Emergency assistance after Turkish Airlines aircraft accident, Haarlemmermeer 25 February 2009 Emergency assistance after Turkish Airlines aircraft accident, Haarlemmermeer 25 februari 2009 The Hague, July 2010 (project number M2009CH0225-02) The reports of the Dutch Safety Board are available to the public. All reports are also available on the website of the Dutch Safety Board: www.safetyboard.nl THE DUTCH SAFETY BOARD The Dutch Safety Board was established to investigate and determine the causes or probable causes of individual incidents or categories of incidents in all sectors. The sole purpose of a Dutch Safety Board investigation is to prevent future accidents or incidents and, if outcomes give cause to do so, issue associated recommendations. The organisation consists of a Board with five permanent mem- bers, a professional Bureau manned by investigators and support staff and a number of permanent committees. Guidance committees are set up to oversee specific investigations. Board Advisory committee Chairman: Pieter van Vollenhoven Annie Brouwer-Korf Vice chairman J.A. Hulsenbek J.P. Visser Annie Brouwer-Korf B.J.M. Ale F.J.H. Mertens Mrs G.H. Faber J.P. Visser A.H.P. van Gils J. Groeneweg N.S. Klazinga P.J.P.M. van Lochem P. Patka General Secretary: M. Visser Project leader: R. Smits Visitors address: Anna van Saksenlaan 50 Correspondence address: Postbus 95404 2593 HT Den Haag 2509 CK Den Haag Telephone: +31 (0)70 333 7000 Fax: +31 (0)70 333 7077 Internet: www.safetyboard.nl This report is published in the Dutch and English languages. In the event of conflict in interpretation, the Dutch text will be deemed binding. CONTENTS CONSIDERATION .............................................................................................................. 5 1 INTRODUCTION .................................................................................................. 17 1.1 Reason for the investigation ............................................................................17 1.2 Goal and definition of the investigation .............................................................17 1.3 Other investigation into the same accident ........................................................18 1.4 Investigation method .....................................................................................18 1.5 investigation by the Dutch safety board ............................................................19 1.6 Reader’s guide ..............................................................................................19 2 DESCRIPTION OF EMERGENCY SERVICES ASSISTANCE PROCESS ........................ 21 2.1 Introduction ..................................................................................................21 2.2 The first few minutes after the aircraft accident .................................................21 2.3 Alarms and attendance of the emergency services units ......................................22 2.4 Emergency services on site .............................................................................29 2.5 Registration, verification and communication of victim information .......................33 2.6 Communications via C2000 .............................................................................36 3 ASSESSMENT FRAMEWORK ................................................................................. 37 3.1 Introduction ..................................................................................................37 3.2 Legislation and regulations..............................................................................37 3.3 National guidelines, guides and handouts ..........................................................39 3.4 Regional and local elaborations in plans and manuals .........................................41 3.5 General assessment framework for safety management ......................................44 4 INVOLVED PARTIES AND THEIR RESPONSIBILITIES........................................... 51 4.1 Local and regional involved parties ...................................................................51 4.2 National organisations involved .......................................................................54 4.3 Foreign organisations involved .........................................................................57 5 ANALYSIS ........................................................................................................... 63 5.1 Introduction ..................................................................................................63 5.2 Processing reports and alerts issued by emergency services ................................65 5.3 Triage, distribution of casualties and information provision to hospitals by the Dutch Medical Assistance at Accidents and Disasters (GHOR) .....................83 5.4 Registration, verification and communication of victim information .......................89 5.5 C2000 communication problems ......................................................................97 5.6 Uniform and feasible agreements ...................................................................111 6 CONCLUSIONS .................................................................................................. 117 7 RECOMMENDATIONS ......................................................................................... 123 Annex 1 Injuries and distribution of the casualties ..............................................................127 Annex 2 Investigation information ....................................................................................129 Annex 3 Reading responses .............................................................................................141 Annex 4 Time indication difference analysis information carriers ...........................................151 Annex 5 General background information about emergency assistance at accidents ................153 Annex 6 Background information about the integrated control room system ...........................159 Annex 7 Exploratory study regarding survival aspects .........................................................161 Annex 8 Flight routes mobile medical teams (MMTs) ...........................................................165 Annex 9 Overview of information on victims ......................................................................171 Annex 10 C2000 communication summary ..........................................................................173 Annex 11 2006 Dutch Victim Registration Form ....................................................................179 Annex 12 Summary deployment scenarios (fire brigade and GHOR) airports in the Netherlands .185 LIST OF ABBREVIATIONS ............................................................................................. 200 3 4 CONSIDERATION The crash of a Turkish airlines Boeing in The haarlemmermeer The number of fatalities during the aircraft accident on 25 February 2009 remained relatively limited in view of the circumstances. The aircraft had 135 people on board of which seven were crew members. Five passengers and four crew members died during the accident. Almost all of the 126 survivors sustained injuries. Only six people were physically uninjured. Due to the efforts of all emergency services workers and the employees of the Municipality of Haarlemmermeer and Schiphol Airport but also due to the fact that the passengers were able to cope themselves and the spontaneous assistance provided by those in the vicinity, the negative consequences of the accident remained limited relatively speaking. invesTigaTion inTo course emergency assisTance provision afTer aircrafT accidenT The Dutch Safety Board decided to investigate the sequence of the emergency assistance provision in addition to the statutory mandatory investigation into the cause of the crash1 after the report on 25 February 2009. Contradicting signals emerged about the course of the emergency assistance provision on the day of the accident itself and also during the days that followed. The late release of the names of the victims especially attracted attention as well as the reports that victims were trapped for a long time in the aircraft before they could be freed by the emergency services providers. In addition, much criticism was expressed by the emergency services providers about the way in which C2000 operated, that is, the national communication system for the emergency services. Immediately after the aircraft accident, the Municipality of Haarlemmermeer and the Kennemerland Safety Region jointly had the emergency assistance assessed. This assessment was performed in the shape of a quick scan by the Dutch Public Order and Safety Inspectorate in partnership with the Healthcare Inspectorate. The Public Order and Safety Inspectorate published the results in June 2009 under the title ‘Poldercrash 25 februari 2009’ (25 February 2009 Polder Crash). The learned lessons were broadly shared thereafter. The Safety Board appreciates the taken initiatives of the Municipality of Haarlemmermeer and the Kennemerland Safety Region and the fast publication of the report by the Inspectorate. The Safety Board continued with its own investigation after the publication of the investigation of the Inspectorate. Despite the made efforts of all those involved, it has been determined that the emergency assistance was flawed with regard to specific issues. The issues concerned were the following: • Time lost before the actual arrival of the emergency services