Probe of Deadly Spanish Subway Derailment Ordered Reopened

By George Potter

Just past midday on July 3, 2006, the urban transport system of Valencia, Spain experienced the country's gravest subway accident and one of the world's most serious urban transport incidents. Forty-two passengers and the conductor lost their livers and 47 other passengers suffered various injuries.

Valencia is Spain's third largest city, with a population of 810,000 in the 52-sq.-mile municipality; the 700-sq.-mile metropolitan area population reaches 2.3 million, depending on the season. Valencia is the nation's second most important sea port. Two America's defenses were held there, in 2007 and 2009, and the specially laid-out urban motor sport circuit has hosted five Formula 1 Grand Prix races between 2008 and 2012.

The Valencia subway system, known in Spanish as MetroValencia, is a 12-mile underground portion of the 109-mile network of the Valencia Regional Railway, or Ferrocarrils de la Generalitat Valenciana (FGV), in the regional language, Valenciá. This urban/suburban railway system serves 169 stations, many as far as 25 miles from the center of Valencia, as well as several mid- and long-distance passenger and freight rail lines, including the high speed AVE line connecting Valencia with the nation's capital, Madrid.

THE ACCIDENT

The accident occurred as 1:04 PM (13:04) between two downtown subway stations; Plaza de España and Jesús. The four-car train traveling on Line 1 was approaching the Jesús station when, for unknown reasons, the conductor increased speed from the 30 mph limit along this particular curved section to approximately 65 mph, causing the lead car to derail and flip onto its side and skid for several yards along the rails before coming to a halt some 150 feet from the Jesús station. Nearly all of the fatalities were due to people being thrown out of the lead car and dragged along side or under the train, crushing and dismembering many of the victims. None of the passengers in the following cars were killed, although all of the injured passengers had been in these cars.

During the post-accident investigations, it was discovered that the glass windows of the cars had been replaced with plastic panels with the objective of reducing damages caused by vandals throwing stones at the trains. These plastic panels had not been securely mounted and broke out when the car overturned, allowing the passengers to be thrown out of the car. It has been hypothesized that if the glass windows had been retained, the number of fatalities might have been reduced.

It was also ascertained during the investigation that the railway system had been equipped with a very limited safety system that supposedly would indicate when brakes should be employed. This system is far less expensive than another, more sophisticated system used in the subways of Spain's other major cities and the national railway system that would have automatically provoked the activation of brakes.

INVESTIGATION

The regional parliament established an investigation commission to interview government and FGV personnel and establish the cause or causes of the accident.

The official cause of the accident was conductor error--excessive speed in a dangerous sector of the line. No political responsibilities, technical failures, or corporate errors were declared. The investigation commission heard what was later discovered to be "scripted" testimonies and rather quickly and silently closed the investigation. There were numerous cases of press censorship, creating a sensation of political "cover-ups."

However, recent press and television reports that have brought to light numerous, very serious contradictory allegations, several from the former security/safety director of the railway. These have caused the local District Attorney, Fiscal in Spanish, to order the case to be reopened. It is suspected that there may be possible political repercussions resulting from this renewed investigation.

VALENCIA FIRE SERVICE

The Valencia municipal Fire and Rescue Service (VF&RS) is a paid, public service entity composed of 400 people, including senior command officers, divisional officers, operational officers and subofficers, driver/operators, firefighters, and medical assistance personnel. The operate out of six stations with a fleet of some 20 engines including RIVs and tankers, seven aerial devices (ladders and platforms), and specialized apparatus including a mobile command post, rescue vehicles, air supply, ambulances and other vehicles. One station is situated in the port area with specific assignments, including shipboard firefighting, hazmat, and water rescue. The service operates on a 24 hours on/96 hours off, with 70 operational personnel on duty at any given time.

On the day of the subway tragedy, the operational structure was enhanced by personnel of the fire prevention office, civil protection, administration, and mechanics, bringing the total presence to nearly 100 people.

FIRE SERVICE RESPONSE

At 13:04:48, seconds after the derailment, the fire service communications center received a phone call from the wife of an off-duty city firefighter informing that their daughter had just called by cell phone saying that the metro in which she was a passenger had crashed. The wife said she had little more information as the call from her daughter was unintelligible. Less than a minute later, the command center received notification from the regional emergency call center, 112, informing of the accident based on information received from numerous other callers from the wrecked train.

INITIAL RESPONSE

The VF&RS standard operating procedures for an incident in the metro system called for the following first response:

  • One engine with a crew of five
  • One urban rescue truck with a crew of three
  • One ambulance with a driver and an EMT
  • Two command vehicles with two officers

On arrival, the responding incident commander (IC) and crews found massive devastation in the tunnel but no fire. The IC immediately requested assistance because of the apparent magnitude of the incident. Another engine and another rescue van responded with eight more personnel, bringing the number of fire service personnel on scene to 20. Several senior officers were deployed either to the scene or to the command center, including the fire service chief, who assumed command and established the incident command site in the Jesús station. First responders began searching the tunnel for victims and survivors. As they progressed towards the wreckage, they found an injured passenger walking away from the scene who gave them valuable information on the situation and conditions at the wreck site. The search team leader immediately communicated the need for reinforcements for search and rescue.

The more-than-24-hour operation of the VF&RS at the wreck site can be divided into three distinct stages, according to personnel on scene and the operations performed.

• STAGE 1 (First response until 15:00 hours): Search, rescue and evacuation of injured passengers.

- IC was VF&RS chief

- One operations chief

- One logistics unit chief (at command center and later to IC Site with resources)

- One shift commander (the equivalent of a battalion chief)

- Two station chiefs-sergeants (the equivalent of a captain)

- Four crew chiefs-corporals (the equivalent of a lieutenant)

- 21 firefighters

- One subofficer from a logistics unit

- Two sergeants from logistics

- Six firefighters from logistics

- One off-duty officer

- Two off-duty firefighters

During this phase of the emergency, 43 fire service personnel were on scene. Forty-two off-duty people called in to the command center, placing themselves at the disposition of the service. Another estimated equal number of off-duty personnel also called in, while still more went directly to the incident scene. Although the names and phone numbers of all these "volunteers" were noted, the IC decided that the on-scene personnel would be capable of handling the situation.

• STAGE 2 (15:00 to 22:00 hours) Removal of victims

- VF&RS chief (IC)

- Operations chief

- Logistics chief

- 47 firefighters of all ranks

This was probably the most psychologically demanding phase of the emergency as nearly all of the firefighters were involved in victim recovery and removal. This meant finding and removing crushed bodies and even amputated parts of bodies. Operations in this phase were performed in collaboration with personnel of the scientific investigation unit of the Spanish National Police Force.

The increased number of service personnel on scene was due to the shift change at 7:00 PM-19:00 hours. Several off-going firefighters remained to continue participation in the operations.

• STAGE 3 (22:00 to 14:37 the following day) Technical collaboration with Metro personnel

- VF&RS chief (IC)

- Logistics chief

- 29 firefighters of all ranks

This phase was dedicated principally to removing the wreckage from the tunnel to get the line back into service.

It should be noted that the VF&RS chief remained on scene as IC for more than 25 hours.

PSYCHOLOGICAL EFFECTS

The head of the VF&RS medical unit immediately established a rehab point to attend to the personnel participating in rescue and recovery actions. This proved to be extremely beneficial for all those involved.

Many of the responding firefighters and commanders were seasoned veterans of the fire service, but very few had ever been exposed to damage of such magnitude. Many suffered post-traumatic shock for some time afterward.

Long after this incident, several firefighters were still affected by specific memories of the incident. Apparently during the search and rescue operations, numerous cell phones of victims rang continuously with no one answering. This caused anxiety among personnel when a companion's phone rang and the receiver did not answer immediately. The prolonged ringing with no reply became very stressful.

MAJOR DIFFICULTIES AND PROBLEMS

Although VF&RS, the National Police Force, Valencia municipal police, the Red Cross, and other emergency response agencies all had protocols and SOPs established for major emergency situations, none really had any experiences with real emergencies of this magnitude. During the initial phases of the incident, there was a lack of coordination between agencies since no real interactions had ever been undertaken.

Nonetheless, the most important problem was communications. Radio and cell phone communications were extremely poor and ineffective, due principally to the underground location of the wreck. The VF&RS logistics officer mobilized more sophisticated radio equipment that was delayed in deployment, and the most effective solution was to station firefighters at specific locations along the tracks to relay communications between the accident scene and the command post at street level.

LESSONS LEARNED

The most outstanding lesson learned from this disaster was that established protocols or SOPs are extremely valuable when needed. For some time prior to this incident, the VF&RS had established operational protocols for response and operations in a possible accident in the metro system. These protocols did indeed prove to be proper and adequate. Nonetheless, several questions came up that required further attention and actions. The following are translations of postincident observations by intervening personnel:

  • It's a good idea to conduct simulated emergency operations and coordination exercises involving all the agencies who would participate in major incidents. Mutual knowledge amongst those responsible in the diverse organizations of their respective resources and operating procedures would facilitate improved coordination in case of major incidents.
  • Knowledge of infrastructure:. From the initial construction stages of the metro system, the VF&RS and the Valencia Metro have maintained very close relations. During the time from the inauguration of the metro in 1988, fire service personnel have visited and inspected all of the lines as they have been placed into operation.
  • Extensive risk assessment: The VF&RS has recognized from the outset the technical difficulties involved in any rescue action in the underground system and that complete knowledge of the lines and installations is the key to successful emergency operations.
  • Mutual collaboration: The Metro management has offered outstanding assistance to the fire service by continuously inviting visits and inspections of the lines and installations. They are conscious of the tremendous dangers involved in a possible accident and the potentially catastrophic results of an accident. They have provided computerized plans and any other resources requested by the fire service.
  • Simulated exercises: At the time of this incident, all of Valencia's 400 fire service personnel had been familiarized with the metro system, its installations, fire protection measures, and controls. This knowledge proved to be fundamental during this operation.
  • Reliable communications must be established and confirmed from the outset of an emergency. This incident brought to light numerous material weaknesses. Exhaustive tests and trials of a variety of communications resources should be made where it may be suspected that problems could happen.

The author expresses his sincerest appreciation and gratitude to VF&RS Chief, Tomás Asensio Martin, and to Julian Rodríguez Muñóz, chief of the service when the accident occurred and who acted as IC.

At the time of this incident, the Valencia Fire & Rescue Service staff of 400 was slightly better than the national ratio of fire fighters per inhabitant in Spain; VF&RS covers the municipality with one firefighter per 2,010 inhabitants while the national ratio is approximately 1 firefighter per 2,300 inhabitants. The towns surrounding Valencia (metro area) are covered by the Valencia provincial fire service.


George H. Potter is a practicing fire protection specialist who has lived in Spain for the past 45 years. He served as an Anne Arundel County, Maryland, volunteer firefighter with the Riva Volunteer Fire Department and the Independent Hose Company in Annapolis and as an ambulance driver with the Wheaton (MD) Rescue Squad. He served six years in the United States Air Force as a firefighter, an apparatus driver/operator, and a crew chief. He has been involved in fire protection system installation, mobile fire apparatus design, and construction and fire safety training. He is a Spain-certified fire service instructor and a hazmat specialist, and is a member of the Board of Governors of the Spanish Firefighters' Association (ASELF).

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