for heavy rain at
the u pper riv er bas in sho uld be suf ficiently carried o ut. (For e xample, i nvestigations of the fl ood
career of the river and precautions for heavy rain at upper river basin etc.)
・ It is necessar y to pre pare for unusual s ituation and countermeasures should be e xamined. It is also
important to carry out the virtual exercise and to confirm the criterion of risks.
6Failure Knowledge Database / 100 Selected Cases

・ The c onstruction dir ector s hould gras p t he si tuation o f the fi eld a ccurately in the em ergency. Riskshould be assessed calmly, and instructions should be given in order to take measures to avert the riskin an early stage.
・ Even when there is difference of judgment of the situation among the construction director, the site
agent and workers, protection of the workers' lives should be prioritized.
・ The fi eld dire ctor s hould se cure the m easures t o c ommunicate i n order to contact closely with t heconstruction director and with the outside in unusual situation.
・ Assuming the case that information is transmitted via some traders, the simulation and field exercise
should be carried out in advance.
・ The designer sh ould g rasp t he si tuation o f th e fie ld and c arry o ut t he de signing wi th su fficientconsideration to t he safety. In the c ase of chan ging t he desig n, t he i nformation s hould be s hared
among contractors, the designer and the owner, and safety should be secured from the planning stage.

7．Sequel
Early on the 20th, the day after the accident, a se cond accident occurred when the drainage work had
been carried out in the tunnel. The city road of Matsudo just above the edge of the tunnel caved in, and a
big hole of 8m diameter appeared was got in the road. It was caused by a reduction in the strength against
the pressure of the t unnel because of t he drainage work. As a result , the nearby inha bitants evacua ted
immediately. The in habitants a lso sh owed an ger an d d oubted to the c onstruction its elf because a"accident caused by others" occurred.

＜Reference＞
・"Construction accident"(Nikkei Construction published by Nikkei BP)
・ Asahi Shim bun edited on 20th (evening), 22nd and 23rd September in 1991.
・ Mainichi Shim bun edited on 20th (morning and evening), 22nd and 24th September in 1991.
・ The law reports of the Supreme Court：http://courtdomino2.courts.go.jp/schanrei.nsf（The case of professional negligence resulting in death, the year of 1998, (あ) 677th, judged at second
petty bench on 7th February in 2001.）
Graduate school of Frontier Sciences, The University of Tokyo（Note1）7