Concorde’s last flight in 2000. A piece of metal on the runway caused a tire explosion. Debris from the tire punctured the wing fuel tank and the fuel caught fire.
Toronto, Ontario, Canada
An Airbus 340 crashed in Toronto in 2005 during inclement weather (Figure 20.2). The aircraft touched down on the 2,700-meter long runway but was unable to stop before reaching the end of the landing strip. It finally came to rest approximately 180 meters from the runway, with its fuselage split into several pieces. Four minutes later, the Airbus was burning furiously; however, all 297 passengers and 12 crewmembers escaped the aircraft without major injury before the fire started. In this crash, the evacuation procedures worked well, and the 4-minute time period before the aircraft caught fire was sufficient for a successful evacuation.7
The top photo, taken just after the crash, shows the evacuation in progress with the fire beginning. No evacuation slide is seen, however, at the emergency exit.
Errors: Socioeconomic Environment and Failure in the Organization
Stockholm, Sweden
A 1991 crash of an MD-81 aircraft in Stockholm was caused by lack of proper ground crew procedures and insufficient information in the pilot’s flight manual.15 After departure from Arlanda Airport on a winter day in December, an abnormal noise was heard shortly after the plane became airborne. In clouds, after 25 seconds of flight, clear ice was pulled from the wing into the right engine, which triggered a surge in thrust. The captain throttled back on that engine but the surging did not cease. After 50 seconds, the engine shut down. This same series of events occurred almost simultaneously with the left engine. The captain made an emergency landing in a field and 17,000 liters of jet fuel spilled out. Wet snow on the ground probably prevented a post-crash fire. All on board survived.
The Swedish Board of Accident Investigation concluded that the crash was caused by inadequate company instructions to both the pilots and to ground personnel. It is necessary to climb up and directly inspect the upper wing surface to identify the presence of clear ice. This was not done. Furthermore, the pilots lacked training in identifying and correcting engine surges in an aircraft equipped with an automatic thrust regulation (ATR) system. In this case, the pilots were unaware the aircraft they were flying contained an ATR system and information on ATR was not included in their flight manuals. The ATR automatically increased the engine thrust, ultimately causing engine shutdown, even though the throttles were pulled back to abort the engine surge. As such, the pilots did not anticipate or understand the events as they unfolded.
Crashes Caused by Shootings and Terrorist Attacks
Sakhalin, Russia
In 1983, a Korean Boeing 747 jumbo jet was shot down by a Soviet fighter plane over the Russian island of Sakhalin and 269 were killed.
Irish Sea
An Indian Boeing 747 was the target of a terrorist bomb over the Irish Sea in 1985. All 329 people on board were killed, making it the sixth-deadliest incident prior to 2013.
Iran
In 1988, an Iranian Airbus A300 passenger aircraft was mistakenly shot down by a missile from the American war ship USS Vincennes, which was patrolling the Persian Gulf. All 290 people on board were killed, making it the eighth-deadliest crash prior to 2012.
Lockerbie, Scotland
The Lockerbie incident in 1988, in which a Libyan terrorist bomb killed 270 people in a Boeing 747, is also a well-known act of terrorism. A Libyan man was later convicted for this action in 2001. This crash is also among the ten most deadly.
Intentional Crashes: Suicide
Crashing an airliner in an act of suicide is probably a rare event. In a few situations, however, suspicion of such a possibility has been raised, as illustrated by the following case. Half an hour after takeoff from New York, an aircraft with 200 passengers on board steeply descended from approximately 10,000 meters into the Atlantic Ocean in 36 seconds. The data flight recorder showed that the autopilot had been disconnected just before the dive and no technical explanation or malfunction was found.7
The Disappearance of Malaysian Airlines Flight MH 370
A Malaysian Airlines Boeing 777 with 239 people on board disappeared suddenly during a night flight from Kuala Lumpur to Beijing on March 8, 2014. “Good night, Malaysian 370” was the last voice message from the aircraft to the Malaysian Air Traffic Control Center 38 minutes after departure. A few minutes later, the automatic radar transponder signal from the aircraft was lost. This happened at a position over the South China Sea. The circumstances surrounding this series of events remain confusing in many ways. Even after investigators collected extensive multinational data from radio, radar, and satellite systems, they were not able to identify an explanation for the events. The most probable crash site (after analysis of all available evidence) is assumed to be in the southern part of the Indian Ocean, 2,000 km west of Perth, Australia. This is a vast area difficult to search effectively. No debris has been found. This is an area with no possible landing sites. In the first 6 months after the disappearance of MH 370, the most extensive search and rescue activity in modern aviation history failed to provide a cause for the incident. The search activities were scheduled to continue for up to an additional year. Many theories exist regarding the cause of MH 370’s disappearance. Several have been discussed by the media and include passenger, crew, or cargo factors. However, no clear explanation has been found to date (2016).
What the Human Body Can Survive
The miraculous survival of 22-year-old Yugoslavian flight attendant Vesna Volovic in 1972 is an interesting anecdotal story, indicating what the human body can withstand under advantageous conditions. She was a crewmember aboard a JAT Airways aircraft when it exploded at an altitude of approximately 10,000 meters. She was found in a mountain area, in her chair, unconscious. She suffered severe spine and lower-extremity injuries and was in coma for 1 month, with no memory of the incident when she awoke. After an 8-month hospitalization, she returned as a crew member to JAT Airways, where she worked until her retirement. During World War II, at least three cases were reported of airmen surviving falls without a parachute from altitudes of 5,000–7,000 meters. A common factor is landing on a cushioning surface such as in a tree, on snow, or in a marsh. A similar story is also reported from South America, in which a 10-year-old girl survived a fall from 4,000 meters after a suspected bomb explosion on board her aircraft. She landed in soft marshland, injured but conscious.
Preparation
What are the chances of finding survivors after an aircraft crash? In some cases, the crash is so violent that all on board are obviously killed; however, even a violent impact such as the Boeing 747 crash into a Japanese mountain in 1985 can produce survivors. In that case, the aircraft lost its tail fin (a weakness caused by an earlier faulty repair) during flight. It remained airborne for approximately half an hour before it violently crashed into a mountain. Four people survived in the rear section of the cabin, but the other 520 people on board all died, making it the deadliest single aircraft crash on record through 2012. This crash put heavy demands on the rescue teams that had to negotiate hostile terrain.
In approximately half of all airliner crashes, everyone on board is killed. However, in the remaining half, individuals survive, although the numbers vary significantly. In a few of these latter cases, there may be only one or two survivors among hundreds killed.7 In contrast, a spectacular incident with a pleasant outcome occurred in January 2009 when a US Airways Airbus A320 with 155 people on board crashed into the Hudson River in New York City shortly after takeoff (Figure 20.3). The crash presumably resulted after a flock of geese disabled the engines. The experienced pilot was credited with a safe water landing and this, coupled with the rapid actions of the well-trained crew and local rescuers, resulted in all passengers surviving.9
A miraculous emergency landing and rescue on the Hudson River in New York City, after double engine failure after takeoff.
Planning
Airport rescue resources must adapt to local circumstances. In 1985, a Boeing 737 caught fire while accelerating down the runway in Manchester, England. Due to the fire, the pilot aborted the takeoff and brought the aircraft to a stop. The fire spread rapidly and filled the cabin with smoke. In an attempt to combat the violent blaze, which ultimately killed fifty-four people, firefighters tried spraying water into the cabin via the emergency doors. This action actually hindered the evacuation of passengers, exacerbating the already deadly situation. The consequences of attempting to extinguish the fire by pumping water through the exit doors was not foreseen, and argues for better planning and training.
There are few areas in modern society where planning for an incident is more rigorously regulated than in aviation. Commercial airports should have rescue resources ready for deployment to a crash site so they arrive within 1.5 minutes of the event and they should have the capacity to extinguish a fire within 30 seconds after arrival. An aircraft must be designed to permit complete evacuation within 1.5 minutes by using half of the emergency exits (experience from the Manchester crash with fire on one side). The International Civil Aviation Organization regulates many of these standards.16
Equipment
Substantial emergency equipment such as emergency slides, flotation devices, life rafts, and emergency oxygen are carried on board. Automatic fire extinguishers for engine fires have been mandatory for decades. Smoke hoods for passengers were recommended after the Manchester crash but have not been introduced.
Training
The aviation workforce receives more training and is better prepared for handling emergencies than the workforces in most other industries. The cost-effectiveness of the substantial rescue resources assigned to commercial airports might be questioned, but obviously there are cases in which lives have been saved because of this investment in response capability.
Scene Response
Command
Crashes that do not occur at airports often generate debris fields covering large areas, such as the downing of a Pan Am 747 over Lockerbie, Scotland. This causes significant command and control problems for the incident officers in the different task forces. Still more problematic was the management of the post-crash events, debris, and human remains after the Malaysian Airways MH 17 downing by a Russian missile in 2014. This occurred in the war zone of eastern Ukraine and resulted in the deaths of 298 people.
Safety
Establishing a safe environment at the crash site is sometimes difficult. When the aircraft has crashed in hostile terrain, the safety of rescuers and survivors may be compromised. Spilling fuel and the magnesium–aluminum metal structure may catch fire and burn intensively. Modern composite-rich aircraft may not catch fire as easily as previous planes, but the smoke is expected to be more toxic.
Communication
Overload of all types of communication systems has been reported, despite the fact that individuals within the aviation industry are well trained and prepared to manage communication issues. Radio signal interference has compromised rescue operations, even near an international airport as in the Stockholm-Arlanda crash.15 Hopefully modern communication systems will improve the situation.
Furthermore, implementation of a well-developed communication plan after an aviation incident facilitates transmission of information to all participating agencies. Because international flights often carry passengers from many countries on a single aircraft, those in charge of communicating information must account for time differences, variations in cultures, and multiple languages.6 All these factors were exposed during the month after the disappearance of flight MH 370, with many Chinese families staying at hotels in China, or even flying to Malaysia, to obtain more information about the aircraft search.
Assessment
The number of dead and injured may be difficult to assess after crashes in remote areas or at sea. First, it may be difficult to find the crash site, especially in darkness; second, it may be difficult to reach the site if it is located in hostile terrain. Nonetheless, survivors can be expected in half of all crashes, even when they are catastrophic. One example of a difficult situation is the Air France crash in the middle of the Atlantic Ocean, where the first debris was found after 5 days. As such, the assessment must be done very cautiously, and search and rescue efforts should not be withdrawn prematurely.
Triage
The injury spectrum associated with airline crashes is dominated by trauma, burns, and smoke inhalation injuries. Because post-crash fires are quite common, these mechanisms of injury require special attention. More deaths are caused by smoke inhalation than by the flames (such as in the Manchester crash) and this mechanism may complicate the triage process among survivors.
Treatment and Transport
“Load and go” principles have been used most commonly in takeoff and landing crashes because the transport times are often quite short. Sometimes, this policy can create problems if ambulance dispatch is not well coordinated. In areas without roads, other transport modes must be sought, and in these situations, the military or civil defense forces may provide support.
Sea Disasters
Incidence Data
The number of lives lost when the Titanic sank was approximately 1,500. The worst single civilian ship disaster ever occurred in January 1945, at the end of World War II. Approximately 9,000–10,000 people died when the German cruise ship Wilhelm Gustloff was struck by a Russian torpedo and sank in the Baltic Sea. Many passengers were trapped in the sinking ship. Even those who escaped subsequently perished due to the extremely cold air temperature of −18°C; however, approximately 1,200 survived.
The large losses in sea disasters have often been related to warfare. In the civilian context, significant sea disasters occur infrequently. During the years 2000–2012, three incidents occurred with more than 500 victims, and fourteen incidents transpired with 100–500 documented deaths. These are probably conservative figures and may only represent data for better regulated sea transport incidents; some shipwrecks that happened while transporting refugees may be unreported.8,17
The world distribution of these incidents has been quite even. In areas such as Indonesia, the Philippines, and Malaysia (with thousands of islands), and in other countries with fast-growing populations and economies, reports of ferry or boating incidents are increasing in number. In these countries, where millions of often poor people rely on ferries for transportation between their archipelagos, overloading of ferries is a frequently reported factor contributing to shipwrecks. The worst incident in Asian waters with respect to the number killed (4,400), and the worst ferry incident in the world, was the collision between the Dona Paz and a small oil tanker in Philippine waters in 1987.18 The Dona Paz, constructed with modern safety equipment on board, was built for 1,518 passengers and was probably heavily overcrowded. It caught fire immediately and sank within minutes. Twenty-one survivors had to swim underwater to escape the flames from the burning oil on the water. No lifeboats were launched. The deadliest maritime disaster in African waters occurred in 2000. The Senegalese ferry Joola, built for 550 passengers, was also overcrowded and sank, killing 1,200–1,863 people (64 survived).19 Smuggling migrants on board vessels that are barely seaworthy has also caused hundreds of deaths. In the twenty-first century, pirate attacks are being reported in places such as Somalia.
Injury Events: Historical Perspective
From the beginning of the twentieth century, the most frequent types of incidents involving vessels were: 1) sinking in storms or typhoons; 2) fires and explosions; and 3) collisions with other vessels, icebergs, and submerged structures. Better navigation aids, especially radar and global positioning systems, have reduced collisions and navigational errors on ships equipped with such technology. With modern shipbuilding techniques, ferries and other vessels have become less susceptible to inclement weather.
Injury Events: Current Perspective
After 1970, overturning/sinking and fires have been the most frequent types of incidents, with a component of overloading involved in Asian and African ship disasters. Changes in ship and ferry design are one factor in this development. Ferries that permit cars to drive on and drive off in the same direction have an apparent design weakness in that they contain openings in the front and rear. If water flows into the vehicle deck in rough seas, this can change the center of gravity so the ferry becomes unstable, overturns, and sinks.
The construction of ever-larger cruise ships has increased their vulnerability to fire and other incidents. With many people on board, not only does the potential for careless acts increase, but these vessels may also become potential targets for hostile acts. A fire may erupt spontaneously, but may also be intentionally set, as in the Scandinavian Star incident (discussed later).
Errors: Human and Design Shortcomings
Two similar European incidents caused by the increased risk imposed by bow and stern openings in drive-on/drive-off ferries happened during the 1980s and 1990s. The main difference between these two incidents lies in the environmental circumstances, which made the rescue operations quite different. The first happened 1987 in Zeebrugge in Belgium (MS Herald of Free Enterprise), close to a harbor with excellent rescue resources, and in great weather. The second shipwreck – the Estonia – occurred in the Baltic Sea, during a storm with 6–8-meter waves, far from shore and with long flight distances for the rescue helicopters.20
Estonia – Baltic Sea
On an evening in the fall of 1994, the ferry Estonia left Tallinn, bound for Stockholm. The weather was bad, with strong winds and waves of 6–8 meters high.20 Around midnight, a loud noise was reported from the bow opening, and soon thereafter, the ferry rolled heavily 30° when water flushed into the vehicle deck. At 12:20 AM, an emergency call was sent. Ten minutes later, the Estonia‘s radio went silent and the ferry sank at approximately 12:50 AM. The evacuation was not well organized due to the hull’s list, the heavy storm surge, and the speed at which events unfolded. It was later estimated that approximately 200 people escaped the ferry before the ship sank. The incident happened in international waters between Finland, Estonia, and Sweden, so the Maritime Rescue Coordination Centre (MRCC) in Turku, Finland, was in charge of the rescue operations. Helicopters from Finland and Sweden were dispatched to the incident area, as well as ships and ferries. The captain of the Silja Europa ferry was appointed on-scene commander. The Swedish MRCC, however, did not receive the first request for assistance until 40 minutes after Estonia‘s first emergency call.
Ships and ferries arriving at the site found many people in the water; however, most of the vessels were not able to launch lifeboats because of the stormy conditions. Helicopters lifted some victims from the water and placed them on board the vessels, and some were hoisted on board by other means. Of nearly 1,000 people on board, 137 survived and 838 died. The lowest reported core body temperature in a survivor was 26.5°C. Most of the survivors were men. People did not have time to put on clothing and most of those in the sea were not wearing their life jackets properly.
Errors: Human Factor – Command Failure
The Costa Concordiadisaster was the partial sinking of an Italian cruise ship in 2012, with the loss of thirty-two lives (Figure 20.4).21 The ship, carrying 3,206 passengers and 1,023 crewmembers from all over the world, was on the first leg of a cruise around the Mediterranean Sea. It struck a reef during an unofficial near-shore salute to the local islanders. The captain had deviated from the ship’s computer-programmed route to perform this maneuver. The collision with the reef (8 meters deep at this point) could easily be heard on-board and caused some panic. A few minutes after the impact, the head of the engine room reported that the hull had a breach of about 70 meters through which water had entered, submerging the generators and engines.
The Costa Concordia after running aground and taking on water very near the shore. The bottom of the sea was quite steep and the ship had a tendency to slide down into deeper water. The first strategy was to stop this slide by anchoring it to land.
The captain, having lost control of the ship, initially made no attempt to contact the nearby harbor to request assistance. Finally, he had to order evacuation when the ship grounded at 10:44 PM after an hour of listing and partly drifting. Meanwhile, the harbor authorities had been alerted by worried passengers, and vessels were sent to provide rescue assistance. The Costa Concordia is one of the largest passenger ships ever abandoned. The Italian Coast Guard testified that the final grounding of the ship was only a fortunate coincidence of winds and tides, which prevented the ship from sinking in deep water.
Some passengers jumped into the water to swim ashore. Others, ready to evacuate the vessel, were delayed by the multinational crew for up to 45 minutes, as they resisted initial attempts to lower the lifeboats. However, during a 6-hour evacuation, most passengers were brought ashore. The search for missing people continued for several months, with all but two ultimately being located. No lifeboat passenger evacuation drill had taken place for the approximately 600 passengers who had just embarked.
According to investigators, the captain left the ship around 11:30 PM. In telephone calls from the Coast Guard, the captain was repeatedly ordered to return to the ship from his lifeboat and take charge of the ongoing passenger evacuation. One of these calls occurred as late as 1:46 AM.
The captain was arrested on multiple charges of manslaughter in connection with causing a shipwreck, failing to assist 300 passengers, and failing to be the last individual to leave the wreck. He was also charged with failing to describe to maritime authorities the scope of the disaster and with abandoning incapacitated passengers.
There were immediate fears of an ecological disaster, as the partially submerged wreck was in danger of slipping into much deeper water. This would increase the risk of a fuel oil leak and subsequent area pollution that would have devastated this popular tourist zone.
Following this incident, the Cruise Lines International Association, the European Cruise Council, and the Passenger Shipping Association adopted a new policy requiring all embarking passengers to participate in lifeboat passenger evacuation drills (muster drills) before departure. Previously, all passenger ships, including the Costa Concordia, were subject to two major International Maritime Organization requirements: 1) to perform muster drills with passengers within 24 hours after their embarkation; and 2) to launch lifeboats sufficient for the total number of persons aboard within 30 minutes from the time the abandon-ship signal is given. Passenger ships must be equipped with lifeboats for 125% of the ship’s passenger and crew maximum capacity, among which at least 37% of that capacity must consist of lifeboats constructed of solid material as opposed to inflatable ones. Launching systems must enable the lowering of the lifeboats under 20° of list and 10° of pitch.
Errors: Shipwreck and Delayed Rescue
Al Salam Boccaccio
This Egyptian drive-on/drive-off ferry, with 1,400 people and 220 vehicles on board, sank during a night in February 2006 in the Red Sea.22 The ferry caught fire and capsized after only 10 minutes of fire suppression activity. One explanation for why the ship capsized was that the seawater used to fight the fire collected in the hull because the drainage pumps were not working. An emergency call via satellite was received in Scotland, from where it was passed on to the Egyptian authorities. Poor weather conditions hampered the search and rescue operation, and the first rescue vessels did not arrive until 10 hours after the incident. President Mubarak expressed concern that the absence of safety procedures contributed to the loss of 1,000 lives. Rescuers ultimately saved 314 passengers.22
Errors: High-Speed Vessel and Bad Weather Navigation
Sleipner
The cause of this shipwreck was a combination of navigational error, a high vessel speed, severe wind, and large waves.23 The high-speed catamaran MS Sleipner, on its daily route along the Norwegian coast in November 1999, drifted off course and ran aground on a rock in bad weather and rough seas. The rock damaged the bottoms of both hulls extensively, and due to poor design, the water flooding the hulls could not be controlled. Strong winds soon pushed the vessel off the rock and it sank after half an hour with all on board ending up in the cold water. The crew lost control of the vessel’s evacuation. Only one of the vessel’s four life rafts was deployed and it landed upside down. Only four passengers managed to get inside the raft, and two managed to remain there until rescued. Many of the vessel’s passengers reported difficulty putting on the life jackets. Some of life vests came loose in the water and some nearly strangled the wearer. A total of sixty-nine people were rescued and sixteen died. Hypothermia was a severe problem. These experiences illustrate the following principles.
Evacuation routes should be adapted to conform with people’s behavior in life-threatening situations. Evacuation information must identify alternate routes and be delivered in the local language and in English.
Life rafts must be designed so they automatically turn right side up in the water. Life jackets must be easy to don, have sufficient buoyancy to keep the victim’s head above water, and must also turn an unconscious person into the correct position with the face upward.
The response time of 1 hour for rescue helicopters during off hours is too long in case of an emergency. Fifteen minutes or less would be ideal. Prioritization principles for managing hypothermic patients must be developed.
Errors: Intentional Incident – Fire on Board
Scandinavian Star
One night in 1990, fires were started on board the cruise ship Scandinavian Star while traveling between Oslo, Norway, and Fredrikshavn, Denmark.24 There were 99 crewmembers and 383 passengers on board. The first fire started at 2:00 AM when the ship reached open water. Bedclothes and carpets in a corridor were set on fire. The fire was discovered and extinguished, but a second fire started in another corridor. Within a few minutes, the fire and heavy smoke spread through the corridor and up to the next deck. Only a few of the fireproof doors were activated. A “mayday” message was sent at 2:24 AM. The position was incorrectly given as Norwegian territory, and consequently the Norwegian MRCC was appointed to lead the rescue work (the correct position was in Swedish territory). During the first 30 minutes, several helicopters, vessels, and rescue units were dispatched from Norway, Sweden, and Denmark.
At 2:50 AM, the first two ships arrived. By this time, the Scandinavian Star was burning heavily aft. An hour and a half after the fire began, the captain announced that he and the crew were in a lifeboat and that all people had left the ship, which was completely false. The crew was exhausted and lacked knowledge of the ship, its emergency equipment, and the emergency plan. In addition, they had not made any real attempt to control the fire. These factors contributed to the death of 159 people including a number of children. Sweden has an organization of specialized firefighters (called smoke divers), trained to work in a toxic smoky environment, who are ready for deployment to burning ships, but these resources were not dispatched until later. The post-incident investigation estimated that these firefighters could have arrived 2 hours earlier if dispatched initially. Ultimately, only six people died from burns; the rest died of a combination of hypoxia, carbon monoxide poisoning, and hydrogen cyanide inhalation. It is probable that rescue coordinators could have saved many more lives had they sent the smoke divers immediately. Two-thirds of the fatalities were found in their cabins, one-fourth of them in the bathroom with a towel over their faces. One-third were found dead in the corridors, many of them near locked fire doors they were unable to open.
Preparation
In many incidents at sea, the majority of passengers have been saved, but in a number of the large disasters, most have died. As shown previously, faster and more effective rescue efforts have the potential to improve survival for many victims. In the initial response phase, the on-board crew needs to take responsibility for the rescue effort.
Planning
Sea transportation and rescue are tightly regulated areas in many aspects.25 National authorities standardize the safety of ships, vessel traffic on open waterways, and rescue operations. In addition, the policies of international insurance companies such as Lloyds of London, affect maritime safety. National MRCCs manage emergencies and their planning is often rigorous and well structured. Of course, economic factors influence the availability of rescue resources, such as the number of helicopters and their response times.
Equipment
It is not unusual that a ship or ferry sinks during bad weather or in rough seas. Therefore, it is critical that safety and rescue equipment function effectively. In the cases referred to previously, the emergency equipment performed poorly. Mistakes were avoidable. Crew members could not launch lifeboats, life rafts turned upside down when deployed, and life jackets failed to automatically keep the heads of unconscious and hypothermic victims in an upright position to prevent drowning.
Rescue helicopters appropriately equipped and rapidly available are essential for saving people at sea. In the Estonia incident, the helicopters dispatched to the scene had inferior quality winches and rescuers lost potential survivors during the process of lifting them from the water. Several arriving helicopters could not participate at all in the rescue efforts for this reason. This disaster suggests that a revision of the guidelines governing the types and quality of resources used in such rescue operations is indicated.
Training
An incident at sea often happens far from land and from emergency and rescue resources. This is why the ship’s crew must fill the critical role of first responder during such events. This necessitates extensive training in managing different emergencies. In addition, the training with rescue equipment such as lifeboats and rafts should include experience using these resources under severe weather conditions. Participation by cruise ship passengers in emergency training or drills is equally important.
The use of young, inexperienced persons, such as those fulfilling their military service commitment, is not appropriate for emergency operations such as surface rescue at sea. In the Estonia incident, inexperienced individuals were assigned the demanding position of surface rescuers on Air Force helicopters. It was psychologically stressful for these young people to participate in the response to a deadly disaster, attempting to rescue victims in darkness, with poorly functioning equipment, while enduring extremely high waves.23
Scene Response
Command
Effective rescue operations for an incident of this kind involve practically the entire chain of command, from the individual to the government level. All require training specific to their roles to manage the situation properly. Many sea disasters occur in international waters. The MRCC in charge of the rescue effort is normally determined by the rescue zone in which the vessel is located. A rescue mission must be well planned from both the tactical and organizational perspective. Examples include identifying the captain of the first suitable ship arriving at the site as the on-scene commander, and automatic dispatch of the appropriate units. The error of not immediately dispatching smoke divers to the site of the Scandinavian Star fire probably caused additional deaths and suggests commanders experienced lapses in judgment during a stressful situation.24 Air traffic command and control is also essential when many rescue helicopters are in the air.
Safety
Safety precautions for response personnel and crew are a first priority during a rescue mission but may be in conflict with the sometimes extremely difficult conditions under which they must work. To minimize the risks, responders systematically review all safety factors under the category of “preparation,” including planning, equipment, and training. In addition, emergency drills at the beginning of a voyage may potentially reduce the risk to passengers. Improving the safety of all involved also mandates the use of emergency equipment that is effective under all conditions, including rough seas.
Communication
It may be difficult to communicate the status of passengers to relatives and the press in the initial phase of rescue operations because of the huge numbers of victims. The Al Salam Boccaccio incident is one example in which the delayed release of information regarding survivors created a public outcry; similar reactions have been reported in other incidents. It would be wise for the sea transport industry to have a well-prepared communication plan to reduce these problems.
Assessment
The initial assessments regarding the number of dead and injured in the previously referenced incidents contained a large degree of uncertainty.20,22,24 The final assessments, however, were usually quite accurate. Notable exceptions include some Asian and African ferry incidents, where the number on board was not clearly determined. One seriously incorrect assessment was the message from the captain of Scandinavian Star that “all had abandoned the ship.” In reality, more than 160 were still on board and this erroneous report may have contributed to the high death toll in the fire.
Triage and Hypothermia
Hypothermia may be a complicating factor that is not taken into account in common triage systems. In the aforementioned incidents, hypothermic victims were common. Hypothermia may make it difficult for rescue personnel to know who is truly dead and who is actually alive but profoundly hypothermic. After the Estonia incident, it was observed that the commonly used guidelines regarding survival times in water of different temperatures may be conservative estimates.26 Young fit men with strong survival instincts seem to survive longer.20 It is essential to account for these findings when deciding to terminate a search.
Treatment
Fire victims and passengers who have ingested or aspirated petroleum products, as in the Dona Paz incident, may need urgent treatment. Hypothermic victims must be handled cautiously (so as not to induce ventricular fibrillation), and should ideally be extricated (or hoisted, if a helicopter is involved) in a horizontal position. This is due to cold-induced diuresis and resultant hypovolemia that can cause hypotension if the patient is placed in the vertical position.
Transport
Helicopter transport to the nearest appropriate facility is indicated for severely ill patients, such as those suffering from burns, serious traumatic injuries, and profound hypothermia. One limiting factor in the rescue operation is the time helicopters can remain airborne, which is often approximately 3 hours, exclusive of reserve fuel. In practical terms, if it takes a helicopter 1 hour to arrive at the incident site and requires 1 hour or more to reach a medical facility, the time to accomplish the rescue mission at the site may be very limited. In these cases, the tactic may be to hoist people to a ship in the vicinity, and in this way, save as many as possible, as in the Estonia incident. This would, however, not be optimal for severely ill victims.
Rail Disasters
Incidence Data
During the nineteenth century, the number of train crashes that produced a significant number of fatalities was low, as train speed was limited. In the twentieth and twenty-first centuries, the speed and density of rail traffic increased. In many countries, however, railway infrastructure has not kept pace and has become alarmingly worn and overburdened. Despite extensive crash avoidance systems, severe railway events still occur around the world.27 These crashes which are actually becoming more frequent, cause mass casualties to the extent that they can be classified as disasters (≥10 killed and/or ≥100 non-fatally injured). Throughout the last 100 years, the number of rail disasters, fatalities, and injured passengers has increased. This is particularly true during the last four decades (1970–2009) when 88% of all train disasters occurred in the world (Figure 20.5).28 In 2010–2012 there were twenty-five disasters globally, compared with twenty-three during the three preceding years (2007–2009), indicating that the problem persists and may be increasing.27 The number of fatalities per railway disaster has nevertheless decreased steadily throughout the years.28
(a) Number of global rail disasters with ≥10 fatalities and/or ≥100 non-fatal injuries, 1910–2012; (b) Number of passengers killed and injured in rail disasters, 1910–2012. * Note that this time bracket only consists of 3 years. Data from: EMDAT: The OFDA/CRED International Disaster Database. www.em-dat.net. Université Catholique de Louvain, Brussels, Belgium.
Moreover, railway transportation facilities have become a preferred target for hostile acts. The system is vulnerable: it is open and accessible to all, generally without individual access controls or passenger identification, and utilized by large numbers of people. The attempted terrorist attack on a passenger train in Canada in April 2013 is a recent example. The attacks in Tokyo in 1995, Madrid in 2004, London in 2005, Mumbai in 2006, and Russia, including events in 2007, 2009, and 2010, are examples of completed attacks that had enormous consequences. The evolution toward a considerable increase in number of victims injured by attacks on rail-bound traffic is also clear.29
Preparation
Pre-Event Planning
The trends indicate that emergency response organizations should plan for a severe rail incident since these have the potential to produce mass casualties. Further, the complex nature of responding to such events makes pre-event planning essential. This extends to the rail personnel and passengers. A well-prepared train crew is a factor that can affect the outcome. If passengers have not been provided with appropriate safety-critical information, they cannot be expected to know how to handle the situation.
Equipment
Rescue personnel are exposed to many different hazards when working at a train crash site. This makes the use of adequate PPE mandatory. Staff must also be provided with communication equipment that operates in tunnels and subways. In addition, it is important to investigate whether current rescue tools are effective against the rugged steel construction of today’s trains. In a collision in Hamburg, Germany, passengers were trapped inside the railcars and needed extrication. This required the extensive use of cutting torches and rendered the rescue very difficult. In addition, rescue operations could not be properly initiated until the carriages had been securely stabilized, which consumed significant time.30 Other incidents have demonstrated the difficulty in evacuating passengers due to factors such as a lack of roof hatches (when carriages have overturned) or due to carriage height. Therefore, it is important to test different solutions to facilitate victim rescue and minimize the evacuation time. Using ladders that allow responders to slide a victim down from a window on the stretcher is one effective solution. Another is to create access in the roof when carriages have overturned (see Figure 20.6).
The use of ladders allows rescue personnel to slide the victims down from an elevated window (top picture). When a rail carriage has overturned, one effective solution to facilitate evacuation is creating access through the roof (bottom picture).
Training
It is important that rescue personnel receive education and training in tactics and techniques that minimize the delay in delivering medical care to injured passengers. Studies from train crashes have shown the importance of rapid extrication and evacuation of trapped casualties, as passengers have died from injuries that should not have been fatal.30–32 In the Amagasaki crash in Japan, rescue personnel responding to the event had previously received training in confined-space medical techniques. This experience proved to be most useful. Without this training, the two victims who remained trapped in a railcar for up to 22 hours would probably have died.33 Prehospital personnel also need training to identify and manage potential threats resulting from train incidents and learn how to manage the situation if the disaster results from a hostile act.
Pre-Incident
Investigators have proven that the “human factor,” which denotes the tendency by individuals to misunderstand, miscalculate, or act inappropriately, has clearly contributed to several train crashes. The 1999 crash in Ladbroke Grove, UK, is one example where a train derailment was caused by an engineer failing to stop at a red signal.34 Another example is the head-on collision between a freight train and a Metrolink commuter train in Los Angeles in 2008 when the freight train ran through a red signal. The train’s engineer was distracted by sending text messages while on duty. The crash killed 25 passengers and injured 135.35 A speed limit violation by engineers in the 2005 Amagasaki, Japan, crash caused the train to derail as it travelled along a curved section of track, killing 107 passengers and injuring another 549.33 Miscalculations or infringements by automobile drivers at intersections where rail lines cross roadways are another common cause of crashes.36
Carriage and equipment failure was the reason for the 1998 train crash in Eschede, Germany, when the Intercity Express (ICE) traveling at 200 km/h derailed and collided with a bridge due to a wheel failure (Figure 20.7).37 A similar example is the 2010 train crash in Skotterud, Norway, which resulted in the injury of forty passengers.38 Non-user-friendly instruments, tools, and inadequate equipment design (driver safety systems) inside trains are other causes of crashes because these flaws increase the risk for human error.39
The Eschede, Germany, train crash is one of the world’s worst high-speed train disasters. The carriages jack-knifed into each other during impact, claiming 101 lives and injuring 103 passengers.
Physical environment factors can also be reasons for crashes or exacerbate the situation. The environment proved to be of great importance in the July 2013 high-speed crash just outside Santiago de Compostela, Spain. A passenger train derailed due to high speed (approximately 190 km/h) after entering a curve. Alongside the railway track was an aqueduct with a sharp edge that opened some coaches like a tin can, causing 79 deaths and approximately 140 injuries. Improved materials and performance of railway tracks have reduced the number of crashes resulting from such causes as climate, heat distortions of tracks or ice formations, and problems created by snow.40–42 However, the rail disaster with the highest death count in history occurred in Sri Lanka in 2004, and was caused by the tsunami following the Indian Ocean Earthquake. More than 1,700 people were killed.43 Crashes related to locations where railroad tracks cross roadways (level crossings) are a high priority issue. The number of European level crossing crashes between 1990 and 2009 has remained the same in relation to the number of passenger kilometers travelled, despite the fact that the existing level-crossings have been improved and the construction of new ones has been minimized. 36,44,45
Within the socioeconomic environment, multiple factors are put into a larger context. Train crashes are seldom tied to a single causal factor, but could be the result of systematic failure.34 Lack of a safety culture may be the effect of mismanagement, resulting in deficient train maintenance. This is speculated to have caused the train crashes in Buenos Aires, Argentina. In 2012, concerns related to possible brake failure were repeatedly dismissed. The negligence led to 51 fatalities and more than 700 injuries when a passenger train experienced brake failure and hit the buffers at Once Station (Figure 20.8). In 2013, a passenger train travelling in the morning rush hour was unable to stop and collided with an empty stationary train, killing 3 people and injuring more than 300.
One carriage telescoped approximately 6 meters into another (see white arrow). The train crash killed fifty-one passengers in Buenos Aires, Argentina in 2012. The train ran into the buffers at Once Station when the brakes failed.
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