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In the latest of a series of articles looking back at the events thatshaped Fire and Rescue Service response, Tony Prosser looks at the impact of train-related incidents
MARCH 1989WAS A BAD MONTH for the railway network: major crashes at Purley, South London and at Bellgrove, a suburb of Glasgow, only served to underline the systemic failures that infected British Rail – failures that were only too visible following the Clapham crash three months earlier. Unfortunately for fire and rescue services, despite all the improvements made in network safety since the late 1980s, a railway accident is still the most common event that can be expected to (almost) routinely test the major incident response to disaster. The series of train crashes in the 1980s had a profound effect on the way integrated emergency management developed, and the responses to more recent incidents have benefited fromthe lessons from the railway crashes from nearly 30 years ago. A railway crash has a number of unique features that have the ability to tax the Service response. The huge amount of kinetic energy stored in a three hundred tonne train travelling at 100 plus miles per hour has the potential to alter structural members of the train into complex deformed positions that make heavy cutting and lifting gear an essential itemof equipment for rescuers. Unlike aircraft crashes, the materials in trains are heavy gauge and only rarely disintegrate on impact. Like aircraft crashes, however, they can happen in almost any terrain and location – remote locations, away from any metalled road, in tunnels and on bridges – all of which have been features of recent crashes.
Safety Improvements
Since the first public railway service began, rail travel has not been risk-free. Within moments of the opening of the Liverpool and Manchester railway line on September 15 1830, George Stephenson’s Rocket had killed Liverpool MPWilliam Huskisson. Like other transport industries, the rail industry has constantly improved the way it manages itself and rail travel is among the safest modes of transport available. Nevertheless, and despite safety improvements that have spanned the centuries (and particularly the last two decades), there remains the slight chance that accidents will occur – usually as the result of systematic failures of management rather than deliberate or accidental acts by others. (Although these do occur occasionally). Inevitably more recent events stamp their mark on the consciousness more readily than those in the less recent past. That is why Ladbroke Grove, Southall, Selby and Ufton Nervet, are more readily accessible than Purley, Taunton and Clapham. The disasters at Quintishill and Harrow and Wealdstone are now virtually known only to railway aficionados (see www.therailwayarchive.com). There is a thread that can be traced through all these tragedies, however.
The worst railway accident in the UK happened in 1915 in the Scottish village of Quintishill. Soldiers travelling south on a train in order to serve on the Western Front hit the rear end of a stationary train due to a signalling error. Apart from those killed in the immediate impact of the crash, oil-filled lamps smashed and the subsequent fires were believed to have caused far more deaths than the crash itself. It was only the restrictions of wartime press and the fact that the 227 soldiers that died amounted to a small proportion compared with the daily casualties in France, that made this tragedy so little known. Even in 1952, at the time of the Harrow and Wealdstone crash (caused by a signal passed at danger during a London ‘pea souper’ fog) mass casualties were the result – 112 fatalities and 340 injured.
The rescue service response to these earlier incidents was generally confined to using whatever equipment was to hand on fire appliances and emergency tenders. Powered hydraulic rescue gear and more sophisticated equipment would have to wait for decades after Harrow – fire crews at the time had to principally rely on brute force and wedges, levers and crowbars.
Incident ground organisation was also relatively unsophisticated. Cordons securing access to the scene and control of bystanders wanting to help were difficult to manage. This was, after all, a generation that had lived through the Second World War, where everyone had a part to play, and assisting the stricken was part of a collective responsibility. The respective roles of the emergency services were also less well defined than under the current regime. Paramedics were unknown, the ambulance service using scoop and run techniques, relaying casualties to hospital rather than the sophisticated onscene treatment and techniques available today. The following decades led to a slow incremental improvement in the service provided, but the philosophy of the service still remained principally one of casualty evacuation in the first instance.
Calls for Assistance
On December 12 1988 at around 0810, a crowded rush hour commuter express train from Poole rammed a stationary one from Basingstoke. The first calls for assistance were made by members of the public who heard the crash and saw dust and smoke rising from the scene. The first call was received by London Fire Brigade at 0813 and the first pumps were in attendance within four minutes of the call. The first call from British Rail itself was received at 0820. There was a disputed time lag between the interservice emergency calls, and the Fire Service was criticised for taking six minutes to notify the London Ambulance Service. Given the confusion and large number of calls being received, Sir Anthony Hidden QC, who led the Public Enquiry into the crash, accepted that during major incidents there is a possibility that paper records are not always fully accurate – something that may not be acceptable in today’s litigation bound society. Hidden, in his report into Clapham, was complimentary as to the effectiveness of the emergency services who carried out the rescue operation in an ‘exemplary manner’. London Fire Brigade mobilised 15 pumps, three emergency tenders and 243 firefighters over the 28 hour period of involvement, who were praised for their swift and efficacious response working together in difficult and dangerous circumstances. Thirty five people died. The topography of the Clapham crash illustrated the problems of access for many train incidents. First responders were confronted sequentially by tall metal railings, a steep wooded embankment and a three metre high concrete wall that had to be overcome before accessing the track. Fortunately, being in the centre of a city meant that the reinforcing resources were quickly available. The weather remained favourable to the rescue teams – bright and clear throughout the incident. Typical of high speed collisions, the first three carriages were badly damaged by the crash – the first was totally collapsed, the second (containing the buffet car) and the third had been devastated by the impact. There were about 1,500 passengers involved, many of whom needed extrication and treatment at the scene.
The first attending incident commander ‘made pumps eight’ immediately and declared a ‘major incident’ at 0827, having made a rapid appraisal of the incident. One of the key decisions made at this time was the incident. The only criticism of the fire brigade response at this time (the first ten minutes of their attendance) was the (correct) assumption made by the first attending crews that the power supply to the electrified system had been isolated and that look outs had not been posted – a minor issue, in the opinion of the enquiry, given that the correct decision had been made in the absence of full and accurate information. The role and activities of the London Ambulance Service at Clapham illustrates just how far the ambulance service has changed in the last two decades. In 1988, the largest ambulance service in the UK had all staff trained in advanced first aid and 30 per cent of staff who were trained in intubation and infusion. Compared with the modern ambulance service, things were relatively basic. Due to communications problems, receiving hospitals and staff who had been identified as being responders to the scene of the accident were not notified as quickly as possible, and there was criticism of this delay in the notification process in the event of a major incident occurring. Fortunately, the crash happened at the change of ambulance shift and additional staff were used to support the response – in total 67 vehicles were committed to the incident. Few, if any, ambulances were left in the county to provide basic levels of cover. Surrey Ambulance Service were able to provide some cover for the remainder of the area.
Co-ordinated Response
Inter-service co-operation on the ground was found to be very effective and co-ordinated. The police service used its helicopter to transport rapid responder medics (BASICS – British Association for Immediate Care) to the incident, taking six minutes from collection in Essex to landing atWandsworth Common, and also providing a valuable overview of the scene. The local authority –Wandsworth London Borough Council, had, following the Manor Fields Gas explosion in 1985, prepared an effective emergency plan which resulted in an attendance within ten minutes of notification of the call to the council.Within an hour, nearly a hundred staff were on site helping with heavy duty equipment for facilitating access and egress.
From a command and control point of view, inter-service liaison was aided by the accident occurring near a park, which gave all services a base from which to co-ordinate the response. The set-up of what today would be termed the outer and inner cordon was well managed. LFB had set up a command point overlooking the incident from the bank above. They had then established a forward command point at the trackside. At the first joint service meeting (1020) – emergency services and British Rail – incident primacy was established and operational command and control was designated with the LFB remaining in control of the rescue operation on the track. Establishing the cause of the accident would be the responsibility of British Transport Police, the Metropolitan Police would be responsible for identification of the dead and control of property found at the scene. Importantly, a co-ordinated approach would be taken to briefing the media.
The Hidden Enquiry made many recommendations following the accident, mainly related to the way that railways are managed and the systems that are needed to improve safety on the network. Interestingly, many of the features that are now part of the network were only implemented after several subsequent accidents. For the fire and rescue services, recommendations were categorised into communications, on-site arrangements and identification and command and control. The declaration and notification procedures for declaring a major incident were found to be unclear among all responding organisations – the systems for logging and notifying other services were seen as being an essential element of organising an effective and co-ordinated response to an emergency of this scale. Hidden also identified the need for the principal services to carry out major exercises to test and control their plans. The emergency medical services were given specific recommendations to train staff in radio procedures, call management and warning systems for major incidents. One problem that arose during the incident was the confusion caused by so many responders from the emergency and other services wearing a variety of high visibility jackets and surcoats. There was no coordinated identification system for staff, particularly from non-fire responders, which made identification of incident managers for each service difficult. The recommendation was for a national system of identification for key staff and commanders.
Inner Cordon
For command and control issues, a move had been made during this era on the part of some fire and rescue services to gain primacy for non-crime accidents. This was rejected by Hidden although delegation of trackside control to the Fire and Rescue Service was supported. The preparation of a list of attendees in the inner cordon should have been prepared by each responding organisation but was not – in the event of a site evacuation accountability for staff could have been lost in the ensuing confusion. Following Clapham, organisations started to learn the many lessons that would eventually lead to a more integrated response for major disasters and accidents across the UK. The Home Office publication Dealing with Disaster drew together many of the facets that emerge during times of major emergencies. The planning processes that fall out of the Civil Contingencies Acts evolved in no small part from the lessons learned in railway accidents of this time. Railway safety has improved enormously in the intervening decades since Clapham, Purley and Belgrave despite the massive increase in usage of the rail network.
Accidents still occur with worrying frequency but not with the consequences of the period of the late 1980s. It has been over eight years since the last large scale loss of life in a train crash, Ladbroke Grove in 1999, indicating, hopefully, that many of the lessons of Clapham have been learned by the emergency services but, more importantly, by the railway companies themselves. |
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