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The Estonia disaster - The loss of MS Estonia in the Baltic on September 28, 1994 – KAMEDO-report 68

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.

Summary

The accident and initial rescue operations

At 18.15 on 27th September 1994, the M/S Estonia left Tallinn, bound for Stockholm. (Swedish time is used throughout this report.) The weather was bad, with a strong south-westerly wind rising to storm pitch. South-east of Utö the ferry was 40 minutes late. Waves between six and eight metres high were striking the bow of the ship.
Shortly before midnight, loud noises from the bow door were reported to the bridge. A seaman sent down to the car deck found nothing out of the ordinary. About ten minutes after midnight, two loud bangs were heard in the ship, and it heeled heavily shortly afterwards. A further impact caused the ship to list about 30 degrees. Water poured into the car deck. At 00.20 the alarm was given to the crew. At about the same time the Estonia put out a distress call to the M/S Silja Europa, reporting a severe list and requesting assistance. This message was also picked up by the Åbo (Turku) sea rescue centre and by several stations and ships. After 00.30 the Estonia's radio was silent. At about 00.50 the Estonia sank. A couple of hundred persons on board had managed to get out of the ferry, but organised evacuation with the launching of lifeboats and life rafts had not been possible, owing to the list, heavy storm and the rapidity of events.
The Finnish sea rescue service noted that the Estonia was in international waters but within the Finnish rescue zone. The direction of rescue measures devolved on MRCC Åbo (Turku). Personnel were called in. In addition to helicopters of the Finnish sea rescue service and ships standing by, the alarm was also given to helicopters from the Finnish Armed Forces. Ships relatively close to the Estonia made for the scene of the accident in order to relieve the Estonia, which was still believed to be afloat. The captain of the Silja Europa was appointed on-scene commander (OSC).
The Swedish sea rescue service at MRCC Stockholm received confirmation from Åbo (Turku) at 01.00 that assistance was desired. It was not yet known that the Estonia had sunk. The air rescue service at Arlanda was notified at 01.03 of the need for helicopter assistance and alerted two helicopters. At 01.30, MRCC Stockholm was informed that the Estonia had probably gone down. ARCC at Arlanda was notified of this. All available helicopters were alerted. Between 01.30 and 04.46 a total of nine Swedish helicopters set out for rescue operations at the scene of the accident. Further helicopters were put on stand by.
The M/S Mariella arrived at the scene of the accident at 01.12, the first vessel to do so. There were people in the water and on rafts. Altogether 15 persons were transeferred directly from the Estonia's rafts to the Mariella. In addition, Finnish helicopters pulled eleven persons aboard who had been rescued from the sea. One of those rescued had a broken leg and was flown from the Mariella to Hangö (Hanku).
The M/S Silja Europa arrived at the scene of the accident at 01.30. The ship's lifeboats could not be launched, because of the storm and the waves. A young man on a raft managed to climb aboard the Silja Europa up a ladder down the sida of the ship. A further six persons came aboard. Five of them had been picked up by a Finnish helicopter. The sixth was a Swedish rescue man who, holding on to the hawser of a broken winch, was hoisted aboard by a helicopter. Co-ordination and air traffic control personnel were also conveyed to the ship by helicopter.
The M/S Silja Symphony, which arrived at 01.40, was also unable to use her lifeboats. No survivors could be taken aboard directly from the sea. On the other hand, Finnish helicopters transferred a total of 20 survivors who had been picked up.
The M/S Isabella arrived at 01.52. Seventeen survivors were taken aboard the ship with the aid of two rafts. One of them was suffering from severe hypothermia and was flown by helicopter to Åbo (Turku).
A very large number of additional ships arrived as time went on. One of these rescued a man on a raft at 05.15. The others taking part in the search did not pick up any survivors.
Helicopters from the Finnish sea rescue service and the Finnish Air Force picked up 47 survivors from the Estonia and two members of the crew of the M/S Isabella. Some of those rescued were taken to three of the assisting ships, but the great majority were taken to Finland. One of the helicopters saved a total of 37 persons. The Swedish Air Force took part with five helicopters, and the Swedish Navy with four. They succeeded in rescuing 50 survivors, some of whom were taken to Huddinge Hospital. Others were conveyed primarily to Utö but some to Hangö (Hanku) and Mariehamn.
Additional Swedish Navy helicopters joined in the search and the picking up of bodies during the morning. Two Danish helicopters also took part in the search, as well one helicopter each from Estonia and Russia.
Of the approximately 1,000 persons on board the Estonia, 137 survived. Of these, 94 were passengers and 43 crew members. Most of the survivors were men. The ferry sank in a short time. People did not have time to put on any clothing. Nor was it possible to use the lifeboats; this was also due to the severe list. Most of the people found were not wearing their life jackets properly.

Medical activity in Finland

One of the main tasks of the physicians included in the management staff in Åbo (Turku), where the rescue operation was directed from, was to provide medical resources for the survivors from the Estonia. Both emergency hospitals, long-stay hospitals and health centres were alerted.
Those rescued were flown mainly to Utö for primary medical care before being taken on to hospital in Åbo (Turku) or Mariehamn. In certain cases, the people rescued were flown to Hangö (Hanku) and Stockholm. Several of those rescued were put on board ships. On the morning of the accident, the breakdown of survivors in Finland was a follows:
Åbo (Turku) University Central Hospital 38
Mariehamn (Åland Central Hospital) 8
Hangö (Hanku) Health Centre 8
Ekenäs (Tammisaari) Regional Hospital 4
Helsinki University Central Hospital 1
West Åboland (West Turku region) 4
In Utö, an evacuation centre was set up at a military base. Medical personnel were dispatched to the island, took care of passengers arriving there and also attended them when they were flown on by helicopter to hospitals in Åbo (Turku) and Mariehamn. Deceased persons were also taken to Utö, where death was confirmed and preliminary identification carried out. They were then conveyed by military shipping to the mainland and handed over to the body identification unit.
The first patient to be received by the Åbo (Turku) University Central Hospital arrived at 04.30 by helicopter from the scene of the accident. Survivors who had first been taken to Utö began to arrive three hours later. A total of 38 survivors were admitted to the hospital on the first day. Three of them needed intensive care. The most hypothermic had a body temperature of 26.5 degrees C. He survived without permanent injury, as did all the Estonia patients arriving in Åbo (Turku). Contusions, wounds and a few fractures occurred, but no life-threatening injuries. Thirty-three of the patients could be discharged from hospital the very next day.
One very big problem for the hospital management was the media barrage from all over the world. Police assistance was needed. Four international press conferences were held during the first 24 hours following the disaster. Telephone enquiries from close relatives were a heavy burden and point to the necessity of early measures to cater to the need for information.
The M/S Silja Symphony reached Helsinki just before 18.00 Swedish time with 20 survivors from the Estonia on board. They were conveyed by bus to the Helsinki University Central Hospital. None of them needed to be detained. The M/S Isabella had 16 survivors on board when she arrived in Helsinki at 18.00 Swedish time. They were taken by bus to Maria Hospital. Tölö Hospital, in the Helsinki area, also received survivors from the Estonia. According to information received, none of those taken to hospital in Helsinki were suffering from life-threatening injuries.
A great deal of identification work was needed. It proved difficult to obtain reliable lists of passengers. Inversions and mis-spellings of names occurred in the particulars supplied to the police. Sweden, Norway and Estonia sent police liaison officers to Åbo (Turku). All deceased taken charge of were conveyed to Helsinki, where they underwent forensic autopsy and were identified by the body identification unit.

Medical activity in Sweden

Central management in the Stockholm area

The County Council officer on call at the CAK (Department of Ambulance Care and Disaster Medicine Planning) was alerted at home by SOS-A and immediately alerted Huddinge Hospital, the Karolinska Hospital and Söder Hospital, requesting them to mobilise crisis groups and to make preparations for the reception of the somatically injured and for the psychosocial care of patients and close relativies. The officer also alerted the Staff Medical Officer and two other CAK officers for service at control centres (the police control centre, SOS-A and MRCC Stockholm). The Staff Medical Officer in turn alerted an experienced Senior Medical Officer to serve as medical director on-scene at the Estline terminal, and also a PKL co-ordinator to co-ordinate medical psychosocial supportive activities at the terminal. The medical disaster management staff at SOS-A was in close contact with management group at the Estline terminal, the hospital managements and representatives of the County Adniminstrative Board and the National Board of Health and Welfare. The central medical disaster management was disbanded on the morning of 30th September, i.e. after rather more than two days.

The Estline terminal

A Medical Director on-scene was summoned to the Estline terminal in the early morning of 28th September. Survivors from the wrecked ferry were not expected at the terminal at this stage of things, and the measure was prompted by the large number of anxious relatives who were expected to gather there. These were taken care of, for example, by many persons from Church, the emergency social welfare services and voluntary organisations. An important task of the terminal devolved on the Director of Public Relations from Söder Hospital, who had been summoned to the terminal and was in charge of press contacts. Several press conferences were organised. By about ten in the morning, 50 or so journalists and photographers, many of them foreign, had gathered at the terminal. A press conference for nearly 100 journalists was held at 13.30, with information in English as well as Swedish.
An information office for close relatives was set up at the Estline terminal. During the morning 400 or 500 anxious relatives had gathered there and wanted information. In the absence of reliable passenger lists and with the names of the rescued unknown, the task at the information office in the arrivals hall and that of the phone-in enquiries office became increasingly difficult. The information offices were staffed by clergy, lay workers, personnel from hospital crisis groups and social workers from the social services, under the direction of a priest. A psychiatrist was put in charge of the information offices later on. One information office was open during the night of 29th September. During the day, three information offices for phone-in enquiries were kept open at the terminal. The information office at the Estline terminal closed at 08.30 on 1st October, after which the corresponding information services were managed from crisis centres at Huddinge Hospital and the Karolinska Hospital.

Huddinge Hospital

The Emergency Department was alerted at 02.55, with a request for a medical team (doctor + nurse) by helicopter within 20 minutes and a second medical team to be ready to go soon afterwards.
At about 5 in the morning the secretary of the disaster office and the head of staff (Chairman of the Disaster Committee) were informed, and they both came to the hospital and made preparations for media contacts. Extra security personnel were called in after the head of security had been contacted, in view of the accumulation of journalists expected when patients from the accident began to arrive.
Media representatives arrived already at about 5 o'clock and were kept regularly informed. The first patient (a young Estonian woman) arrived at the hospital at 05.25.
The second helicopter arrived just before 08.00, bringing six survivors (five Estonians and one Swede) and one body. None of the arrivals needed surgery, but some were X-rayed, one was kept under observation in the cronary care unit for arrhytmias and one was transferred to the intensive care unit due to suspected aspiration (inhalation of vomit).
Two more medical teams from the hospital manned helicopters. Seven survivors brought home by Hercules aircraft from Åbo (Turku) or by air ambulance from Mariehamn arrived at the hospital during the afternoon and evening of 29th September. The patients and medical teams were looked after by the "crisis teams" as necessary. Most of the survivors arriving at Arlanda by regular flights from Åbo (Turku) were conveyed to Huddinge Hospital but were able to go home almost immediately, since while in Finland they had been looked after by crisis groups there. Press conferences were arranged at the hospital.

Söder Hospital (Södersjukhuset)

A medical team was dispatched from Söder Hospital to the terminal in the early morning of 28th September. Söder Hospital was detailed for the reception of survivors who had been taken on board by the M/S Mariella and the M/S Silja Europa, 31 persons altogether. The ships were expected to arrive at about 23.00. Medical teams were sent to the terminals to meet them.
Patients were evacuated from one department of the hospital, which was manned by staff from the Emergency Department. This department was was to serve both as reception unit, for registration, examination and primary treatment, but subsequently as an admission department. The idea was to keep the group of injured and rescued persons in one place, for concentration of handling and for greater ease of observation etc. With all activities relating to the disaster concentrated in one department, regular activities in the Emergency Department could proceed at the same time without disruption.
The first patients from the M/S Mariella arrived just before midnight. All of them were admitted directly to the department prepared for them, through a door in the end hall of the department and without having to pass through the Emergency Department. Relatives coming to the hospital were able to meet their dear ones in the department as soon as registration and examination had taken place. All the patients were adults, and none of then was severely injured, but the injury panorama included fractures, concussion and abrasions. None of the patients was hypothermic. Later that night, after 01.00, another six patients arrived from the M/S Silja Europa. Fourteen uninjured or only slightly injured persons were able to leave the hospital after a few hours. All but two of the others were discharded the following day.
Press conferences were held on four occasions altogehter during the evening and nigth and on the morning of 29th September.
Work at Huddinge Hospital and Söder Hospital was able to proceed without any capasity problems occurring. Crisis groups at each hospital helped to look after both rescued persons and close relatives. Most of the rescued persons, however, were Estonians, and so many close relatives making their way to Söder Hospital had no relatives among the rescued persons who had been taken there.

Repatriation of survivors

As stated earlier, seven persons were rescued by helicopter and taken straight to Huddinge Hospital. Thirty-one surviviors arrived by ferry and were all taken to Söder Hospital.
Thirteen patients and one relative arrived at Arlanda from Åbo (Turku) by Hercules aircraft on 29th September, together with a Swedish crisis group. Five patients were brought back from Mariehamn by air ambulance. Seven patients were taken to Huddinge Hospital, while the others were taken home or transferred to their lockal hospitals.
Sixteen persons wanted to go home by themselves and did not feel in need of care. When these persons arrived at Arlanda on 29th September by a regular flight, they were met by a crisis group. Most of them were conveyed to Huddinge Hospital, several against their wishes, because they had already been in hospital in Helsinki and had also been in touch with the Swedish crisis group who had travelled to Finland the previous day. All of them were able to go home almost immediately.

Other activities in Sweden

The Ministries and the Cabinet Office

The Government was informed of the accident early on the same night, in connection with its farewell party. It was above all the Ministry for Foreign Affairs and the Ministry of Transport and Communications that came to be involved in various ways. A crisis group including representatives of both the ministries concerned was set up at an early stage of things. Contacts with close relatives were mainly handled by the Ministry of Transport and Communications.

The National Board of Health and Welfare

The officer on stand by at the National Board of Health and Welfare was informed of the accident early in the morning. Close contact was then maintained with the Medical Management Group in Stockholm. It was the National Board of Health and Welfare which decided that survivors put ashore in Finland were to be brougth home by air ambulance and by a transport aircraft from the Swedish Armed Forces. The National Board of Health and Welfare received many enquiries from news media, but also from other authorities, county administrative boards and a couple of embassies. Close contact was also maintained with the Ministry for Foreign Affairs.

The Stockholm County Administrative Board

The Director of Public Relations at the County Administrative Board was informed of the accident early in the morning. The Board decided not to intervene directly. Instead it kept developments under observation and stationed a couple of persons with the management group at the Estline terminal as liasion officers. Lists of municipal addresses and phone numbers were conveyed to the management group of the Estline terminal through the Social Affairs Unit of the County Administrative Board.

The Police

The Swedish police were not directly alerted. The Police Communication Centre (LKC) in Stockholm learned of the disaster through a Swedish Radio transmission at 02.00. LKC and the National Police Board decided relatively soon that police activites were to be directed by the Stockholm County Police Authority. They further decided that responsibility for the identification of deceased persons should be assumed by the National Police Board. Police patrols were soon dispatched to the Estline terminal and later to Huddinge Hospital and Söder Hospital, where survivors and relatives were expected. The Senior Police Officer at the Estline terminal eventually took charge of the management group there.
The Finnish police were contacted early on, to co-ordinate the work of indentifying the dead and sirvivors. The dead were identified almost exclusively in Finland, only one body being identified in Sweden. Through consultations between the National Tax Board and the National Police Board, various conceivable situations were defined in which a person could be registered as dead in spite of the body not being found.
A number of police authorities elsewhere in the country were also affected by the accident. The other police districts in Sweden were never notified by the Stockholm communication centre. They mostly found out about the accident through the news media. A number of measures were taken by the police authorities concerned. Crisis groups were set up, co-operation was established with other police authorities in the county, with the municipality, with the ID Commission and with the Stockholm County Police Authority. Supportive documentation for the registration of deahts was forwarded to ID officers in Stockholm and Finland.

News media

The Estonia disaster attracted a great deal of attention from all Swedish media. Relatively speaking, this was confined to the first two or three days after the accident, but interest revived whenever there was a particular occurrence relating to the accident.
The Swedish news agency Tidningarnas Telegrambyrå (TT) was informed of the accident by MRCC Stockholm sea rescue service soon after 01.00, i.e. less than half an hour after radar contact with the M/S Estonia had been lost. Barely half an hour later, after the report had been checked, the information was forwarded to Swedish Radio and Television and to Reuters', and in this way information of the accident was broadcast throughout the world.
The first news of the accident already reached listeners through Swedish Radio channels P3 and P4 at 02.00 and Radio Sweden listeners at 02.55. P1 listerners heard of the accident when the channel began broadcasting at 05.30. Information about the accident was then broadcast by local radio stations from the commencement of their transmissions at 06.00. On television too, information about the accident was supplied from the commencement of transmissons at 06.00 in the morning (TV2 and TV4). For the whole of the first day, information about the accident was, in principle, broadcast on radio and television at least once every hour.
The daily newspapers Dagens Nyheter and Svenska Dagbladet were only able to include isolated articles in their latest editions on Wednesday 28th September. Aftonbladet and Expressen published several extra editions on 28th September.

Psychological, psychiatric and social aspects

Various contingecy and action programmes for psychological support and assistance to victim groups have been devised, for example, in the medical services, rescue services, social services, the Church and private organisations. These plans, as a rule, are based on the increased and specific need entailed by a mass injury situation affecting the population within a limited geographical area. In recent years, partly on the initative of the National Rescue Services Board, community based psychological disaster management groups (C-PDM - in Swedish POSOM) have been set up. Support and assistance to persons in situations of crisis forms a natural part of Church social work. This and the hospital chapel organisation have facilitated the establishment of disaster preparedness within the Church of Sweden.
Experience has shown the co-ordination of activities to be particularly difficult in a city region with several parallel organisations, uncertainties in the structure of command, local territorial rivalries etc. Even so, in the localities particularly affected by the Estonia disaster, pychological disaster preparedness appears to have developed in agreement with the recommendations made. One is struck by the rapidity with representatives of the PKL and C-PDM groups were alerted and with which they organised psychological and social support - both in the Stockholm region and in the worst-affected communities. The local communities affected were identified at an early stage, and so adequate preparations could be made relatively quickly.
During the early days, great difficulty was experienced in obtaining reliable information as to which passengers had been rescued, concerning the identity of the dead and concerning which people had been on board in the first place. This uncertainty imposed an extra traumatic burden on the many close relatives who had gathered att crisis centres iln Stockholm and all over Sweden, and it created palpable difficulties in the context of psychosocial supportive activities. For the first 24 hours, the need for information was paramount compared with the need for other psychosocial supportive measures.
One lesson from the Stockholm region was the great need for telephone contact opportunities all round the clock. Active follow-up reguires adequate recording of telephone contacts. This recording has to be carried out in close co-operation with the police command involved. Special resources have to be set aside early on to facilitate adequate debriefing of rescue personnel, psychosocial supportive personnel and personnel in positions of responsibility.
Within the Stockholm region, psychosocial supportive activity during the early months following the disaster came to be concentrated within Ersta Hospital (close relatives support), Söder Hospital (supportive measures for survivors), St Göran's Hospital (support for affllicted families, i.e. households with children, debriefing), the Karolinska Hospital (co-ordination and telephone counselling) and the Stockholm Police (support to close relatives and fellow-employees). Activities within each unit were headed for the first few weeks by a PKL group. Doctors, nurses, social workers, psycholigists and hospital chapel staff provided direct support through personal interviews (on both a group and individual basis) and by telephone.
Close co-operation between medical services and the Church in the ongoing process of psychosocial support was especially noticeable and apparently worked well in Borlänge, Jönköping, Norrköping and Uppsala. Close co-operation between the hospital medical disaster office and reinforced medical disaster preparedness facilitates the logistical support on which good psychosocial care depends. In many of the places affected, the special facilities of the Church for ritualised support, individual and collective, was of great help to many people. In connection, not least, with ceremonies of remembrance for the dead and missing, various rites improvised on traditional foundation provided support and assistance for close relatives.
By far the largest group of persons affected comprisers close relatives to (a) dead and identified persons and (b) dead and missing persons. The latter group runs an obvious risk of incurring considerable psychological disorders in future.
For a large group of people, the absence of the dead body is a powerful complicating factor, due partly to the difficulty of finding an adequate substitute for the important supportive function of traditional funeral ceremonies. Rital acts and collective support are known from experience to be very valuable as a means of initiating an appropriate reaction of grief and of alleviating the psycholigical pain of grief.
Where another group is concerned, the view taken of shipping and the sea is influenced by family traditions and occupational traditions, also as regard attitudes concerning lives lost at sea. These people can also regard the sea as a burial place and invest it with a sancity entailed by awareness of the proximity of death by drowning. Grief the acguires nautal support from these persons' everyday contacts with ships and the sea. From their point of view, far-reaching efforts to salvage dead bodies from a sunken ship can be a desecration and a very harrowing experience.
Thus the measure which to many would have come as support in their grief and a measure for the prevention of future psychological problems - namely the retrieving of as many bodies as possible for burial on shore - can, where others are concerned, be an appalling act which would impede their adjustment to the difficult situation of grief and loss. This being so, it is hardly surprising that the process of finding a course of action in deciding whether to salvage or not to salvage has been so difficult and protracted. Nevertheless, the uncertainty and the long-drawn-out process in this respect have been painful to all the close relatives concerned, whatever their cultural background. This can cause future psychological injury to the close relatives.
One form of support could have been an early collective funeral and memorial ceremony at the location of the sunken ferry. All close relatives would have been actively encouraged to join in this ceremony, and society and the Church could have made resources and arrangements available in the form of ships and rituals of mourning.
Grief, however - and this has to be emphasised - is unique to each grieving individual. Each individual has to process his or her own grief, a heavy task to be accomplished according to his circumstances and the support available from those around him. The duty of society is to identify a pathological reaction of grief and on doing so to provide necessary professional support.
It also has to be recalled, however, that the scale of the Estonia accident was such that ordinary rules concerning delimitation of the group of persons affected do not apply. Large workplaces were affected in their entirety. Local communities experienced collective grief. In fact there still exists a kind of semi-processed nationwide grief following the great disaster which, accordingly, will leave its mark on people's minds for a very long time to come.
Most of the people involved in Sweden's part of the rescue operation were young professional rescue men who had taken part in surface salvage assignments on several occasions previously. The outward circumstances of this assignment, however, were extreme in terms of both the weather conditions and the large number of persons affected. Circumstances being what they were, it was impossible to carry out the assignment in such a way that everyone who had survived when the ship went down could be saved. Professional rescue personnel are well aware of these conditions, but even so are liable to react with feelings of guilt and problems of inadequacy when the somatic and psychological burden becomes heavy enough.
It seems as though the debriefing measures undertaken in Sweden and Finland were pitched at the right level. Misgivings have been expressed in various connections about subjecting divers and other rescue and identification personnel to the intensive mental strain which salvaging of the vessel or alternatively of individual dead bodies would entail. It has been said that a measure of this kind could jeopardise the future psychological health of the personnel committed. Probably this only applies in a situation where salvage measures are not a natural continuation of rescue work, i.e. when salvaging constitutes a new input beginning only at a later point in time.
Several of the survivors also had relatives who died in the disaster. This "dual" traumatisation naturally complicates the post-traumatic reactions. Among many survivors, the acute stress syndrome came to be dominated by relatively pronounced dissociative mechanisms which can possibly protect them against excessively strong reactions in the course of a catastrophic occurrence. The survivor group is a high-risk group with regard to post-traumatic sress syndrome (PTSD), both at the acute stage and with delayed début.
(Dissociatives mechanisms include, for example, a feeling of unreality, of not being present, and parial losses of memory. PTSD is a trauma-specific psychiatric state characterised by painful re-living and avoidance of things reminiscent of the occurrence. Anxiety and depression are prominent symptoms.)
It is too early yet to say whether the early supportive inputs have been able to prevent the occurrence of post-traumatic psychological illness.
A number of books and reports have already been published during the first two years following the accident. Many more can be expected in the ye ars to come. Several interest organisatons have been formed for close relatives and survivors. These associations act on different terms in certain respects and not always in conjunction with one another. Partly different demands have been presented regarding the way in which the authorities propose dealing with the sunken ship and the dead bodies remaining on board. The interest associations are also pursuing matters of financial compensation.

Experience and conclusions

• Rescue operations and effects of an accident of this kind involve practically the whole of society, from the individual to government level

Ships and materiel

• This accident, like many ferry accidents before it, shows that measures need to be taken to prevent vessels from capsizing as a result of car decks flooding and also to improve evacuation opportunities, rescue equipment and relief facilities. The life jackets, for example, did not work satisfactorily. Their design and efficiency must be improved. Then again, use of lifeboats was rendered impossible by the list, rough weather and shortage of time.
• Even a large ship like the M/S Estonia sinks with astonishing rapidity once it has begun to ship water. If danger is suspected, passengers must be alerted and ordered to the lifeboats.
• The ships which came to the scene proved to have very limited possibilities of rendering assistance in a heavy storm. The equipment on board large modern vessels for retrieving people from the water cannot be used in strong winds. For rapid and simple retrieval of people from the water, a kind of net basket or other structure would need to be used, so that many people could be picked up simultaneously.
• Large passenger ships should have contingency arrangements for receiving a relatively large number of persons rescued from wrecked ships. One can assume that the passengers will include medical personnel capable of assisting with the care of the rescued.
• Many life rafts were found upside down. These should be disigned in such a way that they can be used in any position or cannot capsize. It is important that a raft should be easy to enter from the water.

Helicopter rescue, medical response

• Most of the people rescued from the sea were picked up by helicopter. One important reason why so many people could be rescueded by one of the Finnish helicopters was that the crew had training in air-sea rescue and in landing on board ships in rough weather, that the equipment was in good condition, and that there were two rescue men in each helicopter. The rescue men were subjected to very severe somatic and psychological strains. They must therefore have good physical and psychological capabilities for the task and be in good practice and accustomed to working under difficult conditions. Thers should always be two rescue men in every helicopter.
• Medical personnel instructed and trained for accompanying helicopters on rescue missions make an important contribution by providing advanced first aid and other treatment and by relieving the helicopter crew of medical responsibility.
• It is hard to tell whether a severely hypothermic person is alive or dead. All hypothermic persons, if apparently lifeless, must be rescued as quickly as possible, given qualified first aid and taken to where qualified care is available. Resuscitations attempts must not be discontinued too early. There was, however, a pronounced imbalance between the need and availability of effective rescue resources. Attention had to be concentrated in the first instance on vixtims showing clear signs of life.
• Many people were chilled very quickly in the water the temperature was 10 or 12 degrees C. A survival suit is needed in order to cope with immersion in such water for any length of time. Hypothermia was a powerful contributory cause of many people who had escaped from the ship dying in the water or in the life rafts. Many were not strong enough to stay on the rafts and were surprisingly unaffected. These people had relatively quickly got out of the water and onto a raft with an effective windshield. The importance of action to ensure that persons who have entered the water get out of it and into wdarm conditions as quickly as possible cannot be over emphasised. Many people suffering from profound hypothermia recovered completely, however, after warning.

Command

• At control centres and suchlike, it is essential for the Senior Medical Officer, in addition to the customary training for such duties, also to have a knowledge of human survival prospects at different air and water temperatures and in other climatic conditions, and also of accepted principles for the treatment of hypothermia.
• There was some uncertainty as to who ought really to direct activities at the ferry terminal, since the rescue services did not need to take part there. The chain of command in the event of an accident must always be clear, whatever the type of accident involved. The rescue services should always take responsibility for management intially, but can then, if necessary, delegate management to some other organisation (the police or medical services).
• The liaison officers from the organisations concerned who were distributed between the different control centres facilitated liaison between the various centres. In the event of major accidents, at least one representative of each organisation concerned should be stationed at every control centre.
• The National Board of Health and Welfare had numerous contacts with the central medical management in Stockholm and with ministries, authorites and other organisations, and in certain matters came to serve operationally as a connecting link between other organisations. Initiallly, however, there was some uncertainty as to the way in which survivors were to be repatriated from Finland, due to co-ordination initially not having taken place between the National Board of Health and Welfare and the Ministry for Foreign Affairs. Co-ordination between ministries and national authorities should be established at an early stage of things. If an accident affects several regions (county councils), a co-ordinating function is needed from a superior authority (or the equivalent). In matters relating to medical activity, a co-ordinating function of this kind should be formally vested in the National Board of Health and Welfare.

Medical management

• To begin with, the central medical management group in Stockholm misjudged the need for information to the entire medical system, including units not directly affected by the accident. The central medical management should ensure that all medical institutiones receive early information on what is happening. Medical facilities not affected by the accident itself also need early information.
• For several reasons, it was an advantage not distributing the patients between more than two hospitals. Personnel and police resources were saved. In addition, survivors and close relatives derived community experience and security from being together.

Information

• Many telephone lines were needed to meet the big demand for information to anxious relatives and the media. Disaster plans should include rapid connection and manning of large numbers of telephone lines, to make rapid provisions for the information needs of relatives and the media. These phone numbers should be announced as early as possible, e.g. on local radio and on television.
• Much was gained as result of one, specially chosen person taking charge of all the practical details connected with media contacts and press conferences.

Psychosocial care

• The co-ordination of psychological supportive activities between medical services, rescue services, social services, the Church and non-government organisations should be planned thoroughly, especially in metropolitan regions. A special secretariat, common to medical services, the Church and other organisations, should be set up, complete with secretarial staff, computer support, telephones and telephone answering machines, on premises prepared to continuing psychosocial supportive activity.
• It is essential for activities to get started quickly and for the groups of the population affected by and accident to be promptly identified.
• Close relatives should have the opportunity of day-and-night telephone contact with supportive groups for the first week after an accident.
• Adequate reporting of telephone contacts with close relatives is important as a means of facilitating active follow-up. This recording must be conducted in close co-operation with the police command concerned.
• Close relatives of the dead, both identified and missing, are highrisk groups for the future development of psychiatric illness. Ritual acts and collective support are very valuable as a means of initiating an appropriate reaction of grief and alleviating the psychological pain of grief.
• The duration of uncertainty as to what has happened or what is being planned in order to identify and possibly "rescue" the dead should be kept as short as possible. Contradictory information should always be avoided.
• Survivors are a high-risk group for post-traumatic stress syndrome (PTSD), both in the acute phase and with delayed début.

Read the full Summary

Year: 1997
Article number: 1997-0-66
ISBN: 91-7201-221-8
Format: Bok
Pages: 189
Language: Engelska
Price (VAT included): 144 kr

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Susannah Sigurdsson
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