EDMG541Wk7

Koenig_and_Schultz_s_Disaster_Medicine_Ch_18.pdf

Transportation Disasters

Ulf Björnstig and Rebecca Forsberg

OVERVIEW

The Red Cross defines a disaster as an event causing 10 or more deaths and/or 100 injuries. According to the Red Cross World Disaster Report, transportation-related disasters are a major source of morbidity and mortality, causing 45% of all disaster-related deaths in Africa.1 During the 1990s, approxi- mately 80,000 people were killed in different disasters in the world each year.1 This number may be compared with the “low viru- lent epidemic” of road fatalities that annually kill approximately 1.2 million people (16.1/100,000 inhabitants) and injure 50 mil- lion people to such an extent that they require medical attention.2

In the United States alone, 43,000 are killed annually on the highways.3

In commercial aircraft crashes, approximately 1,000 people are killed each year. In sea disasters, the events are more infre- quent, but may sometimes engage a few thousand victims each. A few major train incidents are reported annually with sometimes hundreds of fatalities. Bus and coach crashes kill fewer people in each incident than in prior times but apparently are increasing in frequency. A common feature is, however, that many of these incidents occur in rural and remote areas, creating special rescue problems.

In most of these categories, both unintentional and inten- tional injury events have been reported. More and more fre- quent suicide attacks have introduced a new dimension of inten- tional violence, rendering many previous preventive strategies in- effective.

A structure that helps organize the approach to these events is the Haddon Matrix. Originally created to examine road traf- fic trauma, it is now widely used throughout the transportation industry. Dr. Haddon identified several factors that contribute to injury events and disasters. These are human, vehicle/equipment, physical environment, and socioeconomic environment. These factors contribute in the three phases: 1) pre-event, 2) event, and 3) postevent (Figure 18.1).4 In referring to the rescue work in the postevent phase, this chapter will use the structure from the British Major Incident Medical Management System (MIMMS).5

This system is widely used in Europe, Australia, and several other countries in both civilian and military contexts. The MIMMS

nomenclature for disaster management includes “preparation” (i.e., planning, equipment, and training) and “onscene com- mand.” The command structure is described by the mnemonic CSCATTT (Command, Safety, Communication, Assessment, Triage, Treatment and Transport). In summary, this chapter will use the Haddon Matrix to describe the disasters affecting each mode of transportation and the MIMMS to illustrate how these events are managed.

STATE OF THE ART

The following sections will deal with air disasters, sea (ship and ferry) disasters, rail (train/railway) disasters, and motor vehicle (bus/coach) disasters.

AIR DISASTERS

Incidence Data

During the “Zeppelin” era from 1913 to 1937, the number of fatalities due to dirigible crashes was 14–52 per event. This period ended in 1937 when the Hindenburg exploded, killing 36 of the 97 people on board. In the modern aviation era, from 1970 through 2006, the number of passenger airline crashes has varied from 32 to 73 annually, with a shift toward lower numbers especially after 2002. The fatality rate for this period has been between 517 and 2,556 people killed per year. The number of fatalities per million departures has decreased from approximately 290 fatalities per million departures from 1970 to 1974 to 47 during the years 2000–2004 (excluding the suicide hijack terrorist attacks in the United States on September 11, 2001).6–8

Injury Events: Historical Perspective

The track record on fatality rates varies considerably by airline. The following numbers are current as of early 2009. Qantas Air- lines is free from fatal injury events since 1952. Cathay Pacific is free from deaths since 1972. All Nippon Airways, British Air- ways, and Lufthansa are also companies with low fatal injury rates

253 Koenig and Schultz's Disaster Medicine : Comprehensive Principles and Practices, edited by Kristi L. Koenig, and Carl H. Schultz, Cambridge University Press, 2009. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/apus/detail.action?docID=564432. Created from apus on 2018-03-09 07:37:43.

C op

yr ig

ht ©

2 00

9. C

am br

id ge

U ni

ve rs

ity P

re ss

. A ll

rig ht

s re

se rv

ed .

254 ■ UL F BJ Ö R N S T I G A N D RE B E C C A FO R S B E RG

Figure 18.1. The Haddon Matrix used to organize the analytic approach to evaluation of an injury event.4

per flight. The best crash record among commercial aircraft is the McDonnell Douglas MD-80, a middle-distance aircraft (0.45 events/million flights) and the Boeing 767, a long-distance air- craft (0.6 events/million flights).7

Most crashes per time unit occur during takeoffs and land- ings,6 but some aircraft have experienced problems during flight, mostly related to technical or weather problems. In this business, most incidents are unintentional, but intentional events are also a real threat to flight safety. During the 1980s, an epidemic of aircraft hijacking initiated new passenger and baggage control systems, which have been developed further during the 21st cen- tury due to the terrorist threat.

Injury Events: Current Perspective

The geographical distribution of crashes from different parts of the world for the years 2000 through June 30, 2007 with 10 or more people on board is as follows: Africa (24%), Asia and Middle East countries (19%), South and Central America (17%), Russia and former Soviet Republics (excluding the eastern European Union member states) (15%), Europe plus the eastern European Union member states (14%), North America (10%), and Australia (1%).7

The most disastrous incident involving civilian aircraft is the September 11, 2001 terrorist attack in the United States, when four aircrafts were hijacked and crashed into the World Trade Center buildings in New York, the Pentagon in the Washing- ton DC area, and a field in Virginia. The human losses were approximately 3,000 dead. This incident was extreme and is well described elsewhere.9

Because prevention is the first choice in disaster mitigation, it may be beneficial to more closely examine factors contributing to air disasters.1 Following are selected incidents that illustrate typi- cal factors and sequences of events found in airline crashes. Each event was thoroughly investigated and documented in reports published by different countries “Accident Investigating Boards” (e.g., in the United States, this agency is the National Transporta- tion Safety Board10).

Errors: Human Factors, Lapses in Job Performance, and Communication during Conditions with Ice WASHINGTON, DC

During the departure of a Boeing 737 from Washing- ton National Airport after a severe blizzard in January 1982, several significant mistakes were made.11 Insight into these errors can be gained by examining the captain’s previous training and performance records. His experience with winter departures was

limited to eight and the first officer had two. A flight check in 1980 revealed poor performance by the captain in several areas: adherence to regulations, checklist usage, flight procedures, and approaches and landings. He was temporarily suspended as a Boeing-737 captain. During a new check in 1981, he demon- strated deficiencies in memory, knowledge of aircraft systems, and aircraft limitations. He later completed necessary tests, and was reinstated. The first officer had completed all checks satis- factorily.

After the blizzard, the airport reopened and a de-icing pro- cedure was performed on the aircraft at 3:10 pm. Due to deep snow, it was difficult to push the aircraft back, and the captain tried to facilitate the maneuver by reversing the engines. While doing this, he sucked large amounts of debris into the engines. During taxi, the captain decided to use exhaust from a preceding DC-9’s engines to melt the snow that had accumulated on the wings. This was an unsuccessful maneuver, which only pushed the snow back on the wings where it refroze. The aircraft’s de- icing system could not melt snow on this portion of the wing. While running through the takeoff checklist, he responded “off” to the item “engine anti-ice.” Having neglected to switch on the engine de-icing equipment, the engine instruments showed erroneously high thrust readings during takeoff because ice had formed on the sensor. Consequently, the crew attempted to take- off with ice on the wings and using only 71% thrust because of the wrong thrust reading. During the takeoff at 4 pm, the first officer probably realized that something was wrong, but he was unable to communicate his concern to the captain.

At rotation speed, (when the aircraft’s nose lifts upward) the aircraft pitched up sharply, which was a known behavior of the Boeing 737 with ice on the wings. The first officer’s correction of the nose-up attitude failed and the stall warning immedi- ately sounded. The aircraft continued to stall and fell down- ward.

The aircraft impacted a bridge over the Potomac River, result- ing in four deaths and four injured on the bridge. The aircraft then crashed into the icy water (0◦C) and went to the bottom, approximately 1 km from the end of the runway. Seventy-four (including three infants) of the 79 on board were killed plus four on the bridge. One died of drowning; all the others suffered fatal injuries, most often head and neck injuries. Five were rescued and survived.

The dramatic rescue efforts were extensively covered by the media. The airport’s water rescue equipment was not adapted or tested for winter conditions and was not used. An avail- able U.S. National Park Police helicopter rescued four people between 4:22 and 4:35 pm and ferried them to the shoreline. Two survivors were incapacitated by their injuries and the cold and required hands-on rescue; one by a helicopter crewmember, the other by a civilian bystander who swam out and pulled her ashore.

Errors: Human Factors and Communication during Conditions with Fog TENERIFE, SPAIN

With regard to number of fatalities, the worst crash in history happened on the island of Tenerife in 1977. Two Boeing 747 jumbo jets (from Pan Am and KLM) collided on the runway in heavy fog. A total of 624 people were involved of whom 583 died and 41 survived.7,8

This was the precrash sequence. The Pan Am crew was instructed to taxi behind the KLM jet, but to turn left off the

Koenig and Schultz's Disaster Medicine : Comprehensive Principles and Practices, edited by Kristi L. Koenig, and Carl H. Schultz, Cambridge University Press, 2009. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/apus/detail.action?docID=564432. Created from apus on 2018-03-09 07:37:43.

C op

yr ig

ht ©

2 00

9. C

am br

id ge

U ni

ve rs

ity P

re ss

. A ll

rig ht

s re

se rv

ed .

TR A N S P O RTAT I O N DI S A S T E R S ■ 255

runway and into a taxiway before reaching the end of the run- way. As the KLM aircraft turned to depart on runway 12, its cap- tain immediately powered up for takeoff. The first officer cor- rected him saying, “No, we don’t have our air traffic control clearance yet.” The captain responded with, “I know that, you call for it.” As the first officer was repeating his request for depar- ture clearance, the captain initiated takeoff despite the fact that the control tower did not grant permission for this action. At the same moment, the Pan Am 747 crew was looking through the thick fog for their assigned runway turnoff, and saw the lights of the KLM aircraft approaching at takeoff speed. Just after the nose was lifted the KLM aircraft struck the Pan Am jet just behind the cockpit, climbed to a height of 30 m, and then crashed on the runway. Both aircraft caught fire.

TAIPEI, TAIWAN

Crashes in fog continue in the 21st century in part due to airports that lack ground radar. In the year 2000 in Taipei, a Boeing 747 jumbo jet with 159 passengers and 20 crew initiated takeoff by mistake on closed runway 5R (right) instead of 5L (left), which was open.7 The tower could not see the aircraft in the fog and they did not have ground radar. The first officer notified the captain about a signal indicating the aircraft posi- tion was incorrect on the runway. The captain misunderstood the remark and initiated takeoff. They crashed at high speed into an excavator at a site on the runway where construction work was in progress. The aircraft broke into three pieces. The mid and forward portion of the fuselage sustained extreme fire damage. The airport’s 32-person fire brigade responded imme- diately and arrived at the crash site in 1 minute and 38 seconds. Despite this rapid response, it was impossible to save people from the middle section that was burning heavily. The injury distribution was as follows: fatal 83, serious 39, minor 32, and uninjured 25.

MILAN, ITALY

In 2001, a crash in heavy fog occurred at Linate airport in Milan. An MD-87 was cleared for takeoff on a runway with visibility limited to 225 m. At approximately the same time, a business jet was cleared to taxi, but this plane entered the active runway by mistake and was impacted by the MD-87 during take- off. Both aircraft skidded along the runway and caught fire before they finally hit a baggage hangar, which partially collapsed and also caught fire. All 118 on board the two aircraft and four peo- ple on the ground died. Ironically, ground radar equipment had been in storage at the airport for years but was not installed. Four administrators and controllers at the facility were later sentenced to several years in prison for neglect.

Errors: Aircraft/Equipment Failure THE BRITISH COMET

Metal fatigue (localized, progressive structural damage that occurs during cyclic loading) is a recognized problem with mod- ern aviation airframes and a difficult issue to resolve. The well- known crashes of the British Comet jet aircrafts in the 1950s first brought this problem to the attention of civil aviation authori- ties. These aircraft broke up in flight due to a design flaw causing metal fatigue around the aircraft’s windows.

CHICAGO, ILLINOIS

A DC-10 lost its left engine during takeoff in Chicago in 1979 due to metal fatigue. When the engine separated from the

aircraft, it flew up and over the wing, falling on the runway. When it separated, the hydraulic lines to the rudder and slots systems were disrupted, making the aircraft impossible to steer. All 270 on board were killed.

MANCHESTER, ENGLAND

In 1985, a Boeing 737 crash in Manchester highlighted several important factors.12 When the aircraft with 137 people onboard passed 125 knots (245 km/h) during takeoff, a burn chamber in the left engine exploded due to metal fatigue. Debris flew through a weak hatch into a fuel tank, which caught fire. The captain abandoned the takeoff immediately and brought the aircraft to a stop to the right of the main runway. A wind of 7 knots (3.5 m/s) blew the flames around the rear fuselage, and the fire quickly penetrated the cabin through melting plastic windows. In a few minutes the aircraft was destroyed and 54 persons on board were rapidly killed, most of them by the effects of toxic gases.

The Manchester experience can be summarized by the fol- lowing points.

■ The wind blowing the flames over the fuselage might have been avoided if the tower had reminded the pilot of the wind direction when confirming the fire.

■ Uncoordinated escape attempts began before the aircraft came to a halt, especially among the passengers who were trapped in the rear cabin where the flames had entered. This behavior made evacuation difficult.

■ Evacuation problems were also exacerbated by the loss of usable emergency exits on one side of the aircraft due to the fire, temporary jamming of the right forward exit, and by the heavy, black, toxic smoke.

The combination of these factors explained why so many pas- sengers were killed. Pathological examination showed that 48 passengers died as a result of inhalation of hydrogen cyanide and carbon monoxide, and six died from the heat. Most survivors reported incapacitation by the thick, black, and very hot smoke, which affected visual, respiratory and cerebral functions within minutes.

UNITED STATES: JAMMED VALVE

In 1991 the first of three Boeing 737 incidents occurred, caused by the same type of servo valve jam and dysfunction. All 25 on board died in the first violent crash, which happened during approach to an airport. When the pilots turned into their final approach at an altitude of 300 m, the aircraft went out of control and plunged steeply into the ground within 10 seconds. The investigators were confused and could not establish the cause. Another crash of a Boeing 737 in 1994 showed a similar course of events. The aircraft rolled out of control, despite the pilot trying to compensate by opposite rudder deflection. The dive became steeper and the aircraft fragmented into small pieces in the violent crash, killing 132 people. This also made the investigation very difficult, and it threatened to be one of few unsolved crashes. In 1996, a third Boeing 737 suffered similar problems. After having gone out of control two times with the same pattern as in the two previous crashes, the pilots finally managed to gain control of the aircraft and land it. This gave the investigators an undamaged aircraft to investigate. They finally came to the conclusion that a servo valve in the steering system had jammed, causing the problem. The jam came after rapid temperature changes, typically during descent from cold temperature at high

C op

yr ig

ht ©

2 00

9. C

am br

id ge

U ni

ve rs

ity P

re ss

. A ll

rig ht

s re

se rv

ed .

256 ■ UL F BJ Ö R N S T I G A N D RE B E C C A FO R S B E RG

Figure 18.2. The Concorde’s last flight in the year 2000. A piece of metal on the runway caused a tire explosion. Debris from the tire punc- tured the wing fuel tank and the fuel caught fire. Photo from Associated Press. Available at: http://www.airdisaster.com/photos/afsst/2.shtml. See color plate.

altitude. These findings explained the unexpected and reversed movements of the rudders that all three aircraft had suffered. After modifying the servo valve, no further incidents of this type have occurred.7,8,10

Errors: Physical Environment, Debris on Runway, and Hostile Weather PARIS, FRANCE

The Concorde crash in the year 2000 ended the Concorde supersonic era in civil aviation. The aircraft caught fire during takeoff from Charles de Gaulle Airport (Figure 18.2). The pilots lost control and the plane crashed into a hotel killing all 109 on board and an additional 5 people on the ground. The Concorde had run over a metal strip dropped earlier from another aircraft during departure. This metal strip caused a tire explosion and debris punctured the wing fuel tank.8

TORONTO, ONTARIO, CANADA

An Airbus 340 crashed in Toronto in 2005 during inclement weather. The aircraft touched down on the 2,700-m-long runway but was unable to stop before reaching the end of the runway. It finally came to rest approximately 180 m 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 had 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

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 infor- mation in the pilot’s flight manual.13 After departure from Arlanda airport on a winter day in December, an abnormal noise was heard shortly after the plane became airborne. At 600 m, after 25 seconds of flight, the right engine sucked clear ice from

Figure 18.3. The 1991 MD-81 crash in Stockholm was caused by engine failure at low altitude when clear ice from the wings was sucked into the engines. During the emergency landing, the aircraft’s momen- tum was reduced by hitting a number of trees before crashing on a snowy field. The snow probably prevented a postcrash fire. See color plate.

the wing into the 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.

As the plane descended to approximately 300 m, the captain found a field where he could land. After impacting a number of tree tops, the aircraft slid along the ground for 110 m before it stopped. The fuselage was broken into three pieces and 17,000 L of jet fuel spilled out. Wet snow on the ground and an air tem- perature of 0◦C prevented a fire.

The energy attenuation was optimally distributed during the crash phase, and all onboard survived. Those few with serious injuries were sitting in the right forward part of the aircraft, or where the fuselage was broken, which was what could be expected with regard to the kinematics of the crash (Figure 18.3).

Despite the short distance to Sweden’s busiest airport, the first reconnaissance helicopter did not find the site until 30 minutes after the crash. The alarm was first raised by a passenger calling the dispatch center from a telephone in a house close to the crash site.14

The Swedish Board of Accident Investigation concluded that the crash was caused by inadequate company instructions both to the pilots and ground staff. To identify clear ice on the wings, it is mandatory for the ground crew to climb up and inspect the upper wing surface. 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 automati- cally increased the engine thrust, 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 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.

C op

yr ig

ht ©

2 00

9. C

am br

id ge

U ni

ve rs

ity P

re ss

. A ll

rig ht

s re

se rv

ed .

TR A N S P O RTAT I O N DI S A S T E R S ■ 257

IRAN

In 1988, an Iranian Airbus A300 passenger aircraft was mis- takenly shot down by a missile from the American war ship, the USS Vincennes, while patrolling the Persian Gulf. All 290 peo- ple on board were killed, making it the eighth deadliest aircraft incident through the year 2006.

IRISH SEA

An Indian Boeing 747 was the victim of a terrorist bomb over the Irish Sea in 1985. All 329 people on board were killed, making it the sixth deadliest incident as of 2006.

LOCKERBIE

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.

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. One-half hour after takeoff from New York, an aircraft with 200 passengers on board steeply descended from approximately 10,000 m 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

What the Human Body Can Survive The miraculous survival of the 22-year-old Yugoslavian flight

attendant Vesna Volcovic in 1972 is an interesting anecdotal story, indicating what the human body can withstand under advan- tageous conditions. She was a crewmember on a JAT (Yugoslav Aerotransport) aircraft when it exploded at an altitude of approx- imately 10,000 m, probably due to a terrorist bomb. During search and rescue operations under the flight path, she was found in the Tjeckian mountain area, in her chair, unconscious with severe spine and lower-extremity injuries but with no memory of the incident or her descent to earth. She had landed in deep snow on a mountain slope. After an 8-month hospitalization, she returned as ground crewmember to JAT Airways where she worked until her retirement. A similar story is reported from South America, in which a 10-year-old girl survived a fall from 4000 m, after a suspected bomb explosion on board her aircraft. She landed in soft marshland, injured but conscious.14

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 obvi- ously killed; however, even a violent crash such as the Boeing 747 crash into a Japanese mountain in 1985 can produce sur- vivors. In that case, the aircraft lost its tail fin (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 all the other 520 people on board died, making it the deadli- est single aircraft crash on record. This crash put heavy demands on the rescue teams that had to negotiate hostile terrain.

Analyzing airline crashes involving 10 or more people from the year 2000 through June 30, 2007 reveals that a total of 78 crashes resulted in the death of all passengers on board. In 82

crashes, however, survivors were found, and in 24 of these, no person was killed. In 12 of these 82 crashes, only one or two survived. For some of these events, the total losses were measured in hundreds of lives.7

A notable exception occurred more recently in January 2009 when a US Airways Airbus A320 with 155 people on board crashed into the Hudson River in New York shortly after take-off, presumably after a flock of geese disabled the engines. The expe- rienced pilot was credited with a safe landing and this, coupled with the rapid actions of the well-trained crew and local rescuers, resulted in all passengers surviving.

PLANNING

Airport rescue resources must adapt to local circumstances. In the Washington DC crash, the airport’s water rescue equip- ment was not tested under winter conditions and so was not utilized. To combat the violent blaze in the Manchester crash, in which the interior of the plane was also involved, fire fighters tried spraying water into the cabin via the emergency doors. This action, however, significantly hindered the evacuation of passen- gers. These examples argue for better planning and training.

There are few areas in modern society where the 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). The International Civil Aviation Organization regulates many of these standards.

EQUIPMENT

Substantial emergency equipment such as emergency slides, flotation devices, life rafts, and emergency oxygen are carried onboard. Automatic fire extinguishers for engine fires have been mandatory for decades. Smoke hoods 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. For example, the rapid response by fire fighters in the Taipei crash indicates extremely well-trained rescue forces, which may have helped victims survive.

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. This causes significant command and con- trol problems for the incident officers in the different task forces.

SAFETY

Establishing a safe environment at the crash site is sometimes difficult. When the aircraft has crashed in hostile terrain, the

C op

yr ig

ht ©

2 00

9. C

am br

id ge

U ni

ve rs

ity P

re ss

. A ll

rig ht

s re

se rv

ed .

258 ■ UL F BJ Ö R N S T I G A N D RE B E C C A FO R S B E RG

safety of rescuers and survivors may be compromised. Spilling fuel and the magnesium–aluminum metal structure may catch fire and burn intensively.

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 communi- cation issues. After the Taipei crash, communications failure between the crash site and the dispatch center severely com- promised the distribution of injured passengers to different hos- pitals. As a result, the nearest hospital was overwhelmed with patients, many of whom required transport to the burn hospital in Taipei.15 In addition, radio signal interference has compro- mised rescue operations, even near an international airport as in the Stockholm – Arlanda crash.13 Furthermore, implementa- tion of a well-developed communication plan after an aviation incident facilitates transmission of information to all participat- ing 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

ASSESSMENT

The number of dead and injured may be difficult to assess after crashes in remote areas or at sea. First, it might 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. One example of such a situation is the Swissair crash in 1998, when it took 10 hours to identify the crash site in the ocean off Canada’s coast, despite the use of two aircraft specially equipped to search for fuel spills and debris.6 Nonetheless, survivors can be expected in half of all crashes, even when they are catastrophic. This is why 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 dom- inated by trauma and burns. Because postcrash fires are quite common, this mechanism of injury requires special attention. More deaths are caused by smoke inhalation than by the flames (e.g., in the Manchester and Taipei crashes) and this mechanism may complicate the triage process among survivors.

TREATMENT AND TRANSPOR T

“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 ambu- lance dispatch is not well coordinated. In areas without roads, other transport modes must be sought and in these situations, the military might provide support.

SEA DISASTERS

Incidence Data

The number of lives lost when the Titanic sank was approxi- mately 1,500. The worst single ship disaster ever occurred in January 1945, at the end of WW 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 pas-

sengers 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 appear infrequently. During the 20th century, incidents with hundred to thousands of victims occurred at a rate of approximately three every decade. In the last 20 years, however, the rate has increased, with five incidents occurring from 1990 to 1999 and five during 2000–2007.8,14 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, ferry or boating incidents are increasingly reported. 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 ship wrecks. The worst incident in Asian waters with respect to the number killed (1,565–4,300), 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. 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 min- utes. Twenty-one survivors had to swim underwater to escape the flames. No lifeboats were launched. The deadliest maritime disas- ter 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).16,17 Smuggling migrants on board vessels that are barely seaworthy has also caused hundreds of deaths.18 In the 21st century, pirate attacks are being reported in places such as Somalia.

Other major events have likely gone unreported. As such, the aforementioned estimates may be conservative and may only represent data for the better-regulated sea transports.

Injury Events: Historical Perspective

From the beginning of the 20th 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 navi- gation aids, especially radar and global positioning systems, have reduced collisions and navigational errors on ships equipped with such technology. With modern ship building techniques, ferries and other vessels have become less susceptible to bad 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. Change in ship and ferry design has been 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. Typical examples are the incidents involving the MS Herald of Free Enterprise (Zeebrugge, Belgium, March 1987) and the MS Estonia (Baltic Sea, September 1994).

C op

yr ig

ht ©

2 00

9. C

am br

id ge

U ni

ve rs

ity P

re ss

. A ll

rig ht

s re

se rv

ed .

TR A N S P O RTAT I O N DI S A S T E R S ■ 259

The construction of ever-larger cruise ships has increased their vulnerability to fire. With many people on board, not only is the potential for careless acts increased, but these vessels are 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 Below are two incidents caused by the increased risk imposed

by bow and stern openings in drive-on/drive-off ferries. The main difference between these two incidents is the environmental circumstances making the rescue operations quite different. The first happened close to a harbor with excellent rescue resources and in great weather. The second occurred during a storm with 6–8-m high waves, in the open sea, far from shore and with long flight distances for the rescue helicopters.

HERALD OF FREE ENTERPRISE – ZEEBRUGGE

On a March evening in 1987, the English ferry “Herald of Free Enterprise” left the harbor of Zeebrugge in Belgium. The weather was fine with an air temperature of 0◦C and a water tem- perature of 3◦C. Just outside the harbor, when the ferry turned slightly, water rushed through the bow loading doors, which were left open by mistake, into the two vehicle decks. The ferry’s rolling motion, initiated by the course change, increased dramatically because of the moving water inside the ferry. Within minutes, the ferry was lying on its side on a sand bar with the hull two-thirds under water. The port control was immediately notified and acti- vated the disaster plan. Thanks to NATO exercises in the area, military resources contributed to the rescue operation. Thirty vessels, nine helicopters, and 11 medical teams were part of the rescue operation. This event claimed 188 lives but 351 survived. During the inquiry after the incident, individuals expressed the opinion that one contributing factor was a “disease of sloppiness and negligence at every level of the corporation.”16

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 between 6 and 8 m high.19 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 Center (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: Ship Wreck and Delayed Rescue AL SALAM BOCCACCIO 98

This Egyptian drive-on/drive-off ferry, with 1,400 people and 220 vehicles on board, sank during the night in February 2006 in the Red Sea. The ferry caught fire and after only 10 minutes of fire suppression activity, the ferry capsized. 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. Res- cuers ultimately saved 314 passengers.16

Errors: High-speed Vessel and Bad Weather Navigation SLEIPNER

The cause of this shipwreck was a combination of naviga- tional error, high vessel speed, severe wind, and large waves.20

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 onboard 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 pas- sengers reported difficulty putting on the life jackets. Some of them came loose in the water and some jackets nearly stran- gled the wearer. A total of 69 people were rescued and 16 died. Hypothermia was a severe problem. These experiences illustrate the following principles.

■ Evacuation routes need to be adapted to how people behave 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 SCANDINAV IAN STAR

One night in 1990, fires were started on board the cruise ship “Scandinavian Star” while traveling between Oslo in Norway and

C op

yr ig

ht ©

2 00

9. C

am br

id ge

U ni

ve rs

ity P

re ss

. A ll

rig ht

s re

se rv

ed .

260 ■ UL F BJ Ö R N S T I G A N D RE B E C C A FO R S B E RG

Fredrikshavn in Denmark.21 There were 99 crewmembers and 383 passengers on board. The first fire started at 2 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 acti- vated. 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 Scan- dinavian Star was burning heavily aft. One and one-half hours 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 postincident 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, car- bon 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 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.

PLANNING

Sea transportation and rescue are tightly regulated areas in many aspects.22 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, economical factors influence the avail- ability 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 res- cue equipment function effectively. In the cases referred to pre- viously, the emergency equipment performed poorly. Mistakes were avoidable. Crew members could not launch life boats, 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 avail- able are essential for saving people at sea. In the Estonia inci- dent, 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 emer- gencies. 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. Operators of cruise ships in the Caribbean and many other locations require all passengers to learn how to move to their emergency stations and life boats, and also how to find and test their life jackets.

Training of rescue personnel in hostile weather and environ- mental conditions is also necessary. Use of young inexperienced persons, such as those fulfilling their military commitment, is not appropriate. In the Estonia incident, inexperienced individ- uals were assigned the demanding position of surface rescuers on some of the 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.19

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 identification of the first suitable ship arriving at the site as the On-scene Commander and automatic dispatch of the appro- priate 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.21 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

C op

yr ig

ht ©

2 00

9. C

am br

id ge

U ni

ve rs

ity P

re ss

. A ll

rig ht

s re

se rv

ed .

TR A N S P O RTAT I O N DI S A S T E R S ■ 261

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 Boccac- cio 98 incident is one example in which the delayed release of information regarding survivors created a public outcry; sim- ilar 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 above referenced incidents contained a large degree of uncertainty.16,19,21 The final assessments, however, were usu- ally 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 aban- doned 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 HY POTHERMIA

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 tem- peratures may be conservative estimates.23 Young fit men with strong survival instincts seem to survive longer.19 It is essen- tial 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 cau- tiously (e.g., so as not to induce ventricular fibrillation), and they ideally need to 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.

TRANSPOR T

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 heli- copter 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

Traveling by rail is relatively safe but the global railway industry is growing at a rapid pace. Rail traffic and train speed are increasing significantly, as are the numbers of tunnels and bridges. These factors increase the number of rail disasters. Historically, the challenge has been to find ways of controlling the kinetic energy that dissipates through the train structure during a crash and to protect passengers from the destruction it can cause. Con- siderable progress has been made regarding train structure but insufficient changes have been made to the interior of rail car- riages. This is a direct result of the conflicting demands of safety, comfort, economy, and performance.

Large differences are revealed when comparing safety and security issues between the rail sector and aviation. Safety regu- lations for train travel are limited despite the fact that railway speeds have increased significantly. Furthermore, hostile acts committed against the rail sector are increasing. This raises the question of whether it is necessary to improve safety and security regulations for train travel.

Incidence Data

During the 19th century, the number of major incidents that produced significant fatalities was low because train speeds rarely exceeded 80 km/hour. In the 20th and 21st centuries, the speed and density of rail traffic increased as did the fre- quency and severity of rail injury incidents14 (Figures 18.4 and 18.5).

Injury Incidents: Historical Perspective

The first train carriages were made of oak. These designs pro- tected the passengers from the weather, but in a crash they simply disintegrated. A French crash in 1933 demonstrates this reality. In thick fog, a locomotive struck a slow moving wooden passen- ger express from behind and managed to run through almost its entire length, killing 230 people. In 1937, experts began to exam- ine what happens to wooden carriages during a crash. The inves- tigations showed that the dissipated kinetic energy resulted in complete destruction of the entire rail carriage in a phenomenon called “telescoping”24 (Figure 18.6).

Telescoping was one of the major causes of death and injury in train crashes at that time. Experts were highly motivated to find a way to prevent this from happening. The French decided to construct a new stable rail carriage out of metal. This rail car- riage reflected the kinetic energy and emerged relatively intact, and metal carriages were introduced across the world. By the 1950s, metal rail carriages had more or less replaced wooden ones on the world’s railroads and the new design increased the chances of occupants surviving a rail disaster. Although the concept had minimized the telescoping problem, it inad- vertently created another dangerous phenomenon, “overriding” (Figure 18.7). This problem cast a shadow over railroad safety for decades. As an example, three morning trains collided in

C op

yr ig

ht ©

2 00

9. C

am br

id ge

U ni

ve rs

ity P

re ss

. A ll

rig ht

s re

se rv

ed .

262 ■ UL F BJ Ö R N S T I G A N D RE B E C C A FO R S B E RG

Figure 18.4. Number of rail disasters worldwide with at least 10 or more deceased or 100 or more people injured. (Data from: “EM-DAT: The OFDA/CRED International Disaster Database – www.em-dat.net – Université Catholique de Louvain – Brussels – Belgium”).

Clapham, England in 1988. One train overrode the other and crashed down on the passengers below, killing 33 people.24

After the rail incident in Clapham, experts worked to develop new approaches to carriage design. They started to encourage deformation zones on trains. Between 1980 and 1990, these crash zones were finally investigated as a possible answer to the “over- riding problem.” Corrugated metal plates, which make the car- riages hook together in a crash, were fitted to the ends of each rail carriage. These designs decreased the risk of vertical move- ment that could develop into overriding. The corrugated metal plates, known as anticlimb devices, are a standard safety feature today on many trains. In the United Kingdom and the United States, fitting of crash zones and anticlimb devices have become mandatory on all new rail carriages.24

One last issue remained with regard to carriage safety and this problem was highlighted by the 1987 crash near Chase, Mary- land. Here, 16 people were killed by a crash phenomenon called

2000

4000

6000

8000

10000

12000

14000

16000

N u

m b

Diseased

Injured

Figure 18.5. Number of injured and deceased in major∗ rail disasters. ∗At least one of the following criteria must be fulfilled for inclusion of these data: 1) 10 or more people killed; 2) 100 or more people injured. (Data from: “EM-DAT: The OFDA/CRED International Dis- aster Database – www.em-dat.net – Université Catholique de Lou- vain – Brussels – Belgium”).

“jack-knifing” or “lateral buckling” as it is known in technical terms (Figure 18.8). On impact, the train carriages derail and collide into each other’s sides. The often-weak sidewalls collapse inward, injuring the passengers inside.25

In the Purely train crash in 1989, two trains bound for Lon- don collided. Part of the rear train rolled down a steep railway embankment and jack-knifed against a tree. The passengers were thrown forward in the carriage and against the floor, roof, and sides. Most of those seriously injured or killed had been sitting in the carriage that jack-knifed against the tree.26

Researchers have continued to find ways to reduce the risk of lateral buckling. One approach is the TGV (Train à Grande Vitesse), launched by the French in 1980. At that time, it was the world’s fastest train, traveling at 200 km/hour. This speed required a new conceptual design. The vulnerable point where two carriages are linked was made strong and stable to reduce the risk of carriages buckling either sideways or vertically.24

Nonetheless, it has been difficult to eliminate these problems completely due to increasing train speeds and different carriage designs.

Figure 18.6. Telescoping. Illustrator: Gunilla Guldbrand. See color plate.

C op

yr ig

ht ©

2 00

9. C

am br

id ge

U ni

ve rs

ity P

re ss

. A ll

rig ht

s re

se rv

ed .

TR A N S P O RTAT I O N DI S A S T E R S ■ 263

Figure 18.7. Overriding. Illustrator: Gunilla Guldbrand. See color plate.

Injury Incidents: Current Perspective

The train exterior has thus been developed to reduce the con- sequences of railway incidents; however, what happens inside a rail carriage during a crash is just as critical as what happens on the outside. Published data show that the carriage interior and loose objects have a major impact on passengers’ injuries. Unsecured seat cushions, chairs, luggage, and unrestrained pas- sengers are thrown through the carriages in a crash.26,27 The presence or absence of head restraints also has an impact on the injury panorama. Folding tables significantly increase the risk of facial injuries and tables located between chairs are a risk fac- tor for thoracoabdominal injuries.27 Findings from the Cannon Street disaster in 1991, when a commuter train collided with the hydraulic buffers at the Cannon Street British Rail station, showed that craniofacial trauma was the most common type of injury in those standing at the moment of impact. These injuries resulted from passengers hitting the luggage racks.28 In March 1994, a train traveling at 85 km/hour collided with the back of a stationary passenger train, north of Aarhus, Denmark. All of the resulting injuries were related to victims striking structural elements inside the carriages.27 In October 1999, a passenger train at Ladbroke Grove in London missed a stop signal and col- lided head on with another at a combined speed of 209 km/hour. Thirty-one people lost their lives and many more were injured. Passengers described how luggage and people were flying around inside the carriage. A collision in Placentia, California in 2002 is another example. A freight train missed a signal and smashed

head on into a passenger train. Two people died from hitting the table in front of them.24 At the Amagasaki train derailment in 2005, which left 107 passengers dead and 549 injured, the most common causes of death were severe head injury (39%), chest injuries (20%), and abdominal hemorrhages (20%).29 Many of the severe head injuries were probably caused by luggage (S. Nakayama, personal communication, 2006).

After the 2002 collision in Placentia, California, the U.S. Fed- eral Railroad Administration performed tests with the Hybrid III crash test dummy to demonstrate how a body moves in a crash (e.g., how it impacts a table). Such impact may cause rib fractures and lacerations of internal organs, which are pushed against the spine, and broken ribs. These tests resulted in a new design for a safer table and this design has subsequently been tested. On impact, the table collapses and absorbs the passenger’s kinetic energy, reducing the level of trauma to the passenger’s abdomen. The passengers can also suffer serious head and neck injuries if they impact the seat in front of them. If they fly over the seat in front of them, the final impact will be even more severe.24

When viewed in conjunction with research data from 1975 indi- cating the injury reduction potential of restraint devices, these data raise the question of whether seat belts should be intro- duced on trains.30 The debate on seat belts continues, and these devices have so far not been installed as a standard safety feature on trains. The tests performed with the crash mannequins also demonstrated that it is safest to sit in rear-facing seats relative to the direction of travel.24 At the 1989 train crash in London, almost two-thirds of those killed or seriously injured were sitting in forward-facing seats.26 Experiences from the 1995 train crash in Jelling also demonstrate a significant increase in injury risk when facing forward in a moving train.31

Another concern is the threat from crashes between passen- ger trains and those carrying hazardous materials. These events have the potential to kill more people than any other rail disaster. In Mississauga, Canada, in November 1979, a freight train car- rying deadly chlorine gas derailed and exploded. Some 218,000 residents were forced to leave their homes in one of the largest peacetime evacuations in North American history. In the end, there were no fatalities, but the lives of nearly 250,000 people were placed at risk.24

Recent history has shown that designers have not yet created a sufficiently safe train and many safety concerns remain. One significant problem is the speed. The Shanghai Magnetic Levi- tation Train in China is the first magnetic train in commercial

Figure 18.8. Jack-knifing/Lateral buckling. Illustrator: Gunilla Guldbrand. See color plate.

C op

yr ig

ht ©

2 00

9. C

am br

id ge

U ni

ve rs

ity P

re ss

. A ll

rig ht

s re

se rv

ed .

264 ■ UL F BJ Ö R N S T I G A N D RE B E C C A FO R S B E RG

Figure 18.9. The Eschede, Germany, train disaster is one of the world’s worst high-speed train disasters. The train disintegrated in the crash and the disaster claimed 101 lives and injured 103. See color plate.

operation with a speed of 430 km/hour. The highest recorded speed of a magnetic levitation train is 581 km/hour, achieved in Japan in 2003.32 Engineers and designers try to make the trains lighter, smoother, and above all faster. It is a development that increases the risk for major rail disasters. A carriage wheel fail- ure was the probable cause of the crash in Eschede, Germany in 1998, when one of the world’s fastest and most technologi- cally advanced trains, the German ICE, ended up in ruins (Fig- ure 18.9). It derailed and crashed at 200 km/hour straight into a concrete bridge, disintegrating on the impact. The crash killed 101 passengers and injured 103.33

Increased safety through new design and technology could not improve survival when the world’s worst train disaster to that date occurred in Sri Lanka, in December 2004. A train was simply swept off the rails by the South Asia tsunami, killing as many as 1,700.24

The public transport system, which has occasionally been exposed to hostile acts, appears to have become a preferred target (Figure 18.10). According to the International Union of Railways, this is because of its vulnerability and the number of people it carries. Public transport systems are open and accessible to all, generally without individual entry controls or passenger identification requirements.34

Acts of aggression against the rail transportation system, such as the terrorist attacks that occurred in Madrid in 2004, London in 2005, and Mumbai in 2006 and 2008, indicate a new threat to train security and the potential need for a “bomb proof” train. Of the violent acts directed against railways depicted in Fig- ure 18.10, the most common assault involved the use of explo- sives. As many as 61% of these attacks resulted from bomb- ings. Data indicate that explosions in confined spaces are asso- ciated with a higher incidence of primary blast injuries, with more severe injuries, and with a higher mortality rate (49%), in comparison with explosions in open air (7.8%) (see Chap- ter 26).35

Even before the 1995 incident involving release of the nerve agent sarin in the Tokyo subway, there were growing concerns related to the vulnerability of subways to hostile acts. Due to this threat, security and safety concerns must become a priority and transportation agencies need to address these hazards.36

Countries that have experience in dealing with acts of aggression are working to decrease their vulnerability to such threats and taking actions to minimize the impact of attacks against the railway sector.37 Nevertheless, there is a need to be proactive against this growing hazard.

Preparation

PLANNING

Despite the relative low risk for a rail disaster, emergency response organizations must plan for such an incident. A rail disaster involving a high-speed train has the potential to pro- duce mass casualties; the dissipated energy is so large that the expected damage and associated injuries will be severe. The com- plex nature of responding to such events makes pre-event plan- ning essential.

In Kaprun, Austria, the track, the tunnel through the glacier, and the train itself were considered fireproof. So there was no plan for a fire incident. The train was supposedly built of fire safe material; however, the material was combustible and served as fuel for the fire that started in an overheated fan. The doors could not be opened manually, either from the inside or the outside, and the passengers could not contact the driver when they discovered the fire. The possibility of escape was further diminished because of the narrow tunnel in which the train was located when the fire started. The 3.3-km long tunnel had

1970-1979 1980-1989 1990-1999 2000-2007

N um

be r

Year

Figure 18.10. Number of hostile acts∗ against the rail transportation sector in which people have been injured (acts of war are excluded). ∗Hostile act: Action performed by an individual, group or organized group with intention to injure or kill people. (Data from Wikipedia).

C op

yr ig

ht ©

2 00

9. C

am br

id ge

U ni

ve rs

ity P

re ss

. A ll

rig ht

s re

se rv

ed .

TR A N S P O RTAT I O N DI S A S T E R S ■ 265

only one emergency exit in the middle with steps 0.7 m wide and without orientation lighting. The incident claimed 155 lives; only 12 passengers survived.38

The Japanese believed that the Tokyo subway was the safest transportation system in the world, but the sarin attack uncov- ered many problems. Authorities now acknowledge a lack of preparedness for a chemical disaster, including the absence of decontamination resources at the scene and personal protective equipment for rescuers. These factors have now radically altered the approach to disaster management.39 Hostile acts directed against the railways can occur anywhere, as history has shown. In Madrid and London, the police, fire brigades, and ambulance personnel were placed at significant risk due to lack of plan- ning regarding the necessary safety measures for such events40

(J. Edmondson, personal communication, 2006). Therefore, res- cue operations need specific plans that address the extraordinary safety risks that these acts create.

EQUIPMENT

Working at a train crash site exposes rescue personnel to many different hazards. Adequate personal protective equipment is 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 high-speed trains. The electrical high-voltage power is another danger. Even if it is disconnected by the rail company, first responders need the skills and equipment to perform the necessary protective grounding. It can be difficult to enter a carriage and even harder to evacuate passengers due to the carriages height. Therefore, it is important to try different solutions such as gangways. At the 2004 train crash in Nosaby, Sweden, a passenger train drove into a truck at a street level motor vehicle railway crossing, killing 2 and injuring 48 passengers. It took approximately 8 hours until the fire brigade could establish that there were no passengers trapped under the derailed train. The reason for that lengthy operation was lack of efficient equipment to lift the carriage (A. Nählstedt, personal communication, 2008).

TRAINING

Prehospital personnel need training to identify and manage potential threats resulting from train incidents including chem- ical exposure, fires, and risk of electrocution.41 In addition, all must learn how to control the risk of further explosions and exposure to toxic agents, especially in situations in which the disaster resulted from a hostile act.

It is also important that personnel receive education and training in tactics and techniques that minimize the delay in delivering medical care to injured passengers. Investigation of a train crash in Hamburg, Germany, discovered that the four vic- tims who died were only slightly injured initially, but expired due to traumatic asphyxia and suffocation.42 A review of the injuries sustained by the 113 people in the Moorgate tube train disaster has also shown the need for early extrication and evacuation of casualties. Those who died of traumatic asphyxia and crush syndrome might have survived if they had been rescued more rapidly.43

On the morning of April 25, 2005, a Japan Railway express train derailed and jack-knifed against a parking garage in an urban area of Amagasaki, Japan. The crash left 107 passen- gers dead and 549 injured (Figure 18.11). The responders used confined-space medicine techniques to aid trapped passengers.

Figure 18.11. A Japan Railway express train derailed in 2005, and jack-knifed against a parking garage in an urban area of Amagasaki, Japan. The crash left 107 passengers dead and injured 549. See color plate. Used with permission from Scanpix.

These techniques allow the rescuer to conduct a medical evalua- tion and institute appropriate medical therapy while the patient is still entrapped. Such interventions can expedite the victim’s safe extrication from the confined space. Confined-space medi- cal techniques can effectively prevent crush syndrome resulting from prolonged entrapment. The critical need for these skills was illustrated earlier during the Kobe earthquake, when hundreds of deaths were caused by crush syndrome. After the Kobe incident, a number of emergency physicians were trained in confined-space medicine, and some of these physicians were present at the Ama- gasaki crash site. Without this training, it was estimated that at least three of the last survivors rescued would probably have died before reaching the hospital.29

Scene Response

COMMAND

Command is not a new problem, but in a rail disaster, it can be particularly problematic. Command and control at the scene of a rail incident with injured victims scattered throughout the site is a challenge. Following the train collision in Eschede, the disaster site encompassed an area over 450 m long, making it difficult to maintain control when the communication lines failed. As a consequence, medical teams had to act independently. This contributed to an overload of the nearest small hospital in Celle, while the nearby trauma hospital in Hannover received only four patients.44 The 2004 terrorist attack in Madrid involved four different disaster sites and emergency managers also reported command and control difficulties. First responders encountered problems in identifying different emergency support functions within cooperating organizations and difficulty in obtaining a global perspective regarding the disaster.40

Lack of a structured command system resulting in poor coor- dination also existed at the crash in Amagasaki, Japan. The com- mand chain worked well within each agency, but there was no overarching response plan that connected all the responding agencies, which created confusion at the site.29

SAFETY

Rescue efforts adjacent to railway tracks expose response per- sonnel to great risks. Electrical, kinetic, thermal, and chemical

C op

yr ig

ht ©

2 00

9. C

am br

id ge

U ni

ve rs

ity P

re ss

. A ll

rig ht

s re

se rv

ed .

266 ■ UL F BJ Ö R N S T I G A N D RE B E C C A FO R S B E RG

hazards are the most common dangers encountered when work- ing at a rail incident site. From full speed, a train needs over 2 km to stop. Unless railway supervisors have given clearance, it may be very hazardous to approach the tracks. Bridges, tunnels, and nar- row cuttings may contribute further to an unsafe environment on one or both sides of the track. Gaining access to the interior of carriages can be difficult, owing to their height and heavily reinforced construction. Use of ladders and the need to walk on sloped surfaces also contribute to the hazards. Concrete cable ducts are covered by small paving stones. Responders may fall when walking on these stones because they are often unstable. In addition, cross ties are often covered in oil and can be slippery. Another danger is the moving blades of switch tracks because these can be operated remotely and could trap a foot without warning. Old trains still contain chemical substances that can be very toxic if ignited in a fire, and the huge array of chemicals that are transported as freight further complicates the issue. Some parts of trains are extremely hot and it is not uncommon for emergency personnel to receive burns during their rescue work. Finally, the power lines may carry up to 25,000 V of electricity. Maintaining a safe distance of 3 m from live cable is recom- mended. It is necessary to wait until the power is disconnected and the cables are grounded.41

In the Eschede crash, the carriages had a tendency to slide and it was difficult to lift the carriages without causing further damage.44 Additionally, it is not always possible to use the metal cutters and other rescue equipment due to the high risk of ignit- ing a fire. At the Amagasaki crash, gasoline leaked from vehicles in the garage struck by the train. This precluded the use of these devices and the rescue teams were forced to work with hand- driven tools.29

Another major safety issue is emergency evacuation. The stairways within double-decked carriages are small and often destroyed in a crash, trapping passengers on the upper deck. The sliding doors that serve as dividers between the vestibules and seating compartments are also problematic. The doors can jam on impact and prevent passengers from escaping.30 At the Lad- broke Grove rail incident in 1999, passengers were trapped as a result of these flaws and subsequently died in the fire that fol- lowed the collision. What the Ladbroke incident highlighted was how difficult it is to evacuate from an overturned rail carriage. The doors normally used for carriage access are too heavy for many passengers to open, if they can reach them at all in an over- turned carriage. Seat cushions, suitcases, and clothes obstruct exit routes and make the evacuation even more difficult. The implementation of airplane-style luggage racks and installation of emergency escape routes would facilitate evacuation. Train companies have been slow to adopt these innovations and, to date, have not implemented them anywhere in the world.24

Last, terrorism has also become a hazard. At the 2004 Madrid bombings, the ambulance service established field hospitals close to the railway track, placing themselves and the victims in an area at risk from potential further bomb explosions (Fig- ure 18.12). One of four backpacks containing unexploded bombs was brought to a police station. The bomb was discovered when someone made a call to the telephone in the backpack. The phone was connected to the detonator via the alarm function; however, the timer was incorrectly set to detonate 12 hours later than the others.40

After the Tokyo sarin attack, there was no field decontamina- tion of victims on site and rescue workers did not wear personal protective equipment. Of 1,365 emergency medical technicians,

135 (9%) showed acute signs and symptoms of sarin intoxication from secondary contamination and required medical treatment at hospitals. If the sarin had been in its pure form, the resulting situation would have been much worse.39

COMMUNICATION

Communication problems are exacerbated when the incident occurs in a tunnel or a subway. This is a situation in which communication is particularly important. In Kaprun, Austria, there were also communication problems due to radio signal interference at the disaster site, and the mobile phone network was overloaded. When the rescue personnel entered the tunnel to secure the scene, they had no contact with the teams located outside.38

ASSESSMENT

Making an initial assessment of the number and severity of injuries at the disaster site can be very difficult, especially if the incident is in a tunnel or a subway and communications are not functional. The 2005 London bombings highlighted this problem. It was very difficult for rescue personnel to assess the situation in the subway due to the absence of electricity and ventilation. Explosions incapacitated both systems. At the same time, there were communication problems (J. Edmondson, per- sonal communication, 2006). Moreover, no passenger list existed, which is typical for rail traffic. Therefore, it was difficult to know how people many were onboard. Because it is quite challenging to estimate the number of fatalities or injured passengers trapped in debris, decisions regarding the withdrawal of rescue activities should be made carefully, as evidenced from the Amagasaki train crash.

TRIAGE

In many rail disasters, responding emergency personnel have not had experience with common medical triage protocols and perform triage poorly at the site40,44,45 (J. Edmondson, personal communication, 2006). In the 2004 Madrid bombings, 191 peo- ple were killed and more then 1,500 were injured. Reasons given for a lack of triage in Madrid was, “it was so obvious who had

Figure 18.12. The 2004 attack in Madrid was Spain’s worst terrorist event in its history to that date. Ten bombs exploded in four differ- ent sites, which killed 101 passengers and injured more than 1,500 survivors. Ambulance services established a field hospital close to the railway track, placing themselves and the injured passengers in an area at risk for further bomb explosions. See color plate. Used with permission from Scanpix.

C op

yr ig

ht ©

2 00

9. C

am br

id ge

U ni

ve rs

ity P

re ss

. A ll

rig ht

s re

se rv

ed .

TR A N S P O RTAT I O N DI S A S T E R S ■ 267

minor or severe injuries” and “we did not have enough triage tags.”40

The Amagasaki train derailment marked the first use of on- site mass casualty triage in a Japanese crisis. The quality of triage was high, and preventable deaths were few. Nevertheless, it was logistically impossible to assign green tags to all of the hundreds of victims with minor injuries. One problem that occurred at the Amagasaki incident was that injuries such as traumatic asphyxia and crush syndrome received a low priority. In the future, triage criteria must account for these conditions.29 In addition, triage of victims from train disasters can be complicated by the presence of chemical substances including nerve agents because symptom onset can be delayed. Ambulance personnel also need training in handling toxic agents and decontamination in these cases.39

Finally, it remains controversial whether it is a reasonable strategy to perform triage inside a deformed rail carriage.

TREATMENT

In a rail crash, it is common that passengers become trap- ped by debris. At the crash in Amagasaki, Japanese physi- cian teams used confined-space medical techniques in treating trapped survivors. It took between 14 and 22 hours until the last injured passengers were extricated. During that time, the doc- tors secured intravenous lines in tight spaces and administered fluids to prevent crush syndrome. Other advanced treatments performed at the site included endotracheal intubation, rapid fluid infusion, and needle decompression of tension pneumo- thoraces.29

TRANSPOR T

Transport of victims to medical facilities can be difficult when a rail disaster strikes, especially in rural areas. In 1991, a Shigaraki Railway local train and a Japan Railway express train, both full of passengers, collided head-on after a signal malfunction. Forty- two passengers died and 614 were injured. The rural setting of the crash hampered rescue efforts and during the unorganized response no triage or effective helicopter evacuations were per- formed.29 At the 1988 rail disaster in Clapham, England, three trains collided and 33 people were killed. Passengers were trapped in three separate and somewhat isolated areas of the site. Lad- ders were needed to climb over the carriages to reach the different inaccessible areas. Significant difficulties were encountered extri- cating the victims and transporting them up the embankment to the road and the waiting ambulances.46

It remains controversial whether volunteers are helpful or not in the rescue effort. While convergent volunteers who respond to the scene may actually hinder rescue efforts if they are not well integrated into the on-scene incident management system, bystander volunteers may, in some cases, improve outcomes. One notable experience comes from Mumbai, India. On July 11, 2006, more than 180 people were killed in coordinated terrorist blasts on commuter trains in Mumbai. Mumbai had no formal emergency medical services system, so people did not wait for ambulance personnel to arrive because there were none. Conse- quently bystanders and other volunteers handled the situation themselves, with the astonishing result that most victims (700) were transported to hospitals within 1.5 hours (R. Nobhojit, personal communication, 2006).

Even in systems with well-developed emergency medical ser- vices systems, there is frequently a maldistribution of casualties to area hospitals after a train crash. One reason given for the uneven distribution of injured passengers among hospitals is

that the facilities could not provide patient care capacity informa- tion to the incident sites. Consequently, medical and fire depart- ment commanders had to guess where they should send the victims.29,40,43,44

MOTOR VEHICLE DISASTERS

Comprehensive data on highway disasters may be more difficult to find than corresponding data on more regulated sectors such as air, sea, and rail. This is not surprising, considering that even an event with a death toll of 50–100 could be considered small within the overall context of the worldwide total of 1.2 million deaths annually in motor vehicle crashes. It might also be possible that a major incident could be missed in countries with immature systems for collecting road injury data.

Injury Incidents: Historical Perspective

The number of fatal motor vehicle incidents and the number of casualties associated with them varies considerably. There are many incidents with approximately 25 dead, fewer with approx- imately 50 dead, and incidents with 100 dead do occur but are quite rare. A majority of the events involve buses. Seven road “disasters” with more than 100 killed were reported from 1970 through June 2007.47 In three of these cases (Afghanistan, Spain, and Nigeria), a gasoline tanker collision and subsequent fire were the factors responsible for the deaths of 120–2,000 people. The other cases (106–127 killed) involved a bridge collapse (Nepal), a bus that crashed into a bridge (Kenya), and a bus that drove into an irrigation canal (Egypt). The worst incident occurred in the Salang tunnel in Afghanistan during the Soviet occupation in 1988. Although details remain obscure, this event is proba- bly the deadliest tunnel fire in history. One hypothesis regarding the incident mechanism is that a fuel tanker crashed into an ammunition truck in a Red Army convoy. The casualty figure is uncertain and varies between 1,000 and 2,000 killed, most of them Afghan civilians. Many died from exposure to toxic gases and smoke. Lethal tunnel fires have also occurred in the Alps. In 1999, some 39 people died when a truck caught fire in the mid- dle of the 12-km-long Mont Blanc tunnel. The fire reached an estimated temperature of 1,300◦C, and 53 hours elapsed before it was finally extinguished.47

The focus of this section will be on the most probable type of traffic mass casualty event that rescue forces will encounter, that is, a bus or coach crash. As these crashes often occur in rural or remote areas, their management is challenging for ambulance and rescue organizations. The majority of bus inci- dents are unintentional; however, intentional attacks, such as the suicide bombings experienced in Israel beginning in the year 2000, and the London bombings in 2005, have highlighted the problem of hostile acts directed against public transportation systems.6

To simplify terminology, the word “bus” will be used to rep- resent all types of motor vehicles carrying more than nine peo- ple. This term includes the following types of buses: commuter, school, intercity, motor, and tour coaches.

Typical Injury Incidents: Current Perspective

Crashes are the most common incidents affecting buses, but these vehicles may also catch fire, either as a consequence of a

C op

yr ig

ht ©

2 00

9. C

am br

id ge

U ni

ve rs

ity P

re ss

. A ll

rig ht

s re

se rv

ed .

268 ■ UL F BJ Ö R N S T I G A N D RE B E C C A FO R S B E RG

Figure 18.13. A timber truck with trailer suffered a front tire blow out and became so difficult to steer that it crashed into an oncoming school bus in rural, northern Sweden in 2001. Timber entered the bus and made the rescue effort extremely difficult. Six of the 42 passengers involved died. See color plate. Used with permission from Scanpix.

collision or spontaneously. These fires can be deadly if passengers are unable to evacuate the bus quickly.

One of the worst bus incidents in the United States with respect to the number killed was the 1988 Carrollton bus disas- ter, when a tour bus caught fire after a collision and 27 people died.48 Another crash resulting in many deaths occurred in rural Finland in 2004 when a frontal collision between a heavily loaded tractor trailer and a tour bus claimed 23 lives. Many crashes with 20–60 fatalities each have been reported in the last decade in countries such as Albania, China, India, Iran, Mexico, Nigeria, and Thailand. Most of them have been single vehicle crashes, with a bus plunging into a ravine or down from a bridge. In a 1976 Swedish event, a tour bus caught fire due to overheated brakes. The fire and smoke were so intense that 15 people died within minutes.

The Enhanced Coach and Bus Occupant Safety project pub- lished a review of bus-associated trauma in Europe in 2002.49

The report states that in Sweden (9 million inhabitants), approx- imately one significant crash with 20–60 injured victims has occurred every year between 1998 and 2007, with a death toll up to nine in the worst crash. Six of these 10 mass casualty inci- dents resulted from single vehicle crashes; the other four were collisions with other buses or trucks.50

Seat belts are mandatory on buses manufactured after 2005 in the European Union. The impact of this change remains difficult to estimate, in part because the presence of seatbelts does not necessarily imply they will be used. Nonetheless, the combined data from actual crashes and simulations of typical single vehicle rollover events indicate that the potential for reducing moderate to severe injuries is approximately 50% with lap belts only and 80% with three-point restraints.50

Single bus crashes in Sweden are characterized by several common elements: 1) they involve intercity and tour buses; 2) events occur during winter, in rural areas under windy condi-

tions; and 3) the buses finally come to rest after a 90◦ rollover to the right, with the door side down and the doors blocked. Arriving ambulance and rescue personnel often discover numer- ous injured people lying on top of each other inside the bus, as few passengers use their seat belts. Responders often have dif- ficulty managing the scene. Fatalities typically result from two mechanisms of injury: Victims are ejected through the large windows and crushed under the side of the bus as it rolls over, and passengers are crushed between the roof and seat back as the bus overturns and the roof collapses. Extrication of victims is complicated and requires a rapid response and the correct equipment. Research, including wind tunnel tests, has shown that high-profile buses can blow off the road. Ten such cases have been reported.51 Although this is especially true in windy winter conditions, simulation studies have also shown that on a dry road, a bus may deviate 1 m or more sideways in wind gusts.

As the Swedish Accident Investigation Board has described, these crashes illustrate the need for improved tactics, techniques, and rescue equipment. This is necessary to prevent rescuers from arriving unprepared at a crash site, for example to find that a tim- ber truck has collided with a school bus and filled it with timber (Figure 18.13) or that a wobbling tractor trailer has collided with a tour bus on a cold winter night and filled it with paper bales weighting 800 kg (the Finnish incident described previously).

Fires can result from fuel spills in connection with a crash, but most fires originate in the motor compartment, wheel housing, or from failed electrical and hydraulic components. Tests have shown that up to 52 passengers can evacuate a double-decker bus in 1 minute. This rate of egress is usually sufficient to safely evacuate a vehicle on fire in most cases. A disabled person or an individual with a baby carriage can, however, delay the process significantly. Sometimes, the margin of safety can be tight, as illustrated by this anecdote. A fire originated in the rear motor

C op

yr ig

ht ©

2 00

9. C

am br

id ge

U ni

ve rs

ity P

re ss

. A ll

rig ht

s re

se rv

ed .

TR A N S P O RTAT I O N DI S A S T E R S ■ 269

Figure 18.14. This tour bus drove off the highway and down an embankment, hit a boulder, rolled 180◦, and landed on a roof that subsequently collapsed. Nine passengers died, but only two had lethal injuries. Six were jammed between the roof and interior structures (usually a seat back), and suffocated due to immobilization of the chest. It took 3.5 hours to extricate the surviving passengers. See color plate.

compartment of a bus traveling in a Switzerland tunnel. The driver recognized that as long as the bus traveled in a forward direction, the air movement over the vehicle would mitigate the effects of the fire and prevent the smoke from entering the passenger compartment. Consequently, he decided to drive to the end of the tunnel and did so successfully. During the drive, he lined up the passengers behind the doors. Upon arriving at the end of the tunnel, he stopped the vehicle, opened the doors, and all passengers escaped. Within a very short time, the entire bus was engulfed in flames (J. Andersson, personal communication, 2006).

Bus incidents that illustrate some of the factors in the Haddon Matrix are discussed next.

Errors: Human, Vehicle, and Regulation Factors The Carrollton bus disaster in the United States incorporates

multiple causative factors: a drunk driver, vehicle construction that enhanced the potential for fire, and a flaw in federal safety regulations.47 The coach involved in this disaster was originally designated as a school bus with chassis construction regulated by older federal standards. Nine days after chassis assembly began, the federal government issued new regulations; however, buses already under construction were exempt and the vehicle was not upgraded to the better standards. These new standards mandated better fuel tank guard frames, emergency exits, and several other features.

This bus was eventually used by a church youth group. At 11 pm, the bus with 66 passengers on board was hit almost head- on by a pick-up truck at high speed, driven by an intoxicated driver, moving in the wrong direction on the road. The impact fractured the bus’ suspension and drove pieces into the unpro- tected fuel tank. Fuel immediately leaked out and quickly caught fire. The fire spread into the bus and thick noxious smoke filled the passenger compartment. The front door jammed shut in the crash and fire blocked the path forward. All tried to evacuate through the single rear emergency door because victims could not open the windows or break them. A beverage cooler in the aisle contributed to problems with evacuation. The congestion of passengers at the rear emergency door also delayed egress from

the vehicle. After approximately 4 minutes, the entire bus was on fire. Twenty-seven people died in the fire and 34 were injured, 10 of whom suffered severe burns. All suffered emotional trauma and survivor guilt syndrome. This bus had no window emergency exits or roof exits, as newer commercial and school buses have. If the bus had been classified for nonschool usage, the applicable standards would have required more emergency exits.

Errors: Human and Rescue Factors In the winter of 2005, a previously healthy bus driver traveling

at approximately 100 km/hour suffered a short absence seizure while behind the wheel. As a consequence, the bus veered off the road and down an embankment, struck a large boulder, flipped over, and landed on the roof (Figure 18.14). The roof collapsed and all the windows broke. The unrestrained passengers (59%) careened around the inside of the bus and a number of belted and unbelted victims became trapped between the roof and interior structures, mostly the seat backs. Extricating the passengers was extremely difficult and neither the rescue nor ambulance person- nel had the training and the equipment necessary for an optimal effort. Traditional “heavy rescue” training was of little use in this situation, when even small degrees of carriage movement caused increased or decreased pressure on trapped victims. The ambulance crews working in the overturned bus had significant difficulties extricating people in the confined space. In addition, personnel had to evacuate the bus each time the rescue service tried to lift or move the bus. It took 3.5 hours to remove all sur- vivors from the bus wreck, exposing victims to cold temperatures for a very long time. The last extricated living victim had a core temperature of 32◦C when arriving at the hospital, and she later died.

Autopsies performed on the nine dead passengers revealed important findings. Only two of the nine victims had clearly lethal injuries. The remaining seven survived the initial crash. The forensic pathologist determined the subsequent cause of death was suffocation, caused by immobilization of the chest wall in six of the seven. In addition, the pathologist estimated survival times to be from 10 minutes to more than 1 hour. At least four victims could have been salvaged if extrication had proceeded

C op

yr ig

ht ©

2 00

9. C

am br

id ge

U ni

ve rs

ity P

re ss

. A ll

rig ht

s re

se rv

ed .

270 ■ UL F BJ Ö R N S T I G A N D RE B E C C A FO R S B E RG

more expeditiously (within 0.5 hours). It was not possible to determine whether the lethal compressing force resulted from the crash itself or the subsequent rescue efforts.

The Swedish Accident Investigation Board (2007) recom- mended the following actions.

■ The National Road Administration should install guardrails preventing vehicles from driving off the road and down steep embankments.

■ The National Road Administration should advocate for improvement in the European Union’s safety standard for bus roof deformation in cases of a rollover. (Author’s com- ment: The current standard with which manufacturers must comply is that the passenger space should not be compro- mised when a bus is tipped over sideways from a height of 80 cm. It must be quite rare for a stationary bus to roll over. Consequently, the test does not reflect real highway condi- tions. This crash demonstrated quite clearly how easily the roof collapses when a longitudinal force is applied.)

■ The Swedish Rescue Service Agency should improve its tac- tics, techniques, and equipment for handling this type of bus crash.

Errors: Vehicle and Environmental Factors In 2001, in windy winter conditions and with a light snowfall,

an intercity bus emerged from a woodland area into an open field at a speed of approximately 90 km/hour. The driver states, “an invisible hand forced the bus to the right.” The vehicle ran over and became entangled with a prebridge guardrail. The left front wheel followed the guardrail to the middle of the bridge before the bus tipped over and landed as “a bridge” over the creek (Figure 18.15). Twelve of 34 people on board were unconscious after the crash. This crash was linked to the wind sensitivity of high profile buses by using an algorithm developed from wind tunnel tests. The wind was blowing at a steady 13 m/second with 21 m/second wind gusts.

Figure 18.15. A high-profile intercity bus blew off the road after driv- ing out from a forest into an open field. The final position of the bus across the creek resulted in lack of passenger exposure to the water, likely preventing morbidity and mortality. Victim evacuation was facilitated after rescuers discovered that the windows were so strong that personnel could walk on them. See color plate. Used with permission from Lars-Göran Halvdansson.

Figure 18.16. If people are trapped under a bus constructed of steel, it can be quickly lifted with extended hydraulic cylinders in the corners of roof hatches or with two air bags. See color plate.

Errors: Environmental Factors (Road and Rescue) On a winter evening in 2003, a bus traveling at 50 km/hour

slid off a small, slippery, road. It drove down a 2–3-m steep embankment and finally turned over to the right. Ten people were ejected. The rescue service lacked the capability to lift the bus quickly. In this situation, however, the terrain was uneven and provided survival space for several victims trapped underneath. Despite the fact that it took nearly 2 hours to lift the bus and extricate the passengers, half of those ejected survived.52

Preparation

PLANNING

A well-developed plan for a major traffic injury event is needed. Problems may arise, however, when individuals believe a plan is in place but have not examined its contents (Swedish expe- rience). As these crashes usually occur during winter, equipment to protect victims from hypothermia must be included. Incor- porating these assets in the plan avoids delays in deployment of appropriate resources.

EQUIPMENT

Equipment for heavy rescue is needed, but is not always available to smaller rescue organizations in rural areas. Procur- ing equipment that can quickly lift an overturned bus that has crushed victims underneath is a priority. A 2-year development project in Sweden on the management of crashes with buses overturned 90◦ has come to a number of conclusions.

■ A bus built with stable steel bodywork may be lifted by hydraulic cylinders in the corners of the emergency roof hatches within 3 minutes (Figure 18.16).

■ A bus built from aluminum cannot be lifted by the roof hatches (too weak), but may be lifted with short hydraulic cylinders against the lateral longitudinal beam, as long as the contact points are not too narrow.

■ Two air bags can be used to lift both types of buses, but the lifting time will be more than three times as long as with the hydraulic cylinders.

■ For rescue efforts inside the bus, low-profile equipment is preferred. A spine board may sometimes be difficult to maneuver.

C op

yr ig

ht ©

2 00

9. C

am br

id ge

U ni

ve rs

ity P

re ss

. A ll

rig ht

s re

se rv

ed .

TR A N S P O RTAT I O N DI S A S T E R S ■ 271

TRAINING

During development of the bus rescue program, standard- ized extrication tests were created using a realistic case scenario involving 22 nonambulatory injured passengers (8 priority-1 cases and 14 priority-2 cases). In the first test, the extrication time averaged between 40 and 50 minutes. After a formal train- ing program, the same rescue personnel successfully evacuated all victims within 9.5 minutes. New skills learned by the responders included the critical action of rapidly cutting an extra opening in the roof (requiring <2 min). This is just one example of the impact that standardized training has on performance and may give an indication of the potential for improvement with effective instruction.

Scene Response

Command In motor vehicle incidents, the area of the crash site is usually

small. The officers from the ambulance, rescue, and police forces can easily communicate with everyone from a command post established on or near the highway. It is an advantage if the representatives from the ambulance and rescue teams act in close cooperation to facilitate extrication of the injured.

SAFETY

Ensuring the safety of rescue personnel from the threat of postevent fires, structural collapse, and on-coming traffic is important. The safety of survivors is a constant concern, espe- cially if they are trapped under or inside the bus. In these situa- tions, rapid extrication may be critical.

COMMUNICATION

As with command, problems with communication are gen- erally minimal. The most significant concern is the availability of communication from crash sites in remote areas to the dispatch center.

ASSESSMENT

In developed countries, the potential for death or injury from a motor vehicle incident is usually limited to the estimated max- imum number of passengers in the actual vehicles. Accurately estimating the number of injured passengers in highway crashes is generally easier than in other types of transportation-related events.

TRIAGE

In reality, triage prior to extrication has seldom been per- formed at an incident site. There may be several reasons for this: It is “forgotten,” it is deemed unnecessary as sufficient ambu- lance personnel are on-scene, or responders believe the best way to extricate victims is to remove them in the order they are found. Many professionals advocate this latter strategy, arguing that it is the fastest and most effective method. In addition, they believe that for some situations, it might be the only method. To address this controversy, a Swedish project evaluated both strategies (triage vs. extrication in the order found) using the standardized injury model characterized by 8 priority-1 cases and 14 priority-2 cases. (All priority-3 cases are capable of walk- ing out by themselves according to the MIMMS triage). Given that a victim’s deterioration is related to the number of min- utes the person remains trapped in the bus, the total number

Figure 18.17. Cutting an opening in the roof, which is feasible in 2 minutes with a circular saw, facilitates evacuation. This intervention permits ambulance personnel to work in the passenger compartment and to evacuate victims by using the most appropriate exit pathways. See color plate.

of person-minutes was used as the outcome variable. Investi- gators compared extrication time for the triage group (remov- ing priority-1 patients first and priority-2 thereafter) to those extricated in order they were found. The researchers found that evacuation time for priority-1 patients when using the triage strategy was 20 person-minutes shorter than when using the alternative method. Extrication time for the priority-2 victims, however, was 150 person-minutes longer in the triage group than for those extricated using the alternative strategy. These results raise additional questions. It is possible that priority-2 cases may deteriorate to a priority-1 status as a result of the additional delay. One compromise would be to evacuate in order of priority, but if a priority-2 victim obstructs the evacuation process, that victim should be removed first.

TREATMENT AND TRANSPOR TATION

In a typical single vehicle crash, head and upper-extremity injuries are the most common, followed by chest and abdominal injuries. Neck injuries are rare in single crashes but occur fre- quently (∼50%) in multivehicle collisions. In a frontal impact crash, the typical movement of passengers regardless of restraint status is forward, head first, into the seat back in front of them resulting in extension of the neck. In a rear impact collision, espe- cially in a bus with low seat backs, nearly all passengers would suffer neck hyperextension and subsequent painful injuries. Con- sequently, rescue personnel must be prepared to protect the cer- vical spine in these cases. People may also be wedged under seats, or found in difficult positions in a restricted space. In these situa- tions, a simple cloth lift technique may be fastest and safest. Some of the trapped victims may require treatment on site; confined- space medicine techniques would be beneficial.

In a typical bus crash, the vehicle is usually found on its side after a 90◦ roll to the right. An effective rescue approach is to cut openings in the roof providing extra evacuation routes (Fig- ure 18.17). The optimal responder configuration is four ambu- lance personnel in the front half of the bus and four in the rear half. This permits each group to evacuate victims by using sep- arate routes, avoiding interference with each other. Evacuation

C op

yr ig

ht ©

2 00

9. C

am br

id ge

U ni

ve rs

ity P

re ss

. A ll

rig ht

s re

se rv

ed .

272 ■ UL F BJ Ö R N S T I G A N D RE B E C C A FO R S B E RG

through existing roof hatches is possible, but these openings are so narrow on many buses, that it is difficult to maneuver a spine board and patient out through these emergency exits.

RECOMMENDATIONS FOR FURTHER RESEARCH

Air Disasters

1) Mistakes, misunderstandings, and management errors con- tinue to cause aircraft crashes. Behavioral scientists and oth- ers must address these problems and find ways to mini- mize further their occurrence. A potential solution might be implementation of an anonymous incident reporting system to help identify risk factors, such as the system now imple- mented for European civil aviation by a European Union directive. The aim of these anonymous reports is to find sys- tem shortcomings, not to punish individuals. A system that shares some of these features is also used in the United States. Further research on this promising concept is indicated.

2) The frequent postcrash fires remain a challenge. Increas- ing utilization of carbon fiber structures within airframes now under way in the aircraft industry will make these parts more fire resistant than the magnesium–aluminum alloy cur- rently in use. When these carbon structures do catch fire, however, they produce very toxic fumes. Further research is needed to develop other nonflammable materials. As toxic smoke kills most people in aircraft fires, new strategies are needed to improve passenger survival. Potential solutions include supporting them with oxygen (an aircraft carries sig- nificant amounts of emergency oxygen), or through use of smoke hoods, as the Manchester crash investigators recom- mended.12 Finding solutions to these problems remains a challenge for scientists and engineers.

3) The use of rear-facing seats would probably distribute crash impact forces more favorably, but scientific evidence from commercial aviation is scarce. In contrast, this seating con- figuration is used widely in space aviation to distribute forces.

4) After the British Broadcasting Company aired some concern- ing programs in 2006 on aircraft crew’s alcohol consumption, the aviation industry examined the issue of substance abuse by their employees more closely. Some companies have intro- duced random testing programs. The effectiveness of these programs, as well as compulsory testing of all personnel, needs to be carefully evaluated.

Sea Disasters

1) The basic construction flaw with drive-on drive-off ferries needs to be resolved: both with respect to reducing the risk of water intake through the bow and stern openings, and with respect to reducing the movement of large water masses on the vehicle deck should water intrusion occur.

2) Better measures are needed to mitigate the threat of fires, including implementation of fire prevention and suppression strategies and interventions that reduce injury. Automatic sprinkler systems and other measures aimed at reducing and extinguishing fires are necessary and should be required on all vessels.22 Because most deaths result from exposure to toxic smoke, it is critical to develop methods that will deliver breathable air to passengers and protect them from inhaling toxic fumes.

3) Lifeboats, life rafts, and life jackets (even those placed on modern vessels) have functioned poorly in rough seas, which is the typical condition when vessels are wrecked. Problems have also plagued helicopter winches. These experiences sug- gest more research and development is needed to ensure this equipment works appropriately.

Rail Disasters

1) Unlike the aviation and motor vehicle industries, safety issues within the rail sector do not receive the same level of scrutiny. The numbers of rail lines, train speed, and volume of passen- gers are increasing, and so are the numbers of rail disasters. Therefore, research devoted to the improvement of safety features on trains is necessary.

2) Avoiding injury incidents in the first place is the primary goal; however, experience to date demonstrates this is diffi- cult, despite the increase in number and quality of signals and implementation of electronic control. Many improvements have been made in carriage design, including more robust construction, stronger couplings, and the addition of defor- mation zones; however, insufficient emphasis remains on the reduction of passengers’ injuries related to the interior. This is a neglected research area, despite studies that show carriage interior has a major influence on these injuries. Therefore, further efforts are necessary to improve the interior design of trains to reduce injuries. One specific area for investigation is identifying the optimum method for storage of luggage and other unrestrained objects.

3) Preliminary studies show that a significant increase in injury risk exists when passengers are seated facing forward in a moving train. Additionally, these studies indicate the injury reduction potential for restraint devices. Owing to these find- ings, further research in this area has the potential to signifi- cantly improve passenger safety. Improvement in design and subsequent implementation of rear-facing seats and restraint devices could potentially reduce passenger injury in future crashes.

4) The last few decades have witnessed considerable changes within the railroad industry, especially concerning the con- struction of high-speed trains. Disasters involving these trains will place new demands on the tactics, techniques, and equipment used by rescue personnel. Studies from rail crashes show that passengers die of traumatic asphyxia and suffocation, as well as of crush syndrome in the absence of any other significant injuries. Therefore rescue activities must be rapid and efficient, with the goal of transporting the severe and critically injured to an appropriate medical facility as quickly as possible. Further research is needed to develop early and rapid passenger extrication techniques and training in confined-space medicine. Introduction of passen- ger safety instructions, improved emergency exits, larger and roof hatches are factors that may also improve the efficacy of evacuation and rescue operations.

5) Recent history has shown that the railway sector is vulnera- ble to hostile acts contributed to by the absence of passenger screening and the large number of people who utilize the sys- tem. Therefore, it is critical to identify measures that improve security and reduce the rail transport system’s vulnerability. One possible solution is to design rail carriages that chan- nel the blast wave from an explosion in a way that mini- mizes injuries to the passengers. Channeling the blast wave

C op

yr ig

ht ©

2 00

9. C

am br

id ge

U ni

ve rs

ity P

re ss

. A ll

rig ht

s re

se rv

ed .

TR A N S P O RTAT I O N DI S A S T E R S ■ 273

through the roof might be one option. Such design changes could also facilitate passenger evacuation when a train has overturned. Additionally, trains can sustain severe deforma- tion damage after an explosion and become wedged inside narrow tunnels. Implementing this new design for channel- ing the blast wave could minimize carriage deformation and thus prevent this problem from occurring inside tunnels. Further research is also needed to identify preventive mea- sures that reduce the potential for hostile acts against railways and facilitate the discovery of additional unexploded devices. Last, finding solutions that minimize injuries and protect first responders from secondary explosions and exposure to chemical, biologic and radiologic agents remains a challenge. The development of training programs for responders in the management of terrorist attacks that involve explosives and chemical/biological/radiological agents is a priority.

Motor Vehicle Disasters

1) The stability problems, especially of high-profile buses with engine and cargo compartments in the rear, should be high- lighted. This configuration results in a center of gravity dis- placed to the vehicle’s rear with relatively less weight on the front wheels. These buses are extremely wind sensitive and their speed should be restricted in windy weather. The development of monitoring devices that can warn drivers of potentially dangerous wind gusts would improve bus safety.

2) The effectiveness of 2- and 3-point seat belts (and the anchor point of the diagonal belt) needs to be established and opti- mized, as well as the most beneficial type of locking mech- anism. If such data were available, they could facilitate leg- islation mandating such devices. In addition to regulatory solutions, studies of human behavior to determine how to achieve compliance with seat belt use would be beneficial.

3) In case of bus bombings, a strategy to divert the shock wave away from passengers requires investigation. It might be pre- sumed that an explosion in the upper compartment of a double-decker vehicle may be less damaging than one in the lower compartment (supported by the experience from the Madrid train bombing referred to previously).

4) Bus fires remain a persistent and serious threat. Fire indica- tors and automatic extinguishers in the engine compartment have the potential to substantially mitigate this danger, but so far, it has been difficult to enforce installation of these devices. Better bus construction to prevent fuel spills in case of a crash, such as installing crash safe fuel tanks similar to those in helicopters, would be a substantial improvement and justifies further investigation.

5) Rescue techniques and equipment require further improve- ments that will permit responders to manage incidents more rapidly and effectively when buses have landed upside down. Vehicles constructed with emergency exits and entry open- ings for emergency personnel would also minimize the time to rescue passengers. All these issues need further refinement through more research and development.

Common Challenges: All Modes of Transportation

Every method of transportation has its own specific problems; however, it seems all modes are at a growing risk from terror- ist attacks. Suicide bombing has invalidated traditional security strategies. The approach to addressing this problem has been fun-

damentally different within the airline industry compared with other modes of transportation. Extensive and intrusive control of airline passengers is accepted in a way that probably would be questioned in other transport modes. It is also extremely expen- sive, not only with respect to direct costs, but also the cost of time air travelers loose waiting in the airport security queues. There- fore, this approach would be very difficult, if not impossible, to implement on public ground transport systems such as a subway in a major city used by millions of people every day. The London and Madrid bombings are examples of the disastrous impact terrorist attacks can have on commuter trains. The number of lost lives and injuries generated may be greater than from an attack against an aircraft (excluding the unusual attack on Septem- ber 11, 2001 in the U.S.). New solutions to this problem must be identified such as: 1) strategies that reduce the opportunity to place bombs in critical locations, and 2) new methods to mitigate the impact of an explosion in case of detonation.

A second problem shared by all members of the transporta- tion industry is the issue of alcohol and/or drug intoxication involving those who drive or pilot the various vehicles, vessels, and aircraft. It is well known that those in the transportation industry represent a group at risk for addictive behavior. Some companies have instituted random drug and alcohol testing pro- grams, but verification is needed as to whether these interven- tions will be sufficient to improve safety or whether mandatory testing of all personnel is required.

A final common problem is that transportation disasters occur relatively infrequently, making it difficult to study them. This situation could be substantially improved if the world’s experience with such disasters were available for investigation. This suggests a potential solution: incorporating the global experience with these events into a common, well-structured database. The existence of this repository could serve as a basis for significant future research.

Acknowledgment: Professor Ulf Björnstig acknowl- edges and appreciates the contributions to this chapter and authorship of the section on rail disasters by Rebecca Forsberg, RN, BA in Peace and Conflict Studies.

REFERENCES

1. Cherpitel DJ. World Disaster Report. Geneva: Red Cross; 2003.

2. WHO. Injury – A Leading Cause of the Global Burden of Disease. Geneva: WHO; 1999. WHO/HSC/PVI/99.11.

3. National Highway and Transport Agency. Fatal Accident Report- ing System. Available at: http://www.fars.nhtsa.dot.gov/2007. Accessed January 15, 2009.

4. Haddon W. A logical framework for categorizing highway safety phenomena and activity. J Trauma. 1972;12:193–207.

5. Advanced Life Support Group. Major Incident Medical Man- agement and Support. 4th ed. Bristol: British Medical Journal Publishing Group; 2000.

6. Levinson J, Granot H. Transportation Disaster Response. 1st ed. San Diego: Academic Press; 2002.

7. Accident database. Available at: http://www.airdisaster.com/cgi- bin/database.cgi. Accessed January 14, 2009.

8. Wikipedia.org. List of Disasters. Available at: http://www .en.wikipedia.org/wiki/List of disasters. Accessed January 15, 2009.

C op

yr ig

ht ©

2 00

9. C

am br

id ge

U ni

ve rs

ity P

re ss

. A ll

rig ht

s re

se rv

ed .

274 ■ UL F BJ Ö R N S T I G A N D RE B E C C A FO R S B E RG

9. Wikipedia.org. September 11, 2001 Attacks. Available at: http:// en.wikipedia.org/wiki/September 11 2001 attacks. Accessed January 15, 2009.

10. National Transportation Safety Board. Aviation Accident Database. Available at: http://www.ntsb.gov/aviation/aviation .htm. Accessed January 15, 2009.

11. National Transportation Safety Board. Aircraft Accident Report – Air Florida, Collision with 14th Street Bridge. Technical Report. Washington DC: National Transportation Safety Board; 10 August, 1982. NTSB-AAR 82–8.

12. Fries H. The Aircraft Fire in Manchester (in Swedish with English abstract). Stockholm: National Board for Health and Welfare; 1985. SoS Report 14:1991.

13. Laurell L, Lorin H, Lundin T, et al. Aircraft Crash at Gottrora (in Swedish with English abstract). Stockholm: National Board for Health and Welfare; 1994. ISBN91–38–11384–8.

14. Brandsjö K. Katastrofer och räddningsinsatser (in Swedish). 1 ed. Stockholm: Informationsförlaget; 1996.

15. Häggmark T, Riddez L. Aircraft Crash in Taiwan 2000 (in Swedish). Stockholm: National Board for Health and Welfare; 2004. KAMEDO Report 81:2004.

16. Wikipedia.org. Al salam Boccatio 98. The sinking. Available at: http://www.en.wikipedia.org/wiki/Al salam Boccatio 98. Ac- cessed January 15, 2009.

17. World Sea Disasters. Available at: http://www.mapreport .com/century/subtopics/d/n.html. Accessed January 15, 2009.

18. Wikipedia.org. SIEV X: Suspected Illegal Entry Vessel X. Avail- able at: http://www.en.wikipedia.org/wiki/SIEV-X. Accessed January 15, 2009.

19. KAMEDO. The Estonia Disaster. Stockholm: National Board for Health and Welfare; 1997. KAMEDO Report 68:1997.

20. Brandstrom H, Sedig K. Sinking of the MS Sleipner. Stockholm: National Board for Health and Welfare; 2003. KAMEDO Report 77:2003.

21. KAMEDO. The Fire on the Passenger Liner Scandinavian Star 1990. Stockholm: National Board for Health and Welfare; 1993. SoS Report 60:1993.

22. International Convention for the Safety of Life at Sea (SOLAS). International Maritime Organization, 25 May 1980. Available at: http://www.imo.org/Conventions/contents.asp?topic id=257& doc id=647. Accessed January 15, 2009.

23. Hayward JS, Eckerson J, Collis ML. Thermal balance and survival time prediction of man in cold water. Can J Physiol Pharmacol. 1975;53:21.

24. Sayce E. Crash Science Trains. National Geographic Channel International. 2007.

25. Wikipedia.org. Chase, Maryland Rail Wreck. Available at: http://en.wikipedia.org/wiki/Chase, Maryland rail wreck. Ac- cessed January 15, 2009.

26. Fothergill NJ, Ebbs SR, Reese A, et al. The Purely train crash mechanism: injuries and prevention. Arch Emerg Med. 1992;9:125–129.

27. Ilkjaer LB, Lind T. Passengers injuries reflected carriage interior at the railway accident in Mundelsturp, Denmark. Accident Anal Prevent. 2001;33:285–288.

28. Cugnoni HL, Fincham C, Skinner DV. Cannon Street rail dis- aster – lessons to be learned. Injury. 1994;25:11–13.

29. Nagata T, Rosborough SN, VanRooyen MJ, et al. Express rail- way disaster in Amagasaki: a review of urban disaster response capacity in Japan. Prehosp Disaster Med. 2006;21:345–352.

30. Braden GE. Aircraft – type crash injury investigation of com- muter train collision. Aviat Space Environ Med. 1975;46:1157– 1160.

31. Madsen CF. Can injuries caused by train crash be prevented? Experiences from the train crash in Jelling in 1995. Ugeskrift for laeger. 1998;160:7126–7129.

32. Wikipedia.org. Land Speed Record for Rail Vehicles. Available at: http://www.en.wikipedia.org/wiki/Land speed record for railed vehicles. Accessed January 15, 2009.

33. Oestern HJ, Huels B, Quirini W, Pohlemann T. Facts about the disaster at Eschede. J Orthopc Trauma. 2000;13(4):287–290.

34. www.uic.asso.fr. Introduction. Available at: http://www.uic.asso .fr/surete/article.php3?id article=37. Accessed May 3, 2007.

35. Levibovici D, Gofrit ON, Stein M, et al. Blast injuries: bus versus open -air bombings – a comparative study of injuries in survivors of open- air versus confined- space explosions. J Trauma Injury Infect Crit Care. 1996;41:1030–1035.

36. Gershon RRM, Qureshi KA, Barrera MA, et al. Health and safety hazards associated with subways: a review. J Urban Health. 2005;82:10–20.

37. Jenkins BM, Gersten LN. Protecting Public Surface Trans- portation Against Terrorism and Serious Crime: Continuing Research on Best Security Practices. San Jose: Mineta Transporta- tion Institute, College of Business. San José State University; 2001.

38. Larsson S. Train Tunnel Accident in Kaprun 2000 (in Swedish). Stockholm: Crismart (Crisis Management Research and Train- ing); 2004.

39. Okumura T, Suzuki K, Fukuda A, et al. The Tokyo subway sarin attack: disaster management, part 1: community emer- gency response. Acad Emerg Med. 1998;5:613–617.

40. Bolling R, Brändström H, Ehrlin Y, et al. The Terror Attacks in Madrid, Spain, 2004 (in Swedish with English summary). Stock- holm: National Board for Health and Welfare; 2006. KAMEDO Report 90:2006.

41. Calland V. A brief overview of personal safety at incident sites. Emerg Med J. 2007;23:878–882.

42. Hambeck W, Pueschel, K. Death by railway accident: incidence of traumatic asphyxia. J Trauma. 1981;21:28–31.

43. Robinson OJ. Moorgate tube disaster. Part 2. Clinico-patho- logical review. Br Med J. 1975;3:729–731.

44. Iselius L. Train Accident in Germany 1998 (in Swedish with English abstract). Stockholm: National Board for Health and Welfare; 2004. KAMEDO 79:1998.

45. Ebbs SR, Fothergill NJ, Hashemi K. The Purely train crash: procedural difficulties. Arch Emerg Med. 1992;9:130–133.

46. Stevens KLH, Partridge R. The Clapham rail disaster. Injury. 1990;21:37–40.

47. Wikipedia.org. Road disasters. Available at: http://en.wikipedia .org/wiki/List of disasters#Road disasters. Accessed January 15, 2009.

48. Wikipedia.org. Carrollton bus disaster. Available at: http://en .wikipedia.org/wiki/Carrollton bus disaster. Accessed Janu- ary 15, 2009.

49. ECBOS. Cause of Injury, Summary. Graz: Technical University Graz; 2002. Enhanced Coach and Bus Occupant Safety Report No 2:5, task 2.5.

50. Albertsson P. Occupant casualties in bus and coach traffic. The- sis. Umeå, Sweden: Department of Surgery, Umeå University; 2005.

51. Petzäll J, Albertsson P, Falkmer T, et al. Wind forces and aero- dynamics, contributing factors to compromise bus and coach safety? Intl J Crashworthiness. 2005;10:435–444.

52. Backman C, Albertsson P, Pettersson S, et al. Report from major accident. Protocol from the coach crash in Ängelsberg, Sweden, January 2003. Intl J Disaster Med. 2004;2:93–104.

C op

yr ig

ht ©

2 00

9. C

am br

id ge

U ni

ve rs

ity P

re ss

. A ll

rig ht

s re

se rv

ed .