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HIGH-SPEED CRASH KILLS 101

HIGH-SPEED CRASH KILLS 101 (.pdf 1,539KB)

GunnarJ. Kuepper

On Wednesday, June 3, 1998, a high-speed train traveling 120 miles (193 kilometers) per hour derailed and crashed into a highway overpass in northern Germany, killing 101 people and injuring 88, most of them critically. It was the first rail crash since the high-speed trains, called ICE-ls, were introduced in Germany in 1991. Over seven years of operation, more than 130 million passengers had traveled safely between most of the country's major cities.
  Like every ICE-1, the ill-fated train, which departed northbound from Munich at 8:00 a.m., consisted of two electric-powered locomotives on either end and 12 pas- senger cars, seating approximately 200 passengers. Each ICE-1 train is 1,200 feet (410 meters) long and weighs about 800 tons (725.8 metric tons), and each passenger car is 95 feet (29 meters) long. The travel time for the nearly 500-mile (804.5-kilometer) trip from Munich, in the south, to Hamburg, in the north, is 5'/2 hours.
  The high-speed train was traveling through the flat, rural areas of Lower Saxony when a rear wheel on the first passenger car failed, and the wheel rim began to disintegrate. The engineer wasn't aware of the failure because there was no monitoring system. Two minutes before the crash, however, some passengers in the first car heard noises and felt vibrations that probably were caused by debris attached to the tire-assembly rim striking the tracks.
  Three miles (4.8 kilometers) before the crash occurred, the debris from the damaged wheel cut the #9 track inductible cable loop (LZB), which is an auto- matic control system overlaid on the signal system that continuously calculates the train's safe stopping distance and monitors the traffic ahead. In Germany, the LZB is required on lines where trains travel faster than 100 miles (160.9 kilometers) per hour.
  The train continued for three miles (4.8 kilometers), traveling 200 yards (182.9 meters) on its damaged wheel, until it approached two track switches at separate turnouts before a bridge. The broken wheel rim, still hanging on the track brake, collided with the guide rail of the first turnout, forcing the rear left wheels of the first passenger car to the inside of the left track rail, and the car derailed. One hundred twenty yards (109.7 meters) further, the derailed wheel assembly hit the next turnout switch, causing the open switch point to close against the running rail lining. The first two passenger cars went straight through the switch, derailed, and skidded along the tracks, but they didn't fall over. The third car followed the first two, but its rear wheels were diverted to the sliding track, and it derailed 80 yards (73.2 meters) in front of the highway overpass. The trailing end of the third car hit the concrete overpass, knocking out its support columns, but it slid under the falling bridge and came to a stop without tipping over. The fourth car, which also cleared the bridge, slid down the railroad embankment into a wooded area and fell on its side. The concrete over- pass then collapsed into the middle of the fifth car, crushing it, tearing it apart, and burying its rear end under 300 tons (272.2 metric tons) of concrete.
  The sixth passenger car turned sideways across the track in front of the collapsed bridge, and the following six cars, including the rear locomotive, hit the blockade at 120 miles (193 kilometers) per hour, causing the train to fold up like an accordion. The sixth and seventh passenger cars were partially buried under the bridge debris.
  Sometime during the crash, the front engine separated from the rest of the train, and it was only when an emergency braking system activated automatically 2 miles (3.2 kilometers) later that the engineer realized what had happened.
  At 11:00 a.m., the 6,000 residents of the small town of Eschede, which has no industry and no freeways, were faced with the chaos, confusion, and casualties of a major disaster.

The response
At 11:01 a.m., the county fire and police departments received the first calls reporting the crash and dispatched the volunteer fire department of Eschede and the local EMS ambulance. The first units arrived six minutes later, and the county fire dispatcher received the first radio message describing the crash's magnitude.
  At the time, only one person was on duty at the county fire and rescue dispatching center, and he wasn't prepared for a disaster of this magnitude. Nonetheless, he began to alert additional county fire departments and EMS units and asked surrounding counties for mutual aid. By this time, local volunteer fire departments, EMS heli- copters, volunteer organizations such as The Red Cross, search and rescue helicopters from nearby military bases, and others who were notified or had heard about the crash on broadcast or emergency radio channels rushed to the scene. Unfortunately, the dispatcher failed to alert others who could have helped, such as a volunteer organization in the county with four Basic Life Support (BLS) units and a state firetraining institute, which hadn't been included in the county's emergency plan. When these organizations heard of the crash on their own, they, too, responded with all available vehicles and personnel.
   Town residents and a few EMS units initially gave medical aid. Within an hour of the derailment, however, additional EMS resources arrived. Trauma physicians from the county hospital in Celle, which was 15 miles (24.1 kilometers) away, from university hospitals in Han- nover, 40 miles (64.4 kilometers) away, and from Hamburg, which was 100 miles (160.9 kilometers) away, formed teams and flew to the scene.

Responders mill through the wreckage in search of survivors.

   At 12:05 p.m., ambulance and rescue helicopters began to evacuate 27 of the most critically injured victims. By 2:00 p.m., an estimated 800 to 1,000 first responders were at the site, and 87 extricated passengers were en route, in ambulances and helicopters, to 22 hospitals and trauma centers within a 100-mile (160.9-kilometer) radius. The last three survivors were discovered and sent to trauma centers between 4:00 and 4:30 p.m. Five survivors later died of their injuries.
   During the first four hours of the incident, the responders goals were to dispatch emergency personnel and equipment; conduct search and heavy-rescue operations; extricate trapped victims; triage, treat, and transport the injured; and coordinate the activities of 190 military personnel and their heavy equipment and helicopters, 100 fire vehi- cles with 500 personnel, 19 EMS helicopters, 98 ambulances, and at j least 40 physicians.
   At 3:00 p.m., the second phase of emergency response began with a secondary search. Bodies were recovered, the first press conference was held, and the first responders were relieved. Train passengers were accounted for, the dead were identified, and the injured and uninjured were registered. Passengers' relatives were notified, and onsite stress debriefings were held.
   The third phase of response began the next day at noon, when more bodies were recovered and the investigation continued. High-ranking officials such as the Chancellor and Secretary of the Interior rushed to the scene, where public relations professionals fielded questions from 200 journalists. Responders also took care of logistics, collected private baggage, salvaged the wreckage, and searched for body parts. Bodies were still being recovered on Friday.
   By the time operations were suspended, 96 bodies had been recovered, many of which had to be identified by dental or DNA records. Most had died on impact. At 7:00 a.m. Saturday, command of the crash scene passed from the fire service to the police.

Train safety
According to the news magazine Der Spiegel, the train that derailed had been audited by computer the night before the crash as part of its regularly scheduled maintenance. Safety engineers found an irregularity in one of the two pivoting wheel assemblies, each of which has two fixed axles, or four wheels per assembly, with one wheel on each end topped by a metal sleeve to improve passenger comfort.
   In the Munich Inspection Center, sound resonance sensors measure each wheel's outer diameter and the thickness of each sleeve. The wheel diameter is 37 inches (93 centimeters), while the sleeve is 2.28 inches (60 millimeters) thick, giving an overall outer diameter of 39 inches (99 centimeters). The acceptable tolerance is +/- Vi.ooo of an inch (0.6 mil- limeters). Though one wheel on the train that derailed showed a variance ofl/2w of an inch (1.1 millimeter), safety engineers believe that this variance would only affect the smoothness of the ride by causing some vibration. Even if it had been clearly out of tolerance, it wasn't considered unsafe, so the wheel wasn't changed or repaired.
  All procedures associated with this crash are still under criminal investigation. The final report has yet to be released.

Lessons learned
The County Fire/Rescue Calling and Dispatching Center was staffed by one man who was overwhelmed by the simultaneous tasks that had to be done. Radio frequencies and cellular phone networks were also overwhelmed in the rural area. Since different agencies—military, public, private, and volunteer—work on distinct radio channels, it took hours to establish a comprehensive incident command system with clear functions and control.

The first responders searched the wreckage for four hours.

   During the initial phase, there was almost no coordination. The county had no mobile command vehicle, and its fire chief wasn't equipped with a fax machine or a cellular phone. Due to lack of expe- rience with a disaster of this magnitude, first responders had no clear means of identifying command functions. The incident command system is virtually unknown in Central Europe, as are functional identification vests. People wearing "chief" or "medical leader" name tags could always be seen, but they weren't in charge, and they weren't informed. Responding units that didn't receive organized functional assignments either waited for them or began to work on their own. Units that had experience with mass casualty incidents, such as rescue helicopter squads and the military, organized themselves. Too many volunteer groups responded without being dispatched, and many weren't needed until later in the incident.
  Operations were also hampered by the trains modern construction. Rescue tools such as saws and the jaws of life slipped on the polished skin of the passenger cars, and windows were virtually unbreakable, even with sledgehammers. Rural fire departments had neither the experience nor the skills needed to work with modern train compartmentation. In Germany, no training program had ever been conducted for fire and rescue services in anticipation of this type of crash, and the railway company had never provided material explaining train construction. Luckily, the crash site was close to paved streets, allowing heavy equipment such as cranes, fire apparatus, and ambulances to reach the scene without hindrance. And there was enough open space to establish a heliport and staging areas for vehicles and personnel. Many townspeople were also able and willing to help rescue people and comfort them. A triage and treatment area was set up in a com- munity hall, which was later used as a temporary morgue. University hospitals in Hamburg and Hannover had the necessary skills to help the victims, most of whom suffered life threatening injuries. Teams of experienced trauma physicians and paramedics were taken, along with their medical equipment, by private ambulance and federal police helicopters to the site, where they organized triage and treatment.

The day of the crash was sunny, warm, and bright, with temperatures in the 70s and clear visibility. Had the same crash occurred in rough terrain on a bitter cold night, miles from paved access routes, a community, and a supportive infrastructure, the casualties would have been worse. Nonetheless, many young and inexperienced volunteer EMTs encountered horrible injuries for the first time and were later involved in the search for and recovery of bodies. Fortunately, a broad psychological support program for the responders was established for the first time in Germany, where the devastating effects of a disaster on emergency workers have often been ignored. This disaster raised awareness and initiated a valuable discussion about critical incident stress debriefing policies.
   In addition to traumatizing the victims, their families, and responders, this train crash caused Germans to lose faith in what they once considered a safe mode of transportation. According to a poll in May 1999, nearly one year after the crash, 30 percent of those questioned still believed trains were unsafe, and 10 percent felt they were at high risk riding on trains for at least some time after the crash.
  As with any crash, this one confirmed Murphy's Law: If something can go wrong, it will. The only answer to saving lives is preparedness and a comprehensive emergency management plan. Safety departments and emergency services are in charge, and it's up to us to make a difference.

GunnarJ. Kuepper is director/chief of Operations of Emergency and Disaster Management, Inc., in Los Angeles, California.