The latest reports from South Korea now suggest that of the 476 people on board the Sewol, 174 were rescued, 159 bodies have been recovered and 143 people are still missing.

BLAME GAME:

It is human nature to want to blame someone after a tragedy.  But when a disaster of this magnitude occurs, it is time for a nation as a whole to reflect on its safety culture, and not simply blame a few individuals. We should be looking at the safety culture on board the Sewol, in the company that owns and runs the vessel, within the South Korean maritime industry and within South Korean culture as a whole.  It is far too easy to point a finger at a few people, as the South Korean President has done.  To address the real problem and ensure that this type of disaster never happens again, we must identify and address the root cause(s) of the problem and this is likely to be the result of a number of factors, beyond the immediate actions of the Captain and crew.

PREVIOUS DISASTERS:

To put this disaster into context it is useful to compare it to two other Ro-Ro ferries that have capsized in recent history resulting in large loss of life. In 1987 the Herald of Free Enterprise rolled over shortly after leaving port due to her bow doors being opened in less than 4 minutes and claimed the lives of 94 people while in 1994 the Estonia capsized in rough seas within about 15 minutes and claimed the lives of some 850 people.  So Ro-Ro vessels such as the Herald of Free Enterprise, Estonia and Sewol can capsize very rapidly if water gets onto the large open car decks.

HOW MUCH TIME WAS AVAILABLE?:

We believe that the crew of the Sewol first called the coast guard (CG) at 08:56 to say that they were in distress – however, it is not clear how long they waited after realising that they were in trouble before called the CG. It was reported today that the first call to the authorities was actually made by one of the children on board as he was frightened that the ship would sink.  This is believed to be some 3 minutes before the crew made their first call.

From the official transcripts: 

9:10 a.m.

Sewol: Jindo VTS, this is Sewol

Jindo Coastal VTS: This is Jindo Coastal VTS.

Sewol: We’re tilted, so it looks like we’ll flip over soon.

Jindo Coastal VTS: Okay. How are the people on board? Boat A is nearing your boat as fast as possible.

Sewol: We’re so tilted that (we) can hardly move.

9:17 a.m.

Jindo Coastal VTS: Sewol, do you read Jindo Coastal VTS? (four times). How flooded are you?

Sewol: With the boat now tilted at least 50 degrees to the left, people can’t move to their left or right. The crew have been told to wait with their life jackets on. But it’s impossible to check whether they’re actually wearing them. Crew members gathered on the bridge are unable to move. Please hurry up.

So at 09:10 (some 14 minutes after first official message to the CG) they state that the vessel was severely leaning over, but no firm indication as to the degree of heel apart from saying they can hardly move. At 09:17 they estimate that they are on a heel of about 50 degrees, this is some 21 minutes after the crew first contacted the CG and some 24 minutes after the child made his call.

So the vessel appears to have a severe list some 14 to 21 minutes after the crew first radioed the CG to inform them of their emergency. We do not know how long it took them to radio the CG after the incident began, but it appears to be some 3 minutes after the child on board made his call. So it appears that they may have had around 17 minutes (or more) before conditions on the vessel became very difficult.

It will be important to establish when the crew first attempted to contact the passengers and when the message to “stay where you are” was made.

Given that around 17 minutes may have been available before conditions deteriorated to the point that movement became almost impossible, it is unlikely that all 476 souls on board the Sewol would have been able to reach the assembly points from which they could relatively easily abandon the vessel.  Nevertheless, had a command to commence the assembly phase been given at the earliest possible time, it is likely that considerably more of those on board could have been able to reach the assembly stations and therefore been in a position to abandon the vessel.

SAFETY CULTURE:

Given that there appears to have been sufficient time to allow a greater number of people to evacuate from the Sewol, it is important to establish the following: what were the evacuation procedures? How well did the crew know and understand them? What prevented the crew from implementing them?

These questions allude to the safety culture on the Sewol, in the management company, and in wider South Korean society, particularly:

• What were the evacuation procedures on the Sewol?
  • How appropriate were these procedures for a Ro-Ro ferry?
• Are passengers routinely informed of the evacuation procedures prior to departure?
  • How are they informed?
• How familiar were the Captain and crew with their own evacuation procedures?
  • How often did the Captain and crew drill their evacuation procedures?
  • What did the evacuation drill consist of?
  • What was considered acceptable performance in evacuation drills and does this demonstrate an appropriate level of competence and understanding?
• What oversight of the evacuation procedures did the parent company of the Sewol have?
• What oversight of the evacuation training did the parent company of the Sewol have?
• Did the corporate culture encourage or discourage adherence to safety and evacuation procedures?
• What oversight of the evacuation procedures did the Korean maritime authorities have?
• What oversight of the evacuation training did the Korean maritime authorities have?

Similar questions could be asked relating to other operational issues such as those relating to the safe navigation of the vessel, loading and securing cargo and rescue operations.

Ed Galea
12 Sept 2001

Twelve years after the collapse of the WTC towers, the far-reaching impact of the attacks is still being felt when it comes to the design of new high-rise buildings across the world.

FSEG research is still on-going and the data we have collected, both on the mechanics of large-scale evacuation, and on the human behaviour issues, is being shared across the world, as a valuable international resource.

Using our buildingEXODUS evacuation software, we analysed the evacuation dynamics of the events of 9/11 and also explored what may have happened if the buildings had been fully occupied. From this work, we concluded that, for buildings above a critical population and height, stairs alone were not sufficient for safely evacuating the entire population.

Following this work, FSEG went on to explore the use of lifts for evacuation in high-rise buildings.  We wanted to better understand the choices people make in deciding to use a lift/elevator as part of their evacuation route in an emergency.  Using the knowledge gained from this research, we developed advanced human behaviour models, which simulate human behaviour in selecting to use a lift or stairs to evacuate, and if electing to use a lift, how long they would be prepared to wait for the lift before using the stairs.   This model has been incorporated into the buildingEXODUS evacuation simulation software which now has the capability to explore the impact of lifts on high-rise building evacuation — but not only the mechanical aspects of using lifts, most importantly the human dynamics aspects.

Using the buildingEXODUS software, FSEG simulated a series of high-rise building evacuation scenarios in which the agents could elect to use lifts or stairs or a combination of both.  This research suggests that combined use of stairs and lifts produce better evacuation times than simply using lifts alone.  What’s more, if complex human behaviour is included in the evacuation analysis, the improved evacuation efficiency promised by lifts is not fully realised.  This is because some people will not want to utilise lifts and opt for stairs, while other people who attempt to utilise lifts are not prepared to wait more than a few minutes.   We know stairs alone are not sufficient for full building evacuations in large high-rise buildings.  Since 9/11 there has been a trend to use specially designed elevators for evacuation in large high-rise buildings. But elevators, even fire safe elevators, raise the complex issue of human behaviour, and we know from our studies that many people do not trust using them, or will simply not wait for them, in an emergency.  This is why it is important to have the capacity to utilise both lifts and stairs.

It is vital to take a holistic view of evacuation when designing new high-rise buildings.  When it comes to elevators, this means not just the mechanical issues of using elevators to evacuate people, but the whole issue of human behaviour, and this is what we have built into the buildingEXODUS evacuation model.  However, this is by no means the end of the story.  More work needs to be done to understand the complex human dynamics issues associated with high-rise building evacuation dynamics.

Our analysis of stair travel speeds of people in the WTC evacuation suggested that people were not walking as fast as engineers may have expected.  While our analysis suggested that the lower than expected travel speeds could be explained by the high crowd densities experienced on the stairs, it did bring into question whether the data that engineers have been using to characterise stair speed was out dated and inappropriate given the changes in population demographics in the 50 years since the data was first collected.  As a result, FSEG have started to collect human performance data for people ascending and descending stairs.  While still in the early stages of this work, some of the data that has already been collected suggests that stair walking speeds have indeed changed, at least for the younger demographic.

Twelve years on from 9/11, people need to guard against complacency. Evacuation drills and training always need to be taken extremely seriously, as successful evacuation depends in part on how quickly people respond. We found in our research that some people took many minutes to decide to evacuate the towers, while others didn’t know where the stairs were, for example. The attacks have also highlighted the need for better information systems in buildings, with proper instructions in an emergency, rather than just an alarm going off.

We hope that the insight we have gained into complex human behaviour issues in high-rise building evacuation since 9/11 will contribute to improving building design and evacuation procedures and so contribute to saving lives.

REFERENCES:

“The UK WTC 9/11 evacuation study: An overview of findings derived from first-hand interview data and computer modelling”, Galea, E.R., Hulse, L., Day, R. Siddiqui, A., and Sharp. G. Fire and Materials, Vol 36, pp501-521, 2012, DOI: 10.1002/fam.1070

“Investigating evacuation lift dispatch strategies using computer modelling”, Kinsey, M.J., Galea, E.R., and Lawrence, P.J.,  Fire and Materials, Vol 36, pp399-415, 2012, http://dx.doi.org/10.1002/fam.1086

“Human Factors Associated with the Selection of Lifts/Elevators or Stairs in Emergency and Normal Usage Conditions”, Kinsey, M.J., Galea, E.R., and Lawrence, P.J.  Fire Technology, 48, pp2-26, 2012, DOI: 10.1007/s10694-010-0176-7.

“Individual stair ascent and descent walk speeds measured in a Korean High-Rise Building”, Choi, Jun-Ho,  Galea, E.R.,  and Hong, Won-Hwa, To Appear in the Journal of Fire Protection Engineering 2013, published online 11 July 2013, http://dx.doi.org/10.1177/1042391513492738

“The UK 9/11 evacuation study: Analysis of survivors’ recognition and response phase in WTC1”. McConnell, N.C.,  Boyce, K.E. Shields, J., Galea, E.R., Day, R.C. and Hulse. L.M.. Fire Safety Journal 45, pp 21—34, 2010, http://dx.doi.org/10.1016/j.firesaf.2009.09.001.

“Investigating the Representation of Merging Behavior at the Floor—Stair Interface in Computer Simulations of Multi-Floor Building Evacuations”, Galea, E.R., Sharp, G., and Lawrence, P., Journal of Fire Protection Engineering, Vol. 18, No. 4, 291-316, 2008 http://dx.doi.org/10.1177/1042391508095092.

“Approximating the Evacuation of the World Trade Center North Tower using Computer Simulation”, Galea, E.R, Sharp, G., Lawrence, P.J., Holden, R., Journal of Fire Protection Engineering, Vol 18 (2), 85-115, 2008. DOI:http://dx.doi.org/10.1177/1042391507079343

http://www.usatoday.com/story/news/nation/2013/08/08/airplane-crash-survival-rates/2631567/

I think this is an interesting line of inquiry, but I don’t believe that the analysis presented addresses the whole picture and so can be misleading.  The main point of the story is made in the opening sentences of the article, namely:

 “More passengers are surviving fatal airline accidents during landing, but survival rates during stages of flight when most accidents happen have not improved from decades ago, a new USA TODAY study shows.”

 I am quoted in the article as follows,

“Edwin Galea, a professor at the University of Greenwich in England who is an aircraft evacuation expert, said the USA TODAY study is “interesting” but omits some serious accidents without fatalities.”

However, this is only part of the concerns I conveyed to Mr Stroller.  I have undertaken quite a bit of research on evacuation from aircraft including analysis of past accidents and appreciate how difficult it is to come to any meaningful conclusions when analysing aviation survival statistics (see publication list).  While I do not doubt the accuracy of the data presented in the article, I believe that the analysis is potentially misleading.  You have to look at the questions being asked, not just the answers being presented.  I do not think the questions that are being posed in the article are quite right.  My quotation in the article covers just one of my two main concerns.  These are:

1)      The USA Today analysis covers aircraft in which at least one person has died.  So the analysis definitely includes what could be considered to be serious accidents.  However, this is just a sub-set of serious accidents as it does it does not include serious accidents in which no one died, take for example just three recent accidents:

1. US Flight 1549 on 15 Jan 2009, an A320 out of LaGuardia heading to Seattle, carrying 150 pax and 5 crew.  Aircraft was written-off after a forced landing on the Hudson River, there were five injuries, two of which were serious, yet everyone survived.
2. BA Flight 38 on 17 Jan 2008, a B777 coming in to land at Heathrow, carrying 136 paxs and 16 crew.  Aircraft was written-off, there were 47 injuries, one of which was serious, yet everyone survived.
3. Air France Flight 358 on 2 Aug 2005, an A340 coming into land at Toronto, carrying 309 paxs and 12 crew.  There was a serious fire and the aircraft was written-off, there were 12 injuries, yet everyone survived.

By anyone’s reckoning, these were three very serious accidents — so much so that in each case the aircraft was written-off – yet no one died.   The USA Today analysis simply ignores these type of incidents and so incorporates a bias in the data.

2)      The USA Today analysis includes accidents in which everyone on board died.  Thus the analysis includes technically non-survivable accidents.  These are accidents in which, given that the incident occurs, no feasible technological development is likely to improve the chances of survival as the trauma associated with the accident is simply too severe, for example:

1. Mid-air explosion — Pan Am Flight 103 (Lockerbie), 21 Dec 1988, B747, all 243 paxs and 16 crew killed.
2. Uncontrolled Flight into Terrain — Swiss Air Flight 111, 2 Sept 1998, MD11, all 215 pax and 14 crew killed.

The industry addresses these type of problems by introducing technological or procedural improvements to prevent them from occurring in the first place — prevention rather than mitigation.  The issue here is reducing the frequency of these events from happening in the first place.

Mixing technically survivable and non-survivable accidents into the discussion on survivability in aviation accidents confuses the issue as advances in technology are not likely to impact survivability in non-survivable accidents.  A clearer understanding of whether or not we are improving survivability in aviation incidents would be derived by splitting the discussion into two parts:

i)        First, consider survivability in technically survivable accidents.  The purpose of this investigation is to establish whether or not your chances of surviving a survivable crash is getting better or worse as a result of the advances in technology and regulation.  Related to this would be determining how likely you are to be involved in a survivable crash and whether or not this is improving.

ii)      Secondly, consider the frequency of technically non-survivable accidents.  The purpose of this investigation is to establish how likely you are to be involved in a non-survivable crash and whether or not advances in technology and regulation are improving these chances.

It is essential to filter the raw aviation accident data in an appropriate and meaningful way if truly meaningful conclusions are to be drawn as to the current state of aviation safety and whether or not it is improving.

PUBLICATIONS RELATED TO AVIATION ACCIDENT ANALYSIS:

1)       “Aircraft Accident Statistics and Knowledge Database: Analyzing Passenger Behaviour in Aviation Accidents.”, E.R.Galea, K.M.Finney, A.J.P.Dixon, A.Siddiqui and D.P.Cooney. AIAA Journal of Aircraft, Vol 43, Number 5, pp 1272-1281, 2006.

2)      “An analysis of exit availability, exit usage and passenger exit selection behaviour exhibited during actual aviation accidents.”, E.R.Galea, K.M.Finney, A.J.P.Dixon, A.Siddiqui and D.P.Cooney. The Aeronautical Journal of the Royal Aeronautical Society, Vol 110, Number 1106, pp 239-248, 2006

3)       “An analysis of the passenger to cabin crew ratio and exit reliability based on past survivable aviation accidents.”, E.R.Galea, K.M.Finney, A.J.P.Dixon, A.Siddiqui and D.P.Cooney. Human Factors and Aerospace Safety, Ashgate publishing, 5(3), pp 239-256, 2005.

4)      “An Analysis of human behaviour during aircraft evacuation situations using the AASK V3.0 database.”. Galea E.R., Finney, K.M., Dixon, A.J.P., Siddiqui A., and Cooney D.P. The Aeronautical Journal, Vol 107, Number 1070, pp 219-231, 2003.

5)       A Database to Record Human Experience of Evacuation in Aviation Accidents.  The Aircraft Statistics and Knowledge Database (AASK). Authors: E R Galea, K M Finney, A J P Dixon, A Siddiqui and D P Cooney.ISBN 9780117908390, CAA PAPER 2006/01. June 2008.

http://www.caa.co.uk/application.aspx?catid=33&pagetype=65&appid=11&mode=detail&id=3176

6)       The AASK Database: Aircraft Accident Statistics and Knowledge. Authors: E R Galea, D Cooney, A Dixon, K Finney and A Siddiqui. UK CAA Paper 2002/3 ISBN 0 86039 803 X, 2002.

Questions are being raised as to how many people were in the nightclub at the time of the incident.  This will become an important issue as the inquiry into the disaster progresses as the level of club occupancy could be used as a factor in contributing to the severity of the disaster and hence in apportioning responsibility.  Another issue that has been raised is whether or not more exits would have made a material difference to the outcome. To examine these issues we can do some simple analysis based on a number of assumptions and what the media are currently reporting.

So what do we (think we) know about the Kiss fire incident according to accounts in the media:

1) The club has a floor area of 615 m².  However, it is not known how this breaks down to dance floor, bar, toilets, circulation space etc.

2) The maximum travel distance to the front door is reported as being 32m.

http://world.time.com/2013/01/29/focus-turns-to-brazilian-club-safety-after-fire/

3) The maximum legal occupancy of the club is reported as being 691 people.

4) The only available exit has a width of 3m.

http://g1.globo.com/rs/rio-grande-do-sul/tragedia-incendio-boate-santa-maria-entenda/platb

5) The club owner insists that there were only 600 to 700 people in the club at the time of the incident.  However, the band’s guitarist told media that there were between 1200 and 1300 people in the club at the time and the police have given the same estimate.  The owner suggests that the higher estimates are due to clubers cycling into and out of the club.

http://www.foxnews.com/world/2013/01/31/nightclub-fire-that-killed-235-prompts-inspections-closures-night-spots-across/

6) It has now been reported that the band did in fact use flares during their show.  The flares were outdoor flares which are cheaper ($1.25 a piece) then indoor flares ($35 each).

http://world.time.com/2013/01/29/focus-turns-to-brazilian-club-safety-after-fire/

7) According to what I understand to be the fire certificate, the club is credited with having 2 emergency exits — hence 3 exits in total, one main and 2 emergency.  However, this is not clear from the article which later refers to these ‘emergency exits’ simply as ‘exits’, in which case the club may have been certified as having 2 exits, 1 main and 1 emergency exit. So it appears from the media accounts that the club was certified as having 3 or 2 exits — depending on the interpretation of the article.

http://g1.globo.com/rs/rio-grande-do-sul/noticia/2013/01/boate-informou-em-laudo-ter-duas-saidas-diz-brigada-militar.html

QUESTIONS:

In discussion with a Brazilian fire safety consultant based inSao Paulo, Dr Rodrigo Machado Tavares, Dr Tavares suggests that the local fire codes would require the Kiss nightclub to have:

– three exits,

– emergency lighting,

– emergency exit signage,

– an alarm system.

This answers many of the questions posed in my last blog (Yet Another Nightclub Tragedy — Grief tainted with anger, 29/01/13) however, it poses many serious questions concerning the licensing, inspection and enforcement process in Brazil.

Furthermore, it appears that the expired license has been reported as suggesting that the club had three (or at least two) exits.  Unless the missing exit or exits have been bricked up since the license was issued, or that the exit(s) were there but were locked or blocked during the incident and so could not be used, how could a license be issued stating that the club had three (or two) exits?  One has to ask if inspections of the club were ever performed.  If they were performed, how could an inspector fail to notice that two (or one) exits were missing?

Given that the nightclub had only a third of the legally required number of exits, one has to wonder whether this would have made a material difference to the outcome.

Concerning the number of people in the club, this is important as it is the manager’s responsibility to control the number of people in the club.  The manager suggests that the there were 700 people in the club, as allowed by the questionable ‘license’.  If there were 700 people in the club, this would be of benefit to the manager as it suggests overcrowding — his responsibility — would not have been a major factor and refocuses attention on the questionable fire license.  If there were 1200 people in the club, this deflects some degree of blame from the band — for allegedly starting the fire using flares — and for the code enforcement agency for permitting the license in the first place.

Is it likely that there were 1200 people in the Kiss Nightclub at the time of the incident?

SIMPLIFIED ANALYSIS:

Let’s do a simplified analysis on numbers of exits and number of people.  Note that this analysis is crude and a more thorough analysis would be required to establish the relevance of these key parameters.  The simplified analysis is dependent on a number of simplifying assumptions detailed below.

1) Assuming the 3m available exit width and a population of 1200 and 700, approximately how long would it have taken for the population to get out?

Let’s simplify the calculation and assume the population reacts immediately (zero response time) and let’s also assume that all the people are queued up at the exit ready to go.  Assuming a unit flow of 1.33 p/m/s (UK ADB) then the exit could sustain a flow of 3.99 p/s and it would require:

– at least 300 s for 1200 people to exit and

– at least 175 s for 700 people to exit.

2) How much time would be available for people to get out?  This is extremely difficult to estimate without doing a detailed analysis.  But let’s use the Rhode Island Nightclub fire as a rough guide.  After about 100 s conditions in the Station Nightclub were non-survivable. The floor area of the Station Nightclub was about 412 m² and so the Kiss nightclub is some 50% larger.  Based on this let’s assume that people had 50% longer to get out, making it 150 s for non-survivable conditions to develop.  This is admittedly a very crude estimation and may over estimate the amount of time available.

In 150 s, using the single available exit we could expect about 600 people to get out:

– generating a death toll of 100 people assuming there were 700 people in the club, as claimed by the manager,

– generating a death toll of 600 people assuming the band/authorities are correct and there were 1200 in the club.

Given the current death toll of 235, it is possible that there were 835 people in the club.  If correct, this would suggest that while the club was overcrowded, it is unlikely that there were as many people as suggested by the band/authorities.

A note of caution, remember, the assumptions that have been made are rather crude. The population is unlikely to have had zero response times, but evidence from the Rhode Island fire would suggest that in these types of situations, occupant response times are quite small of the order of a few seconds.  We can slightly improve these approximations by relaxing the zero response time assumption and assuming that the first people start to move in 10 s and that the closest people to the exit are located a third of the maximum distance (11m) and that the people located here move at 1.1 m/s.  This would add about 20 s to the estimated exit times OR reduce the available safe egress time by 20 s.  So let’s assume that we have 130 s to get out.

In 130 s, using the single available exit we could expect about 519 people to get out:

– generating a death toll of 181 people assuming there were 700 people in the club, as claimed by the manager,

– generating a death toll of 681 to be killed if the band/authorities are correct and there were 1200 in the club.

Given the current death toll of 235, it is possible that there were 754 people in the club.  This would shift the club occupancy even closer to that suggested by the nightclub owner.

We may also assume that the unit flow achieved by the exit was better than that prescribed in the UK regulations, which by their nature are conservative.  This would get more people out of the nightclub within the 130 s available time, increasing the size of the estimated population within the club.  However, in such situations, especially after the first few people have exited, the exit flow will become competitive rather than ordered, which will tend to reduce the exiting efficiency and hence the achieved unit flow rate.  In reality, the unit flow rate achieved by the exit will vary throughout the evacuation, being somewhat greater than that specified by the regulation at the start of the evacuation and being somewhat less towards the end of the evacuation.  Without undertaking a detailed analysis it is difficult to suggest a reasonable value for the unit flow rate, so for the purposes of this blog we will keep it as it is.

It is worth noting the following:

– if the average unit flow rate of the exit is greater than that used in these calculations, more people would have been able to exit in the available time and hence the estimate of the club occupancy would go up,

– if the average unit flow rate of the exit is less than that used in these calculations, fewer people would have been able to exit in the available time and hence the estimate of the club occupancy would go down.

Given the uncertainties I will stick to the initial estimates.

3) What would have happened if there were the legally required 3 exits in the club?  To answer this requires us to know the total available exit width.  Let’s assume that the club would have followed UK requirements.  An assembly space of more than 600 people would require 3 exits (as apparently does the local requirements).  Using BS 9999, the minimum total exit width for the 3 exits would be 4.3m.  Here we assume that all three exits have the same width.

If we make similar assumptions to that in (1) and in addition that all three exits were available and the population is equally divided between the three exits, then the combined flow would be 5.7 p/s and :

– 700 people would be able to exit in 123 s

– 835 people would be able to exit in 147 s

– 1200 people would be able to exit in 211 s

Assuming the same amount of time is available for safe egress i.e. 150 s, then:

– all 700 people would be able to safely evacuate, i.e. the legal occupancy would have been able to safely evacuate.

– all 835 people who are estimated to have been in the club would have managed to safely evacuate

– of the 1200 people, 855 would manage to get out, and the death toll would have been 345.

So these simplistic calculations suggest that if the club and the legally required minimum number of exits (3) with an exit width as specified by the BS 9999 and:

– the legal maximum population (700), then it is possible that everyone would have managed to evacuate before conditions in the club became non-survivable.

– if the population of the club was 835, then it is possible that everyone would have managed to evacuate before conditions in the club became non-survivable.  So even though the club was overcrowded on the night, it is possible that everyone would have managed to evacuate.

– if the population of the club was 1200, the population suggested by the band/authorities, then it is possible that 855 people would have managed to evacuate before conditions in the club became non-survivable and 345 people would have died.  So if the population was as high as 1200, even if the legally required exit capacity was provided it is unlikely that everyone would have managed to evacuate.

It has to be emphasised that these calculations are extremely crude, but they serve to demonstrate how important it is establish the correct number of people that were in the club at the time of the incident.  They also demonstrate that had the club had the required number of exits, it is possible that the death toll in this incident could have been significantly reduced.

To do a more thorough analysis on this incident would require fundamental data describing the club and the materials within the club, the number of people in the club and their distribution.  With this information it would be possible to undertake sophisticated fire and evacuation analysis of the type undertaken for the Rhode Island Nightclub fire.

Rhode Island Fire Simulation:

https://www.youtube.com/watch?v=o197yeup1BQ&list=PLC82636C7790DE890&index=1

Rhode Island Coupled Fire and Evacuation Simulation:

https://www.youtube.com/watch?v=gmPOIriMiyU&list=PL482FD999D5793B82&index=1

Paper describing simulations: http://fseg.gre.ac.uk/fire/pub.asp

Paper 223. “Coupled Fire/Evacuation Analysis of the Station Nightclub Fire”. Galea E.R., Wang, Z., Veeraswamy, A., Jia, F.,Lawrence, P., and Ewer, J. Proceedings of 9th IAFSS Symposium Karlsruhe,Germany, 2008, ISNN 1817-4299, pp 465-476. DOI:10.3801/IAFSS.FSS.9-465

In the Rhode Island case, fire works started by the band set alight PU foam which was used as sound proofing cladding on the walls.  The PU rapidly burnt producing thick choking smoke, laden with deadly Carbon Monoxide gas and Hydrogen Cyanide gas.  People were rapidly overcome by the toxic gases and the rapid resulting flashover.  Coupled fire and evacuation computer simulations of the Rhode Island nightclub fire produced by FSEG suggest that after approximately 100 seconds from ignition, around 100 people would be dead due to the inhalation of toxic fire gases and the effects of flashover.  In the Rhode Island case, while the club was full, it was within legal limits and the nightclub had four exits (including the main exit), but the majority of the patrons tried to use the main entrance, the exit that they used to come into the club.

Media accounts are suggesting that between 300 and 2000 people were in the Kiss Nightclub at the time of the fire.  It is also not clear how many exits the nightclub had, media reports suggest that the nightclub had only one emergency exit and that fire fighters had to make a hole in the wall to assist people to escape.  As the Rhode Island Nightclub fire demonstrated, fires in such environments, fuelled by PU foam will spread extremely rapidly producing large amounts of highly toxic gases, providing people in the crowed venue little time to get out.

If the reports in the media are correct, then it is surprising that only 180 people have lost their lives.  I would not be surprised if the death toll rises, especially if the occupancy is more than 300.  Large crowds, within a confined space, whose walls are clad with combustible PU foam, with limited means of egress, probably in the dark, a number of who are probably intoxicated and then allowing the use of pyrotechnics is a recipe for disaster.   Indeed, building regulations and planning permission should not permit such death traps to exist in the first place and enforcement authorities should ensure that they do not occur.

Once the blame game starts, I hope that the bereaved families do not simply point their finger at the nightclub owner but look beyond this, to their local government authorities that have responsibility for planning permission and building control and to enforcement authorities that have responsibility for inspecting premises.  It is too easy to simply blame the owner.  More importantly, to do so will simply allow this type of tragedy to happen again and again.

Furthermore, while this type of disaster can happen anywhere in the world, and it has — USA, Russia, China and Argentina to name just four recent disasters – it is to be hoped that a country with the responsibility of hosting the next Football World Cup and the Olympics, will ensure that their building regulations and the enforcement of those regulations are fit for purpose.   Not simply for the new build stadia, but for all the existing hotels, transportation hubs and entertainment venues that will be enjoyed by millions of tourists from around the world.

Finally, I wonder how long it is going to take before the media, and local government officials begin to attribute “panic” as a contributory factor in this tragedy, conveniently diverting attention from other potential systemic failures.

BACKGROUND INFORMATION: 

Rhode Island Fire Simulation: https://www.youtube.com/watch?v=o197yeup1BQ&list=PLC82636C7790DE890&index=1

Rhode Island Coupled Fire and Evacuation simulation:

https://www.youtube.com/watch?v=gmPOIriMiyU&list=PL482FD999D5793B82&index=1

Paper describing simulations: http://fseg.gre.ac.uk/fire/pub.asp

Paper 223. “Coupled Fire/Evacuation Analysis of the Station Nightclub Fire”. Galea E.R., Wang, Z., Veeraswamy, A., Jia, F.,Lawrence, P., and Ewer, J. Proceedings of 9th IAFSS SymposiumKarlsruhe,Germany, 2008, ISNN 1817-4299, pp 465-476. DOI:10.3801/IAFSS.FSS.9-465

LINKS TO NEWS ABOUT THIS INCIDENT:

SKY NEWS: Brazil Nightclub Fire Tragedy: 180 Killed.

http://news.sky.com/story/1043501/brazil-nightclub-fire-tragedy-180-killed

The Independent: ‘At least 180 killed’ inBrazilnightclub fire after pyrotechnics set sound-proofing alight

http://www.independent.co.uk/news/world/americas/at-least-180-killed-in-brazil-nightclub-fire-after-pyrotechnics-set-soundproofing-alight-8468600.html

Part of the problem is getting the passengers engaged enough in the safety briefing so that they pay attention and potentially learn something that could save their lives in the event of an accident.  

Shown here are two safety briefings from the same airline, Air New Zealand.  Both are a little different from your ordinary in-flight briefing.  Both try and capture your attention in the hope that you will engage in the safety messaging.

(a) https://www.youtube.com/watch?feature=endscreen&v=7-Mq9HAE62Y&NR=1

AND

(b) https://www.youtube.com/watch?feature=player_embedded&v=cBlRbrB_Gnc

Which of these two videos do you think is the most entertaining?

Which of these two videos do you is the most engaging?

Were you distracted from the safety message by any feature of the videos?

Which of these two videos do you think is the most effective in conveying the safety messages? 

Let me know what you think, post a comment.

 The BBC headline on their website for this story states,

 Glasgow Airport evacuation: Passenger tells of panic on Jet2 plane

 http://www.bbc.co.uk/news/uk-scotland-20001291

Is this a fair account of the situation on board the Jet2 aircraft?  Were people really behaving irrationally and in a selfish manner during this evacuation?  Had social norms broken down, was it everyone for themselves?  Or is this just another media exaggeration to sensationalise a story?

Other media accounts had more factual headlines, such as from the Express web site:

17 Injured as plane is evacuated at Glasgow Airport after smoke alert.

http://www.express.co.uk/posts/view/353053/17-injured-as-plane-is-evacuated-at-Glasgow-Airport-after-smoke-alert

From the Telegraph web site we have:

Glasgow Airport Seventeen injured as aircraft aborts take off

http://www.telegraph.co.uk/news/aviation/9619600/Glasgow-Airport-Seventeen-injured-as-aircraft-aborts-take-off.html

From the Mail Online web site we have:

20 crew and passengers are INJURED in emergency evacuation by inflatable slides from jet at Glasgow airport after “engine” fills cabin with smoke.

http://www.dailymail.co.uk/news/article-2220041/17-injured-crew-passengers-evacuated-plane-Glasgow-Airport.html?ITO=1490

Evacuating an aircraft is not something that people do every day, and so it is going to be an unusual experience for most people, and a frightening experience for most, especially if you believe, as these people must have, that a fire had started on board.  All 189 passengers will also have to exit the aircraft in an awful hurry and in an unusual and physical manner i.e. jumping onto slides or climbing out of the overwing exit, onto the wing and then jump to the ground.  The cabin crew will have been yelling at the passengers to evacuate, leave your bags, jump onto the slide, while the cabin was filling with acrid smoke.  The passengers on board would have been a mix of people including;  men, women, children, the elderly, family groups and possibly disabled people.  They would have had a range of flying experience from frequent flyers to the ocassional  flyer.  Given this mix of people we would not expect everyone to react in the same way, and not everyone will react without emotion.  But will panic really break out in this situation, will it be everyone for themselves, as the BBC headline suggests?

The opening sentence of the BBC article may give this impression,

 “Passengers on an Alicante-bound plane from Glasgow Airport have described “sheer panic” after “swirling” smoke in the cabin forced an emergency stop.” 

So what do the BBC base this on?  A quote from one passenger was reported as,

“… passenger X said “people started running” as the pilot of the Jet2 737 shouted “get out, get out” following the emergency stop at 07:40.”….”

Well this seems quite normal given the situation, who wouldn’t be trying to run out of an aircraft filling with smoke with the captain and cabin crew yelling at you to get out!  Indeed, you would be in a panicked state if you just froze on the spot and didn’t do anything — this is called negative panic or behavioural inaction.  It is a normal behaviour to try and get out of the aircraft as quickly as possible, especially if the captain and cabin crew are yelling at you to get out!

The BBC inform us that one passenger was travelling with his young family and report the passenger as saying, 

 “I have a nine-week-old daughter and a four-year-old daughter. I had my nine-week-old attached to my chest as I went down the emergency chute and my wife had our four-year-old and was in tears. ……. It was just sheer panic, something no-one would want to go through again.”

Clearly this situation is extremely frightening and traumatic, especially if you have a wife, child and infant to look after, make your way to the emergency exit and then jump onto a slide — all while the other 185 passengers are trying to get out and the aircraft is filling with smoke.  It is not surprising that there were tears and it is not surprising that they would have been extremely anxious and would have had adrenaline pumping.  But the behaviour of this family does not sound like a panic behaviour.  They kept together and assisted each other out of the aircraft.  Their behaviour sounds like a rational response to the extra ordinary situation that they found themselves in.  While the passenger uses the “P” word in his description it would have been helpful had the journalist gone on to ask the passenger to describe the scenes of panic that he reported.  Often people will use the “P” word to describe people running away from danger, or people crying.  This does not indicate that people were behaving in an irrational manner or that social norms are ignored.

The BBC also selectively quote another passenger’s account in their article and also helpfully include a recording of the interview.  In the article the passenger is reported as saying,

“I was sitting in row 11 and I could smell smoke as we were accelerating hard. “I looked up. One or two passengers, including myself, had our reading light on and when I looked up to the lamps and the ceiling, I could actually see smoke swirling around and I thought, oops, there’s something not right here.  “We were accelerating very, very hard down the runway at this stage and I was about to scream out to the cabin crew when obviously the pilot realised there was something wrong and he immediately throttled the engines back and put the brakes on. “It’s the hardest braking I’ve ever experienced in my life.” 

This is where the BBC article leaves the interview.  This selective quotation fits into the tone of the story that is being told by the journalist, smoke filling the aircraft and the dramatic stop.  However, in the recorded interview, which is also available on the BBC website, the passenger goes on to say, but is not quoted in the article,

“….a few seconds later he gave the order to evacuate. Everybody got out of their seats, one or two passengers tried to reach into the overhead lockers to get their baggage but they were politely told in no uncertain Glaswegian terms just get out of the aircraft” both the journalist and the passenger laugh, “leave your bags and get out, but there was no panic”.

The passenger is describing an orderly behaviour and makes the observation that there was no panic.  This unfortunately does not fit into the tone of the article and so is not reported.  The journalist desperately tries to get back to possible stories of panic and extreme behaviour and goes onto to say,

“You are laughing about it now but that is probably not what you were feeling about it at the time.”

 The passenger (helpfully) responds,

 “..There was smoke coming off the right hand engine so I was going out the left overwing exit….we all wanted to get off as quickly as possible but it was all orderly, there was no panic.”

In describing his own behaviour the passenger paints a picture of rational behaviour, a clear thought process that lead him to select an appropriate exit.  He also describes the behaviour of others as being orderly and states that there was no panic.  Clearly this account does not fit with the tone of the article so it is not reported.  The journalist rather go with the easy story, the story that is going to make a sensationalist headline, the story that is in-line with the publics hollywood feed expectations when it comes to evacuation stories — people panic!

While these two accounts are not sufficient to base a judgement on the nature of the evacuation from the Jet2 aircraft, they certainly do not support the BBC headline or the tone of the BBC story.  I am sure that there were people screaming and crying during the evacuation, but this in itself is not an indication of panic behaviour.  Indeed, the accounts in the BBC story support the understanding built up over the past 30+ years that on the whole people do not tend to panic in emergency situations.  Indeed, quite the opposite, people tend to behave in a rational way and social norms are maintained even in the most extreme situations.

Unfortunately, this story simply perpetuates the myth that in emergency situations the norm is for people to panic.  I think that a more interesting, uplifting story is that in emergency situations people tend not to panic, but tend to behave in a rational supportive manner and are more likely to assist others then selfishly think only of themselves.

The Jet2 aircraft after the evacuation (picture from ITV website)

http://www.youtube.com/FSEGresearch/

Come and visit the EXODUS demo stand and check out our most recent research which will be presented through 7 papers:

“Fire and Evacuation Simulation of the Fatal 1985 Manchester Airport B737 Fire”, Wang, Z., Jia, F., and Galea, E.R.

ABSTRACT:

In this paper, fire and evacuation computer simulations are conducted to determine the impact of exit opening times on the evacuation and survivability during the Manchester Airport B737 fire of 1985. The fire and evacuation simulation tools, SMARTFIRE and airEXODUS are used in the analysis. The work is in two parts, the first part attempts to reconstruct the actual fire incident and ensuing evacuation using the known facts derived from the official investigation report.  The second part investigates the impact of exit opening times on the aircraft fire development and subsequent evacuation. The results suggest that the number of fatalities could have been reduced by 92% had the delays in opening two of the three exits been avoided.  Furthermore, it is suggested that opening of the unused aft right exit during the accident did not contribute to the high loss of life in this accident.  Indeed, it is suggested that the opening of this exit improved survivability within the cabin and reduced the death toll by some 17%.

“Investigating the impact of culture on evacuation behaviour — A Polish Data-Set”, Galea, E.R., Sharp, G., Sauter, M., Deere, S.J., Filippidis, L.
ABSTRACT:

In this paper results from an unannounced evacuation trial conducted within a library inWarsawPolandare presented and discussed. This experimental evacuation is part of a large international study investigating the impact of culture on evacuation behaviour. In addition, a framework to enable the systematic analysis of Response Phase behaviours is presented and applied to the trial data. The framework not only provides a consistent method for describing Response Phase behaviour, but also provides a framework for classifying and quantifying the Response Phase other than simply using the overall response time. An empirical response time model, based on data generated using the framework is also presented and applied to the evacuation trial data. The empirical response time model produces a prediction for the average response time for the trial population which is within 3% of the measured value. In addition to presenting Response Phase data, a data-set suitable for the validation of evacuation models is also presented. This consists of both egress times and time dependent density measurements.  buildingEXODUS predictions of the evacuation are compared with the validation data and shown to be in good agreement with the measured data.

“Modelling Human Factors and Evacuation Lift Dispatch Strategies”, Kinsey, M.J., Galea, E.R., and Lawrence, P.J.

ABSTRACT:

This paper presents an overview of a series of evacuation simulations utilising different lift dispatch strategies using an empirical based enhanced agent-lift model developed within the buildingEXODUS software. A brief description of the enhanced agent-lift model is presented. The evacuation scenarios investigated are based on a hypothetical 50 floor building with four staircases and a population of 7,840 agents. While past studies have measured the influence of such evacuation lift dispatch strategies assuming compliant/homogenous agent behaviour, this study extends that work by highlighting the potential influence of human factors upon such evacuation lift dispatch strategies. The study suggests that evacuation lift human factors can considerably decrease evacuation performance and highlights the need for consideration within evacuation strategies based on lifts.  

“An Analysis of the Performance of Trained Staff Using Movement Assist Devices To Evacuate the Non-Ambulant”, Hunt, A., Galea E.R., and Lawrence, P.J.
ABSTRACT:

This paper describes a series of trials undertaken to quantify the performance of trained hospital staff in evacuating a test subject through 11 floors of Ghent University Hospital using four commonly used movement assistance devices: stretcher, carry-chair, evacuation chair and rescue sheet.  In total 32 trials were conducted, using both male and female assist teams.  Presented in the paper are performance results, including: device preparation time, horizontal speeds, vertical speeds, and overtaking potential in stairwells. These data, alongside those established in questionnaire data from the experiment participants, form the basis of the device performance evaluation presented in this paper. A comparative methodology is derived to assess the efficiency of the devices. This methodology enabled performance differences to be established, according to the devices employed and the staff involved.
 

“The UK BeSeCu Fire Fighter Study: A Study of UK Fire Fighters’ Emotional, Cognitive and Behavioural Reactions to Emergencies”, Hulse, L.M. and Galea, E.R.
ABSTRACT:

A survey of UK firefighters revealed them to be seemingly psychologically prepared for what their job would expose them to but not immune to experiencing emotional arousal or perceived risk during emergency events. A number of aspects, such as the event posing serious consequences to their lives/well-being, were singled out as particularly distressing and linked with greater emotional arousal, while other aspects, ones focused on other people/circumstances, reduced perceived risk. Traffic accidents appeared to be a special case, inducing lower arousal and risk than another commonly attended emergency, domestic fires. More years of service had a positive effect on the risk perceived during a stressful event but heightened the emotional arousal in that moment. Received support was one of the most significant predictors of posttraumatic stress and growth, as well as being significantly linked to peri-event thoughts/feelings, although other variables not tested here, e.g. individual differences, might be better at explaining posttraumatic states than event-related variables. The sample reported that safety work with a risk group, migrants, was underway and appeared to be beneficial in reducing instances of “inappropriate behaviour” during emergencies but communication difficulties were an issue and training on this matter would appear desirable. Significant differences in responses across the UK were detected and consequences for international comparisons are discussed.
 

“The Collection and Analysis of Data from a Fatal Large-Scale Crowd Incident”, Pretorius, M., Gwynne, S., and Galea, E.R.
ABSTRACT:

This paper discusses the analysis of data-sets from observations made at the Duisburg Love Parade in 2010 and the large-scale crowd situation that ended in fatalities due to the development of crush conditions. This event is a useful case study of large crowd circulation based on the materialthat was made publically available by the organisers and attendees. The resultant data-set has been used to configure the buildingEXODUS modelto approximate the original incident in order to verify both the model’s performance and the underlying scenario assumptions; i.e. whether buildingEXODUS can reliably represent agent actions, the conditions that develop and the impact of these developments.
 

“Response Time Data for Large Passenger Ferries and Cruise Ships”, Brown, R., Galea, E.R., Deere, S., and Filippidis, L.

ABSTRACT:

This paper outlines research that was carried-out under the EU FP7 7 project SAFEGUARD and presents three sets of passenger response time data generated from full-scale semi-unannounced assembly trials at sea.  The data sets were generated from two different types of passenger ships, a RO-PAX ferry, SuperSpeed 1 (SS1) and a cruise ship, Jewel of the Seas (JoS).  In total response times from over 2200 people were collected making it the largest response time data set ever collected — on land or sea.  The paper presents the analysis methodology used to extract the response time data and the resultant response time distributions (RTD).  A number of key findings from the data analysis will also be presented, which includes: (a) all generated RTDs are log-normal, (b) RTDs from the two SS1 trials using two different populations are very similar, (c) The combined RTD for the SS1 is almost identical to the RTD generated from the earlier published data for the same type of vessel, (d) The RTD derived for the public spaces on the JoS is significantly different to that of the SS1, (e) The RTD for public spaces and cabins are significantly different.  These findings are discussed in this paper and form the basis of a recommendation to be submitted to the International Maritime Organisation to be used to frame the next iteration of the international guidelines for ship evacuation analysis.

The point is that in the 21^st century factory workers should not be dying from these types of disasters.  The Triangle Shirtwaist fire was a milestone in the development of fire safety which lead to changes such as the requirement for improved access and egress within work places and the installation of fire extinguishers, fire alarms and sprinklers.   From fires such as the Triangle Shirtwaist fire and the countless lives lost in the battle with fire over the past 100 years, our understanding of fire and the means to combat fire has improved to the point where fires with multiple fatalities such as the Karachi factory fire should be a thing of the past.  Modern building design, fire fighting technology, regulation and enforcement should have prevented a fire in a Karachi clothing factory from becoming a disaster.

Once the blame game starts, I hope that the bereaved families do not simply point their finger at the factory owner but look beyond this, to their local government authorities that have responsibility for planning permission and building control and to enforcement authorities that have responsibility for inspecting premises.  It is too easy to simply blame the owner.  More importantly, to do so will simply allow this type of tragedy to happen again and again.

http://www.bbc.co.uk/news/world-asia-19577450

http://www.bbc.co.uk/news/world-asia-19566851