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://g1.globo.com/rs/rio-grande-do-sul/noticia/2013/01/conheca-vitimas-do-incendio-em-casa-noturna-em-santa-maria-rs.html

It is even more heartbreaking to learn that this tragic loss of life may have been needless and preventable.  As more details of this tragedy begin to emerge, heartbreak turns to anger.  While the details are still not known for certain, the more that comes out in the media the more this carnage appears to have been a preventable tragedy and a failure of regulation, enforcement and management.

What do we know from the reports in the media:

1) From CNN we are told that the club’s license had expired in August 2012 and had not been renewed.  We are also told that the owners had said that the club was properly permitted and had been inspected by the fire marshal.

http://edition.cnn.com/2013/01/28/world/americas/brazil-nightclub-fire-main/index.html

According to reports on CNN, a state fire official suggested that the maximum capacity of the club was 1000 people.

http://edition.cnn.com/2013/01/28/world/americas/brazil-nightclub-fire/index.html

This suggests that at least up to August 2012 the club had been considered appropriate and compliant with the local codes.

2) It has been reported in most media accounts that the club had only one exit.  In some media accounts the word emergency exit has been used, which suggests that there may be at least two exits, while in other accounts it has been categorically stated that the club had just one exit.

http://www.guardian.co.uk/world/2013/jan/28/brazil-nightclub-fire-police-question

A schematic of the club on a Brazilian web site shows only a single exit (also see below).

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

3) Most recent reports suggest that fire and rescue officials estimate that there were 1500 people in the club at the time of the incident.

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

4) While it is still not confirmed, it now appears likely that the band did make use of pyrotechnics during their show, and this was a well known feature of the band.  Reports have even suggested that they made use of three flares.

http://www.guardian.co.uk/world/2013/jan/28/brazil-nightclub-fire-police-question

http://www.bbc.co.uk/news/business-21196209

http://www.nytimes.com/2013/01/29/world/americas/brazil-fire-nightclub.html?_r=0

It is not clear what is meant by a flare, but it is likely to be more than a sparkler!

5) All accounts so far suggest that the fire started in foam sound proofing and spread rapidly.

http://edition.cnn.com/2013/01/28/world/americas/brazil-nightclub-fire/index.html

However, the fire cause is not known at this stage.  It may, as media accounts suggest, have been caused by the pyrotechnics, or it may have been caused by an electrical fault.  We simply do not know at this stage.

6) The exit route was dark.

http://edition.cnn.com/2013/01/28/world/americas/brazil-nightclub-fire/index.html

7) In none of the accounts that I have read is mention of a fire alarm sounding.

8) At first security guards thought that there was a fight or that people were trying to leave without paying so they initially blocked the exit.

http://edition.cnn.com/2013/01/28/world/americas/brazil-nightclub-fire/index.html

9) Reports have highlighted that many bodies were found in the toilets.

10) Reports have suggested that at least one fire extinguisher failed to operate.

http://news.sky.com/story/1043674/brazil-nightclub-fire-security-blocked-exit

Taking these points one can begin to ask some questions concerning the Brazilian fire safety regulations, the enforcement of those regulations and the quality of the management at the club.

REGULATIONS and ENFORCEMENT:

a) How could Brazilian building regulations (or the local code) permit a place of public assembly, with a reported capacity of 1000 people, to have only a single exit?  Even though the license had expired and was under review, the club was considered compliant up to when the license expired in August 2012, so the exit capacity was deemed to be acceptable. Furthermore, what total exit width is required by regulation?   With a capacity of 1000 people I would have expected at least three exits with a total exit width of at least 6m.

b) It appears that no fire alarm sounded.  Was this because the alarm failed or did the club not have an alarm?  If the club did not have an alarm, how could the building regulations possibly permit this?  Had an alarm sounded, perhaps the security guards would not have initially prevented people from escaping, possibly reducing the death toll.  If the club had an alarm was it operational prior to the fire?  If not, could this have been overlooked during a fire inspection?

c) It is reported that the exit route was dark.  Was there no emergency lighting in the club or did it fail?  If there was no emergency lighting how could this be permitted by the regulations?  Had emergency lighting been available, perhaps people would not have tripped in the exit path and perhaps people would not have mistaken the toilets for an exit route. If the club had emergency lighting was it operational prior to the fire?  If not, could this have been overlooked during a fire inspection?

Schematic of the Kiss Nightclub

d) What does the Brazilian code require in terms of emergency exit signage?  Is this required?  Had it been in place, perhaps so many people would not have mistaken the toilets as a means of escape. If emergency exit signage was required by law and it was in place, was it operational prior to the fire?  If not, could this have been overlooked during a fire inspection?

e) The fire appears to have started in the sound proofing foam that lined the ceiling and spread rapidly producing large amounts of toxic fumes.  What type of foam was this?  Was it protected in some way e.g. coated or covered with a fire resistive material?  What do the Brazilian fire regulations say about the type of foams that can be used in places of assembly?  If the use of foam is permitted, was the foam in place compliant with standards prior to the fire?  If not, could this have been overlooked during a fire inspection?

f) What do Brazilian regulations say about the use of indoor pyrotechnics?  If like most countries they permit the use of such devices, what provisions are made to limit their use and ensure that they are used in a responsible manner?   Concerning the use of flares, surely this cannot be permitted?

g) Is it required by Brazilian fire regulations to regularly inspect mandatory fire fighting equipment? If so, what is the frequency?  If regulations stipulate they are to be inspected, were the fire extinguishers in the club inspected prior to the fire?

MANAGEMENT:

a) It is reported that the maximum occupancy for the club was 1000, yet fire authorities suggest that there could have been as many 1500 people in the club.  What means did management have to ensure that the number of people in the club did not exceed their license limit?

b) If the use of pyrotechnics are permitted under Brazilian code, what measures did the management have in place to ensure their safe use?

c) It is reported that fire extinguishers failed to operate.  Did the club management have the fire extinguishers serviced on a regular basis?

d) What training did the club staff have in terms of fire fighting and crowd management?

These are just some of the questions that need to be answered if the root causes of this tragedy are to be addressed.  It is possible that this tragedy was no accident i.e. an unforeseeable event, but the result of a predictable and preventable failing of Regulation, Enforcement and Management.  If so, then immediate measures must be taken to correct the failings in order to ensure a safer Brazil – let this be the legacy of the Kiss Nightclub victims.

Finally, this tragedy provides a couple of hard learnt lessons for the rest of the world:

1) Stop the use of pyrotechnics indoors, they are just too dangerous.

2) Inspection and enforcement must be taken as seriously as legislation.

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

A key interview that sparked much of the public behaviour was given by Francis Maude, a UK Cabinet Office minister, to SKY NEWS on the 28 March 2012.  You can find the interview on YOUTUBE at: http://www.youtube.com/watch?v=EYqxBmtOkvM

Francis Maude, who has been chairing meetings with government colleagues to plan the government response to the threatened strike, made the following comments outside Number 10 Downing Street:

 “….to the extent that people can get some petrol in their cars some fuel in their cars, as and when, no desperate hurry, because as I say the union hasn’t given notice and they have to give seven days notice, that is going to help.”

The minister made it clear that the strike had not yet been called, and that there would need to be seven days notice of a strike.  However, he also made the point that it would be a good idea for the public to get some petrol in their cars.  This is clearly a message to the public that it would be a good idea to ensure that their cars were topped up with fuel.  He went on to say,

“All we can say is that we need to make sure people know this is happening; it’s up to people to make their own decisions; there is no need for rushing around in a mad dash, this is not about to happen tomorrow.”

The minister reiterates that the potential strike is not going to happen in the next day or so, thereby informing the public that there is no immediate threat, but then goes on to say,

“….as and when, when it makes sense a bit of extra fuel in the jerry can in the garage is a sensible precaution to take.”

Fill those jerry cans - just doing what the minister suggested.

Following government advice

Here the minister directly contradicts himself by encouraging the public, not only to make sure that they have topped up their cars with fuel, but to stock-pile petrol in their garages, even though there is no immediate threat of a strike taking place in the next seven days.  The storage of petrol by the general public in their garages is not normal behaviour.  Indeed, it is very unsafe behaviour, which is discouraged by fire and rescue services as domestic fires fuelled by petrol can become extremely dangerous.  However, despite there being no immediate threat of a strike and hence shortage of petrol for the next seven days, the minister is encouraging the public to stock-pile petrol supplies at their homes.  The minister attempted to clarify the government’s position by adding:

“People need to make their own decision, all we can do is make sure they know what is potentially in the offing, we hope the strike won’t happen …but we do want the public to be aware that there is a risk and that we are making contingency plans to keep essential and emergency services going, and we think that the public should be aware of this risk so that in the ordinary course of their business they can take what ever steps, everyone chooses and takes responsibility for themselves; that’s all we can do.  We are not advising people that they should do this or that, we are pointing out what the possibilities are and pointing out things that they might chose to do if they want to…”

So the message to the public was that your course of action is up to you.  However, in this context, a senior government minister, standing outside Number 10, is a highly authoritative source of advice likely to have influence with the public and it was made clear that the government were already taking measures to ensure that their vehicles would be able to function during a potential strike.  Furthermore, the actions that the public can take to prepare for the strike, should it happen are, top up your cars and stock-pile petrol at home in your garage!

Panic or following instructions?

The messaging from this senior government official, while admittedly not clear, strongly suggested a course of action that the public should follow.   On the one hand the government does not want to be responsible for the actions taken by the public, while on the other hand the government is providing thinly veiled advice to top-up and stock-pile.

If we now put this situation into the context of the upcoming Easter four-day weekend — nine days away at the time — is it little wonder that the public queued at petrol stations to fill up their fuel tanks and jerry cans?   I would not describe this as panic buying, but a rational response to a senior government minister’s advice.   The situation is also self perpetuating, as members of the public see people queuing for fuel, and the media report of petrol stations going dry, more and more people are encouraged to queue for fuel.   This is not panic, but a rationale response to government messaging fuelled by behavioural feedback.

This is yet another example of the incorrect usage of the word ‘panic’ by the media and the public.  It is also an example of the power and importance of messaging in potential crisis situations.  This situation demonstrates what can be achieved by messaging, and how it is possible for an authoritative source to influence the behaviour of the public through messaging.   The challenge is to be clear about your communication objectives and get the messaging, messenger and timing right to achieve them. 

Messaging can also be a powerful tool in accident and disaster management.  In voice-based building fire alarm systems, the correct messaging — again from an authoritative source — can decrease occupant response times, encouraging occupants to start their evacuation.  In large-scale disaster situations, messaging can be used to positively influence the public’s behaviour in ways that may appear to be counter intuitive e.g. advice to seek shelter when the natural response would be to evacuate or visa versa.

Did the messaging provided by Francis Maude achieve the government’s objectives? To answer this question it is essential to know what those objectives were.  I’ll leave it to the politically-minded to decide.

Evacuating a large passenger ship, even in ideal conditions, is a complex and dangerous task.  Large passenger ships are normally evacuated in a two phase process, first the assembly phase and then the abandonment phase.  Each phase of the evacuation is initiated by a command from the Master of the vessel i.e. the Captain. 

 a) Assembly Phase

On the command of the Captain, usually designated by seven short and one long blast on the ships horn, the assembly phase can commence.  In the assembly phase, passengers are instructed by the crew to go to their designated assembly station, this is usually designated by a letter e.g. A, B, C, etc.  The assembly stations are usually spread over one or two decks and can be indoors (the norm) but can also be out doors (not so common).  How the ship conducts the assembly process is down to the company operating the ship and the Captain and so may differ from ship to ship.  For example, some ship operating companies assemble passengers by sending them direct to their designated assembly stations where they will be issued with life jackets.  Other ship operating companies will assemble passengers by first sending them to their cabins to collect life jackets, warm clothing and any essential medication, from their cabin, the passengers then make for their designated assembly station. 

During the assembly phase, crew should be stationed at key locations throughout the vessel to help direct passengers to their cabin and/or assembly station.  Once in the assembly station, passengers will don their lifejackets, or have lifejackets issued to them by the crew assigned to the assembly station. 

How long should the assembly process take?  As part of the ship design process, the duration of the assembly phase is determined through computer simulation, using evacuation simulation software such as maritimeEXODUS (see http://fseg.gre.ac.uk/exodus/air.html#maritime).  The maximum time for the assembly process determined by computer simulation for a ship the size of the Costa Concordia, as set out in IMO MSC circ 1238, is 48 minutes.  It should be noted that according to IMO MSC circ 1238, the simulation of the assembly process is intended to benchmark the evacuation capability of the ship and so an ideal benchmark scenario is used in the assessment.  The benchmark scenarios currently used assume that the ship is in an upright condition and in dead calm conditions.  A safety factor of 25% is added to the predicted time to take account of all the factors that are missed out in ideal benchmark scenario, such as fire and heel and the inherent simplifications in the simulation software. So in reality it should take no more than 1 hour to assemble a ship the size of the Costa Concordia.

My research group (FSEG) is part of an EU FP7 project called SAFEGUARD (see paper 252 at http://fseg.gre.ac.uk/fire/pub.asp).  As part of project SAFEGUARD we have performed five semi-unannounced ship assemblies at sea (not along side as is usual practice for the ship assembly drill).  One of these assemblies was on a ship of roughly similar size to the Costa Concordia but with fewer passengers.  The assembly time for this ship took was about 30 minutes — in ideal conditions but unannounced.   So if the assembly process had started before the ship had taken on a severe heel, I estimate that it should be possible to assemble the Costa Concordia passengers in about 40 to 60 minutes.

b) Abandonment Phase

On the command of the Captain, the abandonment phase can commence.  Starting the abandonment phase is not taken lightly, as boarding and lowering lifeboats filled with people, even in ideal situations, is not a trivial task and one with its own inherent dangers.  This is why it is the Captain who gives the command to commence the abandonment phase.  Furthermore, the abandonment phase can commence before all the passengers have assembled if necessary.  As with the assembly phase, the manner in which the ship conducts the abandonment phase is not set down in regulation, but each shipping company will have its own procedures.  Some companies may board those in greatest need first, perhaps the injured.  Others will board people in no particular order, just simply the order in which they turn up.  From the assembly station a member of the crew assigned to the assembly station will take a group of passengers to the lifeboat and will assist them to board the lifeboat, there will usually be a member of the crew already in the lifeboat to assist passengers as they board.  Large modern lifeboats have a capacity of up to 150 passengers.  Even larger lifeboats with twice the capacity are used on the super large cruise ships. Once the lifeboat is fully loaded, the crew assigned to the boat station will lower the lifeboat and once in the water it is expected to move away from the ship.  However, if the ships angle of heel is greater than 20 degrees, the lifeboats cannot be launched.  Lifeboats are normally lowered into the water only when the ship has come to a full stop.

The entire process of boarding all the passengers into the lifeboats and launching all the lifeboats should take no more than 30 minutes according to IMO SOLAS regulations.

c) Assembly Drills

Assembly drills are mandatory on any passenger ship which undertakes a journey of more than 24 hours.  According to IMO SOLAS regulations, the drill must be undertaken within 24 hours of passenger embarkation.

d) Lifeboats and Lifejackets

Under IMO SOLAS regulations, modern large passenger ships must have lifeboat and liferaft capacity for 125% of the people on board.  There must also be lifejackets for 105% of the people on board.  Lifeboats cannot be launched once the angle of heel exceeds 20 degrees and lifeboats cannot be launched while the ship is still underway.

e) Crew

Most of the ships crew, including waiters, entertainers, bar staff and cabin attendants will have a role in the evacuation process.  They will be positioned at key locations throughout the ship to direct passengers to their cabins and assembly stations, they will be in the assembly stations to manage the passengers, they will be at the lifeboats to assist the boarding of the lifeboats, they will control the lowering of the lifeboats and they will be in the lifeboats to control the lifeboats.   In addition to the assembly drills, which are also a form of training for the crew, the crew will have assembly drill training (without passengers ensuring that they know where to go) and lifeboat drills were they practice releasing and lowering the lifeboats.  Training sessions for crew must occur on a weekly basis, and each member of the crew must undergo training at least once per month (according to SOLAS regulations).

f) Women and Children First

There are no IMO regulations that states women and children must be given preference in boarding lifeboats.  It is not clear where this code of practice originates, but it is suggested to have arisen out of the sinking of HMS Birkenhead in 1852.  The Birkenhead was carrying troops to South Africa when she struck an uncharted rock and started to sink.  The soldiers commanding officer gave the order for the soldiers on board to stand firm and let the women and children, of which there where seven women and 13 children, board the two lifeboats that had successfully been launched.  The soldiers did as they were told and most perished.  The bravery of the Birkenhead soldiers is remembered in the Rudyard Kipling poem (1896) “Soldier an’ Sailor Too”:  

“To stand and be still

To the Birken’ead drill

Is a damn tough bullet to chew.”

The Titanic disaster of 1912 was another example where the “women and children first” tradition was upheld.  The combination of insufficient lifeboats and the Birkenhead tradition, meant that disproportionally more men then women died in this disaster. 

The concept of “Women and children first” is not mandated and it is not necessarily such a good idea.  Most emergency evacuation situations are characterised as being time critical.  In such situations every second counts and can literately make the difference between life and death.   In ship based disasters, the quicker you can get the lifeboats loaded and launched the better.  If you had to prioritise people at the boarding stage this is simply going to waste precious time and may delay the launching of the lifeboats.  Furthermore, family groups have very strong emotional and social bonds.  It is difficult to break these bonds.  To separate a family group on the basis of gender (the men folk being left behind) at the point of boarding the lifeboat would not be easy and is likely to be met with opposition, again delaying the boarding process.

Perhaps Somerset Maugham was a little ahead of his time concerning the position he took on the “Women and Children First” tradition.  He is quoted as once saying:

“I much prefer travelling in non-British ships.

There’s none of that nonsense about women and children first”

If you would like to know more about this, try listening to my BBC Radio 4 Women’s Hour (17/01/12 10:00am) interview from http://www.bbc.co.uk/programmes/b019f9h9#p00n9wlf.

Also check out the Guardian website article, “Costa Concordia: are women still prioritised over men in evacuation procedures?” at: http://www.guardian.co.uk/politics/reality-check-with-polly-curtis/2012/jan/16/costa-concordia-women?newsfeed=true 

g) Panic

I am not going to say anymore about panic, but I refer you to:

• The BBC Radio 4 “Today programme” interview I gave with Dr Drury on the 17 January 2012 at 07:41 http://news.bbc.co.uk/today/hi/today/newsid_9679000/9679490.stm
• An interview I gave for BBC NEWS on the 16 January in the article, “Costa Concordia: The rules of evacuating a ship”, http://www.bbc.co.uk/news/magazine-16576289
• My blog on the Love Parade 24 July 2010.

At the time of writing, information concerning the nature of this incident is far too sketchy to draw any firm conclusions.  Hopefully the enquiry will reveal what actually happened and, more importantly, why it happened, so that those charged with the safety of crowds around the world can learn from this tragic incident.

At this point I have two observations I would like to share with you.

(1) What appears to be the situation a few hours after the incident?

Here’s what I know at the moment, based on as yet uncorroborated media reports:

• The Duisburg Love Parade reportedly attracted a crowd of 1.4 million people — this number has not confirmed by the authorities.
• The event began at 14:00 and took place in a former railway freight yard.
• The event has a single entry point, a tunnel located on Karl-Lehr Street. The tunnel is actually a highway underpass. Dimensions of the tunnel are not known, but photographs suggest that it is about 15m wide at the entrance.  Its depth is also unknown; one media report suggested that it was 600m long (Voice of America Online) and another suggested it was 100m long (Guardian).  Photographs I have seen suggest that the tunnel was very long and appears to be made up of several separate underpasses.
• Photographs appearing in the media also suggest that the crowd outside the mouth of the tunnel and inside the tunnel was enormous.  While it is difficult to get an accurate measurement from the available photographs, they suggest to me that the crowd density was well in excess of 4 people/m² and may have been in excess of 6 people/m².  From the photographs there also appears to be no crowd management officials in sight and the random nature of the crowd further suggests that there was little organisation or control in the dispersal of the crowd.  It is not clear when the photographs I have seen were taken, but I assume that they were just before the event or during the event.
• 19 people were killed in the incident and 340 people were injured.  It is not clear where the fatalities occurred.

I would emphasise again that the information at this stage is sketchy and there are many important details missing.  However, if the little information that is available proves to be correct, I would offer the following observations:

• A single entry point for an event of this magnitude is not a good idea.  Given the size of the crowds expected, a single entry point was bound to make crowd management more complex and difficult with implications for crowd safety.    
• I currently have to assume that there was also only a single way out of the event — the entry point.  If this is the case, again it is poor planning for the same reason that a single entry is not a good idea.  I would hope that other emergency exit points were available which the crowd could use in the event of an emergency, but this is currently unknown to me.
• Another issue with having a single entry/exit point is that it may have to support quite sizeable bi-directional flows as people arrive and leave the event.  If controlled bi-directional flow is planned, this further reduces the effective width of the opening, increasing potential crowd management issues associated with the single entry point.  If the bi-directional flow was not controlled, this could have led to chaotic situations within the tunnel, especially with large flows of people.  From observation of the tunnel layout, I can see no evidence that there was a controlled bi-directional flow environment e.g. barriers in the tunnel to segregate entering and exiting patrons.
• Having a tunnel, and such a long tunnel, as the only entry/exit point, when large crowds are expected is not a good idea for several reasons.  Perhaps the most significant is that it provides poor visual access to what is happening within the tunnel.  In certain circumstances this will potentially have a negative influence on the behaviour of the crowds as they cannot see what is happening further into the tunnel and so cannot perceive that a problem such as a blockage may have developed within or beyond the tunnel.  Indeed, if one end of the tunnel was closed by crowd management officials, as some reports suggests, it would have been extremely difficult for people within the tunnel, at the other end of the tunnel and approaching the entrance to the tunnel to know this and hence would persist in trying to enter the tunnel or continue moving along the tunnel.  Perhaps more importantly, if the crowd management officials cannot see what is happening within the tunnel, it is more difficult to detect a problem in its early stages, which makes diffusing a minor crowd event and preventing it from developing into a tragic event extremely difficult, if not impossible.  It even makes it difficult for crowd management officials to know with any degree of certainty the number of people within the tunnel.  This is potentially a recipe for disaster.
• From what I can see in the photographs of the crowds approaching the tunnel from the station end i.e. the entrance, there appears to be no attempt at managing this flow.  It appears that there was no attempt to meter or regulate the flow of people or to channel the flow of people into the entrance.  I assume that the same was happening at the other end of the tunnel i.e. the event end.  From the pictures I have seen, the approach to the tunnel appears to have been a ‘free for all’.  If a small number of people had been expected to utilise the exit e.g. if there had been a smaller crowd or more entrances/exits, it may not have been necessary to provide this type of crowd management at the entry to the tunnel.  However, for an event attracting an audience of 1.4 million with a single entrance/exit, I suggest such measures would have been essential. 

(2) Subtle blaming of the victims.

As soon as news of the incident in Duisburg began to hit the front pages of the world’s newspapers and websites, familiar terms such as “crowd panic” and “crowd stampede” began to be used to describe the tragic incident in Duisburg.   For example:

• “Stampede at German Love Parade festival kills 19”

BBC online news 25 July 2010
http://www.bbc.co.uk/news/world-europe-10751899

• Sky News Headline live to air 25 July 2010 11:00

“Police in Germany have begun an investigation into how a stampede at a music festival left 19 people dead and nearly 350 others injured.  Panic broke out at yesterdays Love Parade event at the city of Duisburg where crowds of party goers tried to force their way through a narrow tunnel and were crushed.”

• “Stampede at German Music Festival Kills 19”

Voice of America News, 25 July 2010
http://www1.voanews.com/english/news/europe/10-Killed-in-German-Techno-Parade-Panic-99171424.html

• “Officials said the deaths and injuries occurred when panic broke out among huge crowds in a roughly 600 meter long tunnel leading towards the day-long open air Love Parade festival in the German city of Duisburg.”
  Voice of America News, 25 July 2010 
• “A mass panic resulting in a stampede reportedly led to the deaths near a tunnel at the Love Parade electronic music festival in the western German city of Duisburg.”

The Sun 25 July 2010
http://www.thesun.co.uk/sol/homepage/news/3067817/19-die-at-German-street-festival.html

• Love Parade stampede in Germany kills at least 18

Los Angeles Times 25 July 2020
http://www.latimes.com/news/nationworld/world/la-fg-germany-love-parade-20100725,0,2079922.story

• “10 killed in mass panic at Germany’s Love Parade”

Business Week.
http://www.businessweek.com/ap/financialnews/D9H5HJ3G1.htm

• “At least 10 people were killed and another 15 injured when mass panic broke out Saturday in a tunnel at an annual celebration of techno music in western Germany.”

Business Week.
http://www.businessweek.com/ap/financialnews/D9H5HJ3G1.htm

This is the typical media response, and of more concern, the typical first response from officials to fatal crowd incidents all around the world.  I don’t intend to discuss here the lack of understanding that the media, the public and officialdom have of words such as ‘panic’ and ‘stampede’.  Rather, I want to discuss the implications that using such phrases have on the public’s understanding of the event. 

While not directly stated, the implication conveyed when these types of phrases are used is that the incident was the fault of the victims, that it was their ‘unreasonable’ behaviour that caused or substantially contributed to the incident and resulted in the tragic loss of life.  Using such phrases is unhelpful, as it immediately diverts attention from other factors that may have contributed to or indeed been the root cause of the tragic event.  There are many other plausible explanations that may have contributed to this and similar tragedies that must be thoroughly investigated rather than go for the easy option of blaming the behaviour of the crowds.  For example, event planners may have designed an environment (both the physical space and the crowd management systems) that was unsafe for the size of crowds that were expected; approval authorities, charged with ensuring event design and crowd management provision is fit for purpose, may have failed to identify potential problems with the proposed event design and crowd management provision; and finally on-ground crowd management officials, charged with the safety of the public may have been unable to safely manage the crowd or may have allowed dangerous conditions to develop. 

It is all too easy to use these phrases when describing tragic crowd incidents, and thereby pass the blame for the incident onto the victims. In my experience of these types of incidents, it is seldom the victims who are the root cause of the incident, but failures during planning, approval and management of the event.

Keep Safe

Prof Ed Galea, 25 July 2010, 14:00