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Explosion at the fireworks warehouse in the Nederlands in 2000 – KAMEDO-report 82

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

The alarm call came into the fire and rescue service in Enschede, the Netherlands, on Saturday, 13 May 2000 at 15.25. A fire had broken out in a fireworks warehouse in a former textile factory. A series of explosions occurred during the effort to put out the fire and the four fire fighters closest to the site of the explosion as well as one reporter died.
A total of 947 people injured in the explosion were treated by the medical care system, of whom about 600 were treated at Enschede Hospital. Twenty-one people died, of whom three are still missing.
The hospital’s emergency notification chain broke down because the mobile and landline telephone networks were overloaded. The consequences were not as devastating as might have been expected: many medical professionals reported to the hospital spontaneously within 10-15 minutes. The explosion and smoke had served as an alarm.
Hospital staff organized an assembly site outdoors near the scene of the accident where the initial triage was done. There was, however, a large ammonia tank as well as released asbestos within the accident area, both of which were serious hazards.
The first and most seriously injured patients arrived in the trauma rooms in the emergency department in Enschede after only 10 minutes. The most common injuries from the explosion were injuries caused by flying objects.
Enschede Hospital can most closely be compared to a Swedish regional hospital. The primary catchment area serves about 200,000 people and the hospital is a trauma center for a population of about 700,000. There are ten trauma centers in the Netherlands, where the total population is slightly less than 15 million. Sections of the emergency department at Enschede Hospital were undergoing construction at the time. There was good access to experienced personnel with comprehensive medical skills at all levels at the time of the accident. For instance, one of the surgeons involved in writing the hospital’s disaster plan was on call at the hospital that particular Saturday.
In accordance with the disaster plan, patient charts were on hand for 100 injured, but they were far from enough for the heavy influx of patients. Consequently, no charts were made for some patients and as a result some were examined repeatedly by doctors and nurses. Another problem was that the hospital ran out of tetanus vaccine early on. The heavy influx of patients and the many serious injuries led to certain departures from the disaster plan.
Ambulances and trauma teams were sent to the scene from other areas in the Netherlands. Eight helicopters carrying trauma teams were sent from Germany and dog handlers with specially trained dogs came in from Belgium to search for people trapped under collapsed buildings.
Keeping the public informed was awarded high priority. Several press conferences led by the mayor were held within the first 24 hours, which were very effective. The local authority set up a counseling agency during the first week after the explosion where residents were given assistance with every imaginable problem, from insurance matters and financial, medical, or psychological concerns to inquiries about lost pets. The city of Enschede expected to keep the agency open for five years. The local authority also regularly printed and distributed a large number of circulars with information about the accident and where people could go for help. A web site was set up and continually updated.
The fire and rescue service’s command function did not work satisfactorily, which may in part have been due to four fire fighters having died early in the course of the disaster. After the immediate emergency response, command efforts were impeded by lack of clarity between the local authority and the overall disaster organization with respect to allocation of tasks and responsibility.
In connection with a 1992 plane crash in the Netherlands, (Swedish Na-tional Board of Health and Welfare Report 1994:16/KAMEDO 64), it was unclear whether toxic substances had been released. Many of the people involved in the accident believed they had suffered symptoms from those substances. It is likely that the symptoms at that time were mainly psycho-logical reactions, but that cannot be confirmed because no samples were taken from the air or soil at the scene.
In order to prevent psychological problems in connection with the acci-dent in Enschede, samples were taken from the air and soil. All survivors were also invited to answer a survey and to submit blood and urine samples. The results of the blood and urine tests were normal. The survey was re-peated after 18 months and for purposes of comparison was expanded to control groups not affected by the disaster. That survey gave evidence of lingering psychosocial problems. Another follow-up was planned for 18 months later.
Two weeks before the accident, a television team had filmed a report in the area where the explosion later occurred on the social aspects of housing. After the accident, the team returned to the area and filmed all buildings and foundations so that victims could orient themselves. Psychological assistance was offered in conjunction with the broadcast of the video and all victims were given a copy of the film.
The Dutch government appointed several commissions to investigate liability issues and management of the disaster. Their final report identified shortcomings on the part of state and local authorities as well as the company that owned the warehouse.
Conclusions of the observers
Many fortuitous circumstances helped ameliorate the consequences of the accident:
• The accident happened in the daytime and the weather was fine, which meant that many people were outdoors. As a result, they were spared in-jury or death caused by collapsed buildings. When there is risk of explo-sion, authorities should consider whether to advise people not to remain indoors.
• The professionals on duty at the hospital were highly experienced.
• The head of the general disaster organization (GHOR) was about to be replaced but the management change had not been implemented when the disaster occurred.
• It was relatively easy to locate new housing for those whose homes had been destroyed.
Command – organization
• The fire and rescue service’s command function did not work satisfacto-rily. This was partially a result of the deaths of four fire fighters early in the accident phase.
• There was a lack of clarity between the local authority and the general disaster organization (GHOR) with respect to allocation of tasks and re-sponsibility.
Communication
Upon several occasions, communications have proven to be a weak link when major disasters and accidents occur. This was once again the case in the fireworks disaster in Enschede:
• The landline and mobile telephone networks were overloaded and be-came unusable. Communication at the scene was also a problem that was not overcome.
• The emergency notification chain did not work as planned because the telephone network was overloaded. The explosion itself acted as an alarm signal for those concerned.
• Communications within the hospital were difficult to manage because the telephone network was knocked out and because many people di-rected their inquiries to the hospital.
Medical care
• he disaster plan’s patient flow was effective, but the work was inefficient because the registration procedure was inadequate to manage the heavy influx of patients.
• The triage process in the emergency department did not work satisfactorily. Those in charge of triage left the emergency department on several occasions to go to the surgical wards.
• Personnel were forced to depart from certain aspects of the disaster plan and improvise due to the large influx of patients and the large number of serious injuries.
• Coordination between the local authority and the medical care system was important and was effective
Information
• Official information was distributed rapidly in several languages and helped counteract the spread of rumors.
• Keeping the public informed was awarded high priority during and after the explosion. An information agency was set up early on, aimed at mi-nimizing the spread of rumors.
• Several press conferences led by the mayor were held during the emer-gency disaster management phase, which was very effective.
• Victims were informed repeatedly and in various languages both during and after the immediate disaster phase.
• A local radio and television station acted as the primary channel of in-formation, including to other media.
Psychosocial care
• The social and medical organizations in Enschede established close co-operation from an early stage. Plans were made for interagency coopera-tion to continue for at least five years.
• The psychological aspects of the disaster were prioritized, e.g., through the health examinations that were carried out and through the video that was produced.
• It is important that plans are in place for a smooth transition from a short-term, massive, and primarily medical response to a long-term, primarily local, social and psychological response.
Liability
The Dutch investigations into how the fire and explosions could have occurred, as well as how the situation was managed, were described in the Dutch final report (see Allocation of liability from the Dutch perspective in the last section of this report). The report identified shortcomings within state and local agencies, on the part of the business owners involved, and within the disaster organization.
The report also shows that the disaster could have been prevented or at least limited in scope if the authorities and company management had complied with all rules and ordinances. In particular, the reported noted that:
• Communication within and among government agencies was inadequate.
• Those involved had failed to learn from earlier disasters and accidents.
• The fragmentation of responsibility and knowledge within regulatory authorities impeded overall evaluation of, e.g., the risks inherent in storing fireworks.
• Regulatory authorities must react more vigorously to violations of existing laws and ordinances than is now the case.
• As companies in the fireworks business were consulted by the authorites with respect to certain issues, the roles of regulator/regulated were mixed in an unfortunate manner.
• The classification of fireworks was unreliable.

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Contact

Susannah Sigurdsson
+46 (0)75 247 30 00