Mass Casualty Incident: Spanish Train Derailment, Part 2

By George Potter

Picking up from where we left off in Part 1's timeline...

21:24.56—112 alerts local psychologists of the possibility of requiring their assistance in case one or another of the operating organizations requests said assistance.

21:26.11—112 transfers a call from the local head of the state police to the emergency medical entity (EME) in which the police inquire as to the response of a mobile hospital. (No mobile hospital was ever deployed to this incident.)

21:27.55—AXEGA informs 112 that the mobile command post is being mobilized.

21:30.40—The state police requests that 112 inform the EME of the number of injured along the tracks that have not received any medical attention.

21:32.20—Local police request generators and lighting equipment. This communication was followed by several more between the toll highway operator and the police on the availability of generators and lighting equipment.

21:45—Personnel from several surrounding private fire brigades and civil protection groups have been arriving at the scene; their only sources of information, organization, and instructions are Santiago SEIS firefighters.

21:48.16—The EME requests communication with the state police to know how ambulances should arrive to the scene and coordinate its operations; at this time, the ambulances are not able to access the immediate area.

The incident has been evolving now for more than one hour. There is no clear and defined incident commander or incident management structure. State and local police agents, fire service personnel, and emergency medical personnel are operating under their own protocols [no established standard operating procedures (SOPs)]. A large number of local citizens have been participating in rescue operations, nearly all with no personal protective equipment or knowledge of technical rescue, placing themselves at extreme risks. It was later recognized by operational personnel that, in many cases, this altruistic labor contributed positively to the outcome of the incident.

21:50—The Santiago SEIS changes duty shifts at 2200 hours. Several off-going and on-coming personnel prepare to respond to the accident. With no service transport available, the local police take the eight firefighters to the scene. A total of 33 Santiago firefighters are operating at the accident, and some 50 more from other entities are also on scene.

21:51.47—The regional psycologist organization, Psychological Intervention in Catastrophies and Emergencies Group informs, 112 that five specialists are on alert and will be dispatched to the scene when considered necessary.

22:18.57—112 replies to the fire service’s request for more electric generators and lighting some five minutes before, indicating that several units are on the way.

22:19.26—The tollway operator informs that he is unable to obtain any generators.

22:27.36—The fire service inquires as to the situation of electric generating equipment. 112 replies that units are being mobilized.

22:27.54—The mobile command post arrives at the scene. This unit is based in Estrada, around 15 miles (20 minutes) from the accident site.

22:28.27—AXEGA personnel are expected to arrive at any moment, according to 112. Assistance is also en route from nearby municipalities.

22:33.22—112 replies to the inquiry from the EME for more generators that several are being transported to the scene.

 

Nearly two hours have elapsed since the derailment and there is still no concise incident command structure. The level of the incident is still unknown to those operating on site.

23:01.18—The Santiago fire service requests vans for transporting corpses to morgues. The more than 160 injured, including a number of very critically injured persons, were all transported to various private hospitals in the city and to other localities, which were many miles away. No injured were treated in the large public hospital some three miles from the scene.

23:15—The last live victim is removed from the wreckage by a Santiago SEIS firefighter with the aid of a heavy-duty crane; she survived.

Some time after the incident, it was discovered that offers of assistance from numerous municipal public fire and rescue services were refused by AXEGA. The only public fire service on site was that of Santiago de Compostela. However, several small fire brigades run by private companies in villages and rural areas were mobilized by AXEGA. None of these services had received adequate training or had experience in incidents of this nature and magnitude. These brigades have principle assignments for rural and wildland fire protection.

The contracting of private companies to operate local fire protection is quite common in this particular region of Spain and is slowly gaining interest in other regions. The principle advantage of this particular concept is that it supposedly substantially reduces expenditures—mainly in staffing—as duty shifts are generally more frequent; the employees are not subject to public service employees’ labor conditions, and response crews are generally composed of three people.

It was also learned later that none of the four mobile hospital units operated by the EME were actually mobilized.

 

SANTIAGO DE COMPOSTELA FIRE & RESCUE SERVICE (F&RS)

The Santiago F&RS is a fully paid public fire brigade covering the city of Santiago and eight surrounding towns, with a combined population of more than 160,000. The brigade is composed of one subofficer (operational chief), five sergeants (shift leaders), five corporals, and 57 firefighters, all of whom are apparatus drivers/operators. As in nearly all Spanish fire services, the brigade works a 24-hours on, 96-hours off schedule, allowing for between 10 and 12 firefighters on duty at all times. The brigade operates out of one station with a fleet of the following:

  • 1 combined light urban pumper/60-foot aerial ladder.
  • 5 urban pumpers @ 415 gpm and 1,000-gallon tanks.
  • 1 3,600-gallon tanker.
  • 1 100-foot aerial ladder.
  • 1 138-foot aerial platform.
  • 2 command vehicles.

The brigade handles all kinds of emergencies including industrial and nonindustrial structure fires, road traffic accidents, hazmat incidents, technical rescue emergencies and backs up to the international airport emergency service.

 

FACTORS CONTRIBUTING TO THIS ACCIDENT

In the 21 years that high-speed trains have been operating in Spain, this was the first accident with fatalities. A series of factors contributed to this accident; some technical, others operational and one, the primary cause: Human error.

  • According to RENFE engineering and safety specifications, the high-speed lines must be equipped with automatic velocity detection devices that oblige trains exceeding the maximum speed in any particular sector to reduce speed. This system is not installed on the branch where the accident occurred because it is not considered a high-speed line.
  • The Ministry of Public Works, during the period of the construction of the 50-mile sector between the cities of Orense and Santiago during the 2000s, modified several key elements of the initial project including maintaining an older conventional width sector of rail lines, thus saving some $60 million and another saving of some $18 million by not having to install the automatic velocity detection system in this sector.
  • The engineer admitted, just a few minutes after the accident, that he was travelling far and away above the speed limit on this particular sector to recover lost time over the route. RENFE and ADIF economically penalize engineers for late arrivals.
  • It was discovered some days later that the onboard controller telephoned the engineer moments before the accident about making an unscheduled stop for some passengers. This call apparently distracted the attention of the engineer just enough to cause him not to see excessive speed warnings.
  • The engineer also declared that he may have become disoriented or confused regarding through which tunnel the train had just passed. There are four tunnels fairly close together in this particular sector of the route.

This accident calls to mind the accident in the Valencia subway some six years ago in which 41 passengers lost their lives. The initial investigation of that accident placed blame on the engineer, who also perished in the wreck. It was later discovered that there had been considerable political cover-ups in that incident, and the judicial investigation has been reopened. The investigation of the Santiago accident appears to be much more serious, and blame may well be spread over diverse origins including the railway operators.

 

LESSONS LEARNED

There are a number of lessons to be learned from this tragedy. These include but cannot be limited to the following:

  • The need for integrated emergency incident command structure and SOPs that must be thoroughly implemented. Unfortunately, far too many emergency managers in Spain are politicians with absolutely no knowledge, experience and, in some cases, true interest in proper emergency management.
  • There were serious flaws in communications. A number of emergency responders and police officers had to communicate frequently by cell phone, as compatible radio communications were nonexistent. A communications protocol or SOP must be implemented and followed by all responders and their organizations, and compatible communications equipment available.
  • Personnel levels of ALL Spanish public are notoriously low. The average ratio of firefighters to population is about 1:2,300. As the national labor legislation has an established ceiling on annual working hours for all public sector employees of approximately 1,700 hours, this obliges the fire services to operate five 24-hour shift schedules, although there are some variations such as 12-hour shifts, 7 + 7 + 10, and other solutions. Maintaining total personnel but reducing duty tours to four would allow most brigades a roughly 20-percent increase of on-duty responders. The private contractors could modify their operational structures, allowing them to function with even lower staffing levels.
  • The Minister of Public Works announced profound investigations into the safety practices and systems of the entire railway network. One of the principle aims of these investigations is apparently to increase the automatic velocity control systems, incorporating them into a number of lines and sectors considered previously as not worthy of such controls. Another subject under investigation is the limiting and controlling of possible distractions to engineers, such as unnecessary telephone calls, and so on.

 

Photos found on Wikimedia Commons courtesy of Contando Estrelas.

 

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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