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46 detraining directly into the WTC station. The immediate Passenger transit incidents resulted in the largest numbers decision to halt trains into New York City prevented these of casualties and injuries: passengers and the trains carrying them from being stranded in the station or rail tunnels. Moscow terrorist bombing (2/6/2004): 39 fatalities, 100+ The ability to bring all passengers to safety, including injuries; those who were quite literally right under the twin towers, Daegu arson fire (2/18/2003): 198 fatalities, 147 injuries, was attributed to a combination of a culture in which work- 50+ missing; ers are encouraged to think independently and act in an Kitzsteinhorn cable car fire (11/11/2000): 155 fatalities, emergency without waiting for authorization from higher injuries not tallied; levels of management and to an independent communica- Tokyo chemical attack (3/20/1995): 12 fatalities, 6,000 tions system that allows dispatchers and train operators to exposed to sarin gas; communicate freely. The PATH communication system King's Cross Station fire (11/18/1987): 31 fatalities, injuries worked throughout the emergency because it was not not tallied; and located on top of the WTC even though both the WTC and BART Transbay fire (1/17/1979): 1 fatality, 58 injuries. the PATH system are components of the Port Authority of New York and New Jersey. One incident did not result in fire or explosion: Chicago freight tunnel flood (4/13/1992). References "Beneath WTC Chaos, Calm on PATH Tubes"(2003, Sept. 3). 3.4 Conclusions html 3.4.1 Pinpointing Vulnerabilities (Accessed June 27, 2005). Donohue, P. (2001, Sept. 19). "Passengers Put on PATH to Passenger transit tunnels and stations present a high Safety." New York Daily News. potential for large numbers of fatalities and injuries, for tubes/extractfromnydailynewssummary.html (Accessed June worldwide media coverage, and for creating public fear. 30, 2005). While some transit tunnel incidents can be characterized as "Governors to Ride into Station on the Last PATH accidents, many are intentional acts in which the initiators of Train to Leave the World Trade Center on September 11, the incident are suicidal or seeking to kill or injure large 2001" (2003, Oct. 30). numbers of people. Even when there is little or no intent to governorsonfirstridepressrelease.html (Accessed June 30, cause chaos or mass casualties, the possibilities for such out- 2005). comes are strong. Ingrassia, R. (2001, Sept. 22) "Keeping `Bathtub' Dry Road tunnel fires are closely related to truck accidents. Experts Fight to Secure WTC's Foundation." New York Daily These accidents frequently result in fires, and the fires are News. often exacerbated by the goods being carried. Even when the sep22.html (Accessed June 30, 2005). materials being transported are not flammable or hazardous, Schwaneberg, R. (2001, Sept. 19)."Quick-Acting P.A. Steered serious side effects of fires may be toxic fumes or residue. 5,000 Commuters to Safety." Newark Star-Ledger. http://www. Freight and motor tunnel incidents hamper economic (Accessed arrangements by altering patterns for the transport of goods June 30, 2005). and may lead to long-term damage from flammable cargo or the release of hazardous materials. 3.3 Summary of Case Studies 3.4.2 Lessons Observed Table 4 shows the details of each case study at a glance. In total, the case studies represent 10 rail incidents and 2 road All the case studies point to a need for better safety man- incidents, taking place in Asia, Russia, western Europe, Great agement and for better communications. In a number of the Britain, and the United States. All intentional violent acts incidents, no one person or office was responsible for system occurred on passenger transit systems: safety, sometimes because the organizational culture mini- mized the importance of working safely and of maintaining a Moscow terrorist bombing (2/6/2004), clean and safe system. Daegu arson fire (2/18/2003), and There is also a need for better planning of emergency sys- Tokyo chemical attack (3/20/1995). tems and of estimations of overall tunnel usage. Many of the

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47 Table 4. Case study summary. Fatalities Section Incident Date and Brief Description Number Injuries 3.2.1 Moscow Feb. 6, 39 fatalities, A bomb, later linked to Chechen separatists, Subway 2004 100+ injuries exploded inside a crowded Moscow subway train Suicide during the morning rush hour. The bomb destroyed Bombing the second car of the train as it left the Avtozavodskaya station in southeast Moscow; the train was traveling toward the center of the city. The incident was one of three subway-related bombings attributed to Chechens. 3.2.2 Jungangno Feb. 18, 198 fatalities, A subway passenger threw flammable liquid inside (Chungang- 2003 147 injuries, a subway car of a train carrying about 600 people. Ro) Subway 50+ missing The liquid ignited as the train pulled into the Station Arson underground Jungango station, beneath Daegu's Fire central city. A train traveling in the opposite direction entered the tunnel moments after the first train burst into flames. The death toll increased when the doors of the second train locked shut after the driver stopped in the tunnel and removed the master controller key. The passengers were trapped inside as cars filled with smoke and noxious fumes. 3.2.3 St. Gotthard Oct. 24, 11 fatalities, A head-on collision of two trucks about 1 mile (1.6 Tunnel Fire 2001 injuries not kilometers) from the tunnel's southern entrance tallied sparked an explosion and subsequent fire. Part of the tunnel's roof collapsed over a distance of about 328 feet (100 meters). These two separate events combined to make the 10.6-mile (17-kilometer) tunnel unapproachable due to temperatures as high as 1,832F (1,000C) and falling roof debris. Up to 40 cars and trucks were fused into a molten mass at the heart of the disaster zone. The incident resulted in 11 fatalities, including the two truck drivers involved in the accident. Rescue efforts were hampered by the extreme heat and the risk that additional sections of the tunnel roof might collapse. 3.2.4 Howard Street July 18, 0 fatalities, A 60-car freight train, of which eight cars in the rear CSX Tunnel 2001 4 injuries half of the train were carrying dangerous or Fire hazardous materials, caught fire, probably due to a derailment in the tunnel. The train was stopped and staff disconnected the locomotives and escaped. There were no fatalities, but the fire resulted in large quantities of smoke escaping the tunnel. The fire brought the city to a halt and resulted in a series of lawsuits by Baltimore against CSX. 3.2.5 Kitzsteinhorn Nov. 11, 155 fatalities, A cable car packed with skiers caught fire at the Tunnel Cable 2000 injuries not bottom of a tunnel on the 2.4-mile (3.9-kilometer) Car Fire tallied mountain. The cable car halted inside the tunnel; lights went out and initially the doors would not open. The narrow, 11.8-foot (3.6-meter) tunnel width left little room for evacuation. The steep (45- degree) incline turned the tunnel into a chimney, thereby blocking the escape route. (continued on next page)

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48 Table 4. (Continued). Fatalities Section Incident Date and Brief Description Number Injuries 3.2.6 Mont Blanc Mar. 24, 41 fatalities, A truck carrying margarine and flour entered the Tunnel Fire 1999 injuries not 7.3-mile (11.6-kilometer) Mont Blanc Tunnel from tallied France, caught fire, and stopped in the tunnel, where it burst into flames. The fire, fueled in part by the margarine, reached temperatures of 1,832F (1,000C); it trapped approximately 40 vehicles in dense and poisonous smoke. 3.2.7 Channel Nov. 18, No fatalities, A truck on a freight train traveling from France to Tunnel Fire 1996 about 30 Great Britain caught fire, which made injuries disconnecting the burning part of the train impossible. When the train stopped, the fire damaged the power catenary and spread to adjoining cars. The smoke moved quickly because of other trains moving in the tunnel, which also impeded evacuation. Train staff and truck drivers evacuated through a door leading to the service tunnel, but overpressure from that door created a fresh air bubble when the door was opened. Staff were rescued via the adjoining service tunnel; structural damage was considerable. 3.2.8 Subway Sarin Mar. 20, 12 fatalities, The Aum Shinrikyo religious group released Gas Attack 1995 5,000 to canisters of diluted Sarin on five separate trains 6,000 during the Tokyo subway system's morning rush exposed to hour. As many as 6,000 people may have been the gas exposed to the chemical; 12 people died. A review of the response highlighted a lack of coordination. Each agency (police, fire, hospitals, and other governmental units) acted under its own chain of command. This finding led to formation of a Severe Chemical Hazard Response Team. 3.2.9 Chicago April 13, 0 fatalities, A hole in the wall of one of the Chicago freight Freight Tunnel 1992 0 injuries tunnels, 40 feet (12 meters) under the Chicago Flood River, resulted in flooding that knocked out power throughout the Loop, forced the shutdown of the subway system, caused damage to numerous businesses, and resulted in the evacuation of about 250,000 people from the area. The flood was estimated to cost as much as $2 billion in lost revenue, tax assessment losses, and damage to the city's infrastructure. 3.2.10 London Nov. 18, 31 fatalities, King's Cross station, then the busiest station in the Underground 1987 injuries not London Underground system, is the convergence (the Tube) tallied point where five Tube lines operate on four levels. King's Cross There is also a ticket office below street level. A fire Station Fire started in one of the four escalators linking the platform levels. The fire grew rapidly when it reached the ticket office. (The fire's rapid growth was later attributed in part to old paint and the draft created by train movements). The length and steep angle of the escalator also contributed to the fire's intensity.

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49 Table 4. (Continued). Fatalities Section Incident Date and Brief Description Number Injuries 3.2.11 BART Jan. 17, 1 fatality, After a fire broke out in a circuit breaker in the fifth Transbay 1979 58 injuries and sixth cars of a seven-car train, the train was Tunnel Fire stopped by the emergency brake and could not be restarted. An unsuccessful attempt to disconnect the burning cars delayed passenger evacuation by about 30 minutes, during which the tunnel filled with smoke despite activation of the ventilation system. Rescue involved taking the passengers out through the service tunnel. The fatality (a firefighter who died from flue gas poisoning) and injuries were caused primarily by gases from the combustion of plastics. The accident was attributed to lack of communication between the train operator and central operations, poor coordination, and errors of judgment, all of which made the incident a key factor in the development of National Fire Protection Association transit industry guidelines on responses to fire incidents [Ref. 2]. 3.2.12 PATH Sept. 11, No fatalities, Within minutes of the first plane striking the WTC, Evacuation 2001 No injuries multiple Port Authority employees contacted the under the PATH control center to report that an unexplained World Trade explosion or fire had occurred. Based on direction Center from a PATH deputy director who was at the WTC, within 6 minutes the system's trainmaster was issuing instructions to conductors and operators to avoid the station. Had it not been for this prompt response, trains would have kept coming in at 3- and 5-minute intervals, unloading passengers directly into buildings that would soon collapse. This prompt response undoubtedly saved many lives. older systems hadn't been upgraded since they opened. In the The case studies demonstrate the need for the following: case of the European road tunnel accidents, inadequate plan- ning led to traffic volumes far in excess of those anticipated. Interoperable communications networks; The excessive traffic volumes may have weakened the effect of An empowered safety management team; the life safety and ventilation systems and contributed to An understanding of risk and vulnerability to realistically post-incident problems. address prevention and mitigation issues; The vast majority of incidents displayed communication Pre-incident procedures, real-time emergency guidelines gaps. Because all the incidents involved responses from a for operational personnel, and post-incident debriefing number of jurisdictions and agencies, the absence of standards; advance planning and of emergency drills contributed to Planning, upgrading, and testing of emergency systems on post-incident problems. Responses to the incidents were a regular basis; hampered by either an absence of procedures to follow or Inter- and intra-agency cross-training, tabletop exercises, the failure of system employees to follow the established onsite training, drills, and exercises; and procedures and guidelines. The absence of preplanning of An understanding of human factors. communications and emergency response, along with the The case studies also demonstrate the following realities: lack of guidelines on whom to notify and when to notify them, added to the loss of life in some of the incidents and Absolute safety does not exist in tunnels. to the damage incurred in almost all of them. The highest priority must be given to securing escape The problems were apparent in the two primary areas of routes and passages. concern: prevention and mitigation. It was difficult to meas- The probability of accidents can be minimized through ure prevention because, in some cases, there did not appear to tunnel design and materials. be anticipation of potential danger. It is impossible to plan to The damage potential of accidents and fires can be reduced prevent or mitigate something that no one considers might by installing emergency facilities and constructing fire- occur. resistant tunnel structures.