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The fire on the passenger liner "Scandinavian Star" April 7, 1990 – KAMEDO-report 60

The Kamedo-reports are published by the Swedish Disaster Medicine Study Organisation (Kamedo), at the National Board of Health and Welfare. Observers study the medical, psychological, organisational and social aspects of disasters. The results, with a focus on experiences gained, are presented in the reports.

This report is entirely in Swedish. Only summary in English.

Summary

On the night of April 6, 1990, there was a fire on the passenger liner "Scandinavian Star", which was cruising between Oslo in Norway and Fredrikshavn in Denmark. There were 99 crew members and 383 passengers on board. Most passengers came from Norway, some from Denmark and a few from Sweden. Some of the crew members came from other countries.
The ship was not prepared for sea. Several cabins were not cleaned. The crew was exhausted. Knowledge of the ship, her emergency equipment, the emergency plan and so on was not adequate.
The first fire on board started shortly before 2 AM when the ship had reached open water. A pile of bedclothes and carpets in a corridor on the port side had been set on fire. The fire was discovered by some passengers and extinguished.
A second fire was started in another corridor and probably this was also a pile of laundry that had been set on fire. Within a few minutes the corridor was burning right across. The fire spread rapidly and reached the stair-well on the starboard side, from there spreading up to another deck. Dense smoke spread in the corridors on two of the decks.
The captain activated automatic closing of the fire-proof doors within the areas where, according to the fire indicators, there was a fire. But since no fire alarm buttons had been pressed where the fire started, all fire-proof doors in that area remained open, as did other fire-proof doors.
Evacuation of the ship and the conditions at the lifeboats were not in accordance with existing instructions. According to the Board of Accident Investigation report the crew gave the impression that there was a lack of overall command at all stages from the discovery of the fire until the ship was abandoned. A long time passed before it was known who was saved and who was missing because it was not clear who had been taken on board other vessels and brought ashore.
"Mayday" was broadcast from "Scandinavian Star" at 02.24 AM. The position in the Skagerrak was initially incorrectly given, placing the vessel in Norwegian territory. The maritime rescue co-ordinating centre in Norway was therefore appointed to lead the rescue work. The correct position turned out to be on Swedish territory, 11 nautical miles west of Väderöarna.
From the Norwegian maritime rescue co-ordinating centre, Tjöme radio, an immediate alarm was sent out that assistance was needed. During the first half-hour three helicopters and 12 Swedish coastguard vessels, pilot-boats and search and rescue units, and three Norwegian helicopters, coastguard vessels and motor torpedo boats were sent out. From Denmark, several helicopters were sent.
At 02.50 AM the first two assisting ships reached the burning ship. During the next half-hour some more ships came to help. Now the "Scandinavian Star" was burning heavily astern. At 03.23 AM the captain announced that he was in a lifeboat headed for one of the ships and that everybody, passengers as well as crew, had left the disabled vessel.
The crew made no real attempt to control the fire. A first request for smoke divers was made at 03.38 AM and they reached one of the assisting vessels at 05.05 AM.
When the smoke divers, from Gothenburg, had been lowered to the disabled vessel, five survivors were found on the ship. At least two of them survived because the smoke divers brought them to safety. The five were brought to a helicopter. Probably more passengers could have been saved if the smoke divers had arrived two hours earlier.
Of the 324 persons who were saved from the "Scandinavian Star", only about 30 were injured. Most were only mildly intoxicated by fire gases or slightly injured. The first doctor reached the disabled vessel in a Norwegian emergency medical service helicopter about five and a half hours after the fire had started. His main task became to examine several lifeless bodies without external injuries to certify them dead.
Somatic medical treatment in the "Scandinavian Star" accident was inconsiderable. The major work was done by the psychiatric disaster management group and its collaborators at Uddevalla Hospital and the medical social services and the church in Lysekil. This work has continued with debriefing for a long time after the accident.
The very hard work of dealing with the dead was managed by the Norwegian police in co-operation with the Swedish police and voluntary ambulance personnel.
The 158 persons who were found dead on board the "Scandinavian Star" had greatly differing kinds of injury. Some bodies were unaffected by the heat while others were completely cremated. They seem to have died from a combination of hypoxia due to low oxygen content of inspired air (oxygen consumption by the fire and/or high carbon dioxide content) and above all from carbon monoxide and hydrogen cyanide inhalation. Only six persons are assumed to have died in the flames without simultaneous inhalation toxicity (4% of the dead). In 18 persons, hydrogen cyanide concentrations were high enough to indicate hydrogen cyanide poisoning as the cause of death. Most of the dead persons (99) were found in their cabins. 25% of them were more or less lying in the bathroom or shower room, often with a towel covering their faces. About 50 persons were found dead in the corridors.
The primary rescue work and care of survivors and relatives made great demands on satisfactory Scandinavian co-operation for psychosocial care. A crisis centre for survivors and relatives was established in one of the bigger hotels in the centre of Oslo by the shipping company in co-operation with the local disaster psychiatry team. It was judged that three groups of people might need help i.e. the fire service smoke divers, coastguard personnel and passengers and relatives of injured and uninjured passengers.
At Uddevalla Hospital, psychiatric disaster management groups had been established with representatives from the medical social care organization, child and adolescent psychiatry, adult psychiatry and the hospital church. This group organized psychosocial care in Lysekil where many survivors had been taken for transport to Oslo.
Experience and conclusions The call for smoke divers came too late: probably smoke. diving and fire-fighting could have started 1.5-2 hours earlier. Experience from e.g. hotel fires has shown that you can save people who have been shut up for hours after the outbreak of a fire. The injury profile could have been quite different, causing a demand for a medical director as well as medical teams on board the "Scandinavian Star" or one of the rescue ships. A helicopter could easily have brought an experienced medical team at an early stage to take care of the injured. Also from Norway specially trained medical teams could have arrived.
The work of the crisis intervention team has since been discussed. There is a view that sometimes they were too active, especially during the first 12 hours before the real need of immediate debriefing for the rescue personnel was known. Later on there was a balance and the rescue personnel knew that personnel with knowledge of psychological working through were available all the time.
It is important to find satisfactory models for devotions, memorial and farewell services in connection with disasters. It is also important to fix the correct moment to withdraw resources from the disaster site and to de-escalate properly.
The police work was very determined and performed with extremely good spirit. A police command staff was not organized until the third day. Such a staff should have been organized earlier in order to secure a correct distribution of work between chiefs. Furthermore, the police command staff should have had more time for checking, follow-up of decisions and creating direct contacts with the Norwegian preliminary investigation officers and so on.
Decisions and changes concerning cordoned-off areas have to be discussed within the police command and personnel concerned must be informed. "Visiting" senior police officials have no right to give orders. The responsibilities of different decision-makers must be distinct, especially when other countries are involved. A police command staff is a good resource for preparing such questions for the police commissioner. In, for example, registration of dead and injured persons, the use of computers must be considered.

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