There remains a challenge to improve worldwide, the medical response, and the ground safety response to the disaster of an aircraft crash. Statistically more survive all crashes than perish, and if an aircraft crashes with survivors, in most cases there will be more survivors than dead.

The challenge of survival is to ensure that if an aircraft does crash, the medical and rescue response to this disaster must be immediate, competent, technically skilled and adequately equipped to save the maximum number of lives possible, and to help preserve the quality of life for all who survive. Improving safety standards has been stimulated by the excellent work of the Flight Safety Foundation, the International Civil Aviation Organization (ICAO), the United States Air Line Pilots Association — in particular by Captain John Stefanski and by the World Association for Emergency and Disaster Medicine.

Many will recall that at the meeting of the Club of Mainz Association held in Monaco in 1979, a committee was appointed to investigate aircraft crash management at 100 international airports. The task of the Airport Disaster Workshop was to develop a model of emergency care for large and smaller airports, in order to produce a standard for the various groups of airports. The Club of Mainz Association has been concerned with the poor standard of medical response that has been shown at recent flight disasters. As a member of this consultant committee, it was obvious even from very early days of my research that the medical response to aircraft crash in some countries with high air traffic flows is incompetent, inadequate, and demonstrates little awareness of advances in resuscitation and on-site care of aircraft crash survivors.

Endeavors to expand the flight safety programs into the ground safety response to an aircraft disaster have over the last decade involved many flight safety foundations, aviation organizations, pilot associations, and emergency medical societies. Much work has been done to upgrade airport emergency planning and many data from reports concerning airport disaster drills and crashes have been collected.

The goals of an airport disaster plan include the care, treatment and transportation of the wounded with a quality and quantity of care that minimizes the mortality and morbidity of the survivors of the crash. This simple but ambitious challenge is only accomplished by proper pre-planning and management which depends on the quality of the overall plan, the communication systems, the initial life support and resuscitation, the medical equipment, the patient handling and transportation, and the hospital system. According to a variety of reports from many parts of the world, this concept has, however, been difficult to teach, mainly because of insufficient co-ordination in planning, as well as at the scene of the accident.

At Copenhagen Airport — one of the major airports in the northern part of Europe — it was recently decided to have an airport disaster drill. But instead of a “push-button” test it was decided that an executive committee with members from the police, fire brigade, local airport authorities, flight safety council, pilots association, and the medical field should begin the drill by analyzing the topics which are known and expected to be at risk in the overall efficiency.

The speedy development of disaster medicine has made intensive care on accident sites possible for everyday use. This prehospital care Has proved to be an indispensable, life-preserving work. It does, however, require having qualified medical and technical help brought to the site of disasters in reasonable time, and the ability to bring patients back in properly equipped units, supervised by paramedic staff, to ready and well run hospitals which are able to carry on the treatment and secure the results already obtained.

Rescue work associated with air crashes must be of high interest to all nations, as air traffic is global and a European traveller may easily get into trouble in a wilderness in another part of the world. Through the International Civil Aviation Organization (ICAO) membership, nations are bound by means of international regulations, to contribute to security in the air and supervision of planes in their own area, and to co-operate with the FIR-system in adjoining areas. This system contributes to a better chance of detection of an aeroplane in difficulties, but the rescue problem will have to be solved by the existing and available national military and civil rescue service, its organization, material, education, medical preparedness and disaster plans.

Statistics reveals that about 50% of all crashes take place in landing procedures, some of them occurring just outside the airport. To these must be added collisions en route and cases of sabotage. Most crashes at take-off happen so near the airport that there will be no problems of detection, and help in fire-fighting will be available from the airport, if necessary.

If the best intervention is to be achieved at any incident, be it an aircraft disaster or not, there must be the utmost co-operation between all the intervention services attending or connected with the disaster. Such co-operation cannot be guaranteed to happen overnight or on the day of the disaster, but must be the result of lengthy pre-planning. It is necessary for all involved organizations to decide their area of responsibility on the occasion of a disaster, and contingency plans must clearly set out such responsibilities in order to avoid confusion and duplication of effort on the day of the event. Chaos will surely result if the various responsible officers of each organization do not personally meet during the planning stages, if only so as to be able to readily identify those in charge of each service at an incident. More importantly, each leader can learn of the mannerisms, shortcomings and attributes of his colleagues in other services and thus, when the incident occurs, be in a position to readily appreciate what is likely to be the approach of his fellow officers and services.

In serious emergency situations such as the aircraft crash, the medical staff can also be in danger. The risk for the medical and paramedical staff has two sources: (a) factors related to the cause of the accident; and (b) dangers occurring during rescue operations. It is necessary that the emergency staff look to their own security, and avoid exposing themselves to the risks associated with the panicking movements of frightened people (herd effect). The first aid station should be established in a position down-wind, to avoid the toxic smoke from fire. An essential condition is that the medical emergency staff is composed of people physically and psychologically suitable to the sudden effort and the acute stress.

To reduce the risks associated with rescue operations training is essential, conducted under the supervision of experts from the Fire Brigade. A minimum program of training must be arranged between the physician in charge and the airport authorities, so as to reconcile the activities of the two parties and achieve co-ordination. The medical and paramedical staff must be trained to operate with a gas-mask or oxygen auto-respirator, necessary to prevent intoxication with compounds such as tri-o-cresyl phosphate, fire extinguisher compounds such as dibromodil-fluoromethane and bromocloromethane. Metabolites of air contaminants found in airport disasters are not well known. We summarize in the table some toxicologic data of interest.

Major disasters require extensive activity by the fire-fighting, technical and emergency services. Simultaneously, victims have to be rescued, fires have to be fought and other technical aspects of assistance have to be employed. Ill and injured patients have to be removed from danger, prepared for transport, and taken by ambulance, under the care of skilled personnel, to hospitals. The responsibility for these actions lies in West Germany in the hands of the Fire Brigades.

The Alert. Emergency calls arriving at Fire Brigade communication centers or emergency service control centers are often inaccurate. It is necessary for professional emergency personnel to give detailed information from the incident site. This should include the nature and gravity of the damage, the number of injured and their severity, and the best possible access.

Exploration of the Site. In major medical incidents it is highly important to gain a full overview of the scale of the danger and damage. Often incident sites with a great number of injured are difficult to reach and to survey.

Searching for the Injured. It is a matter of high priority to search all over the site for injured persons and those suffering from shock. In large areas, which are difficult to survey, this must still remain a priority. Additional personnel may have to be called in.

Experiences from accidents show that the majority of critical injuries die within the first 1-4 h if they do not receive some appropriate medical treatment. The problems of an accident with many casualties is dealt with by: (a) maximum utilization of resources; and (b) sorting the tasks.

By rapid and skillful evaluation, we may sort out the critical injuries and give priority for treatment and transport. Through experience we have learned the few and very simple principles of dealing with critical injuries: (a) rapid and sufficient first-aid at the scene, (b) rapid evacuation to a hospital, (c) efficient final treatment, and (d) the need for an effective system of communication between the scene, the ambulances and the hospital.

The principle objective of medical first-aid on the scene of an accident is to stabilize the patient and to make him fit for transportation. Only thereafter is the most necessary temporary treatment carried out. The resuscitation must be continued during transportation. Qualified personnel with equipment must accompany critical injuries. During the last decades there has been a considerable development in the first-aid on the site. Each wounded individual must get the maximum benefit. This requires a high degree of field administration and co-ordination of medical activity on site. This may differ from country to country, but in general the principles will be the same.

Coping with an airport disaster is difficult. It is enough to have once been the witness of such an event to understand the enormity of the problem. Instantaneously, the routine atmosphere becomes a nightmare. There are smoke, flames, vehicles, useful people and useless people and above all, the dead, the injured, and the uninjured survivors, some of whom are running about.

An airport disaster plan should be carefully set up and applied as strictly as possible. Many features exist in our favor: (a) we know the place; (b) we can roughly evaluate in advance the magnitude of the problem as far as the number of victims is concerned, thanks to the International Civil Aviation Organization (ICAO) studies; (c) we can keep in mind the classification of the injured and the medical policy with which now all seem to agree, that is to give on-site immediate care and control evacuation; and (d) we can utilize the medical resources of the surrounding community in a co-ordinated way. This paper summarizes the basic principles for disaster control.

In disasters, the success of medical action in the hospital will only be measured according to the number of survivors and not to the number of major operations executed. Thus, for the clinician his usual standards may have to be modified and he must keep in mind the principle of helping the largest possible number of patients in the given circumstances.

According to previous experience it can be expected that 20% of the survivors in a disaster need surgical treatment. Even in well organized and fully equipped surgical clinics, the proportion of immediate treatment capacity to the total number of beds is no more than 5% to 8% under normal conditions. This means that every hospital should make plans to organize facilities to cope with a major disaster. The individual hospital plans should be co-ordinated with other hospitals in the neighborhood and be integrated into the disaster plans for the entire area. Communication between hospital and the central headquarters is of the utmost importance.

Air traffic into Malta is heavy for such a small island', especially during the busy summer tourist season. Almost every type of aircraft flies in, including jumbos with up to 450 passengers. Since the airport has been the sole responsibility of the Maltese authorities, there have been two minor incidents; one in which a small private plane made a crash landing, resulting in minor injuries; and another when a commercial aircraft engine caught fire on take-off. Both incidents were efficiently dealt with. The island is only 10 km in width at the widest point and Luqa airport is 3-4 km distant from each coast. The flight path along the main runway passes over the Grand Harbor on the east and over high cliffs on the west. At landing speeds, this is approximately 1 minute of flying time, so there is considerable likelihood that a disaster could be at sea.

All those persons involved in the aircraft industry whom we consulted have indicated that, forewarned of an aircraft fault, they would always prefer to come down on land, rather than in the sea. An emergency landing at sea compounds the difficulties in rescuing the passengers and salvaging the aircraft, which would be almost impossible. Luqa airport has emergency equipment immediately available, and has procedures selected according to the likely extent of the disaster. These are normally designated as “Priorities” numbered 1-3, following the practices of the International Civil Aviation Organization (ICAO). In addition to procedures for a crash on land, preparations are in hand for rescue at sea.

The Search and Rescue Co-ordination Center Goch called me, some years ago, to the Stuttgart airport with the rescue helicopter of the Federal Armed Forces Rescue Center at Ulm. A single-engine sports plane, whose pilot was a student on his first solo flight, had tried a belly landing. Next to the runway, there were several fire-trucks, two ambulances and one emergency physician's car waiting. Our rescue helicopter stayed hovering for nearly one hour until the student pilot finally managed a belly landing. Safe on the ground, he was surrounded by firemen, paramedics and physicians, while we flew back to Ulm. We had not landed promptly I was told because of the landing taxes an army helicopter has to pay at a civilian airport! This episode prompted me to look for more information.

The Federal Republic of Germany is obliged by international agreements to search for planes in distress—no matter what nationality—to save the passengers and, if possible, the equipment and to provide medical treatment for the survivors if necessary. This Search and Rescue (SAR) Service is executed according to the instructions given by the International Civil Aeronautical Organization (ICAO). In the Federal Republic, the SAR service is provided jointly by the Ministry of Defense and the Ministry of Transport. The Ministry of defense provides the means and the Rescue Co-ordination Center. The Ministry of Transport provides the alarm services through the air traffic control offices.

In aircraft and airport disasters help must reach the site of the accident in a very short time. In addition to the ground rescue service, rescue helicopters can also offer help. The rescue helicopter as a mobile intensive care unit contains a medical crew with a flying physician and a paramedic. The following are required basic equipment for rescue helicopters: resuscitation apparatus with and without oxygen; endotracheal intubation set; suction unit; apparatus for measuring blood pressure; infusion sets and solutions with intravenous cannulas; syringes and needles; bandages; special burn dressings; fixation and splinting material; vacuum mattress; surgical pocket kit; stomach tube; ECG monitor; defibrillator with pacemaker; drugs; and otoscope. This medical equipment has to be portable so that it can be used outside the rescue helicopter.

The medical crew must be trained in emergency medical treatment and in aeromedical problems. Patients who are fit to fly can be transported by rescue helicopters after triage and support of their vital functions. This method is of most value if rapid transport to a distant specialized medical department, for example, to a burn or neurosurgery center, is required.

The German Air Rescue operates seven rescue helicopters at five rescue helicopter centers for primary rescue with the helicopter types BO 105 CBS, BO 105, Bell 206 Long Ranger and 3et Ranger. Another important function of the service are long distance flights with patients to medical centers after aircraft and airport disasters. Specially equipped ambulance aircraft are used in these cases.

One of the most important aspects of disaster planning is providing for early availability of medical equipment, partly stored at the airport and partly brought from outside. The first priority is obviously to evaluate what is required.

Correct Medical Strategy. This is based on the concept that the first priority is to care for the injured whose life is in immediate danger. The activity on site will include: triage, simple at the beginning, based on first aid concepts, but more sophisticated as more experienced personnel become available; on site care, ranging from first aid to resuscitation; and a rational dispatching of patients to hospitals, using resuscitation ambulances, specially equipped helicopters, or standard ambulances.

Classification of Victims. Priority I or red tag. Priority II or yellow tag. Priority III or green tag. Priority IV or black tag (dead).

Some two years ago the Club of Mainz Executive Committee endorsed a proposal to investigate the rescue and medical facilities at a selection of the world's airports. A number of members of the Club agreed to take part in a survey of a sample of airports in their own regions and some of these reports will be presented in this article. Three airports were studied in the United Kingdom — London Heathrow and Stansted — both civilian airports, and one military airport, Brize Norton, in Oxfordshire.

London Heathrow is one of the biggest international airports in the world, handling more airlines than any other. More than 25 million passengers a year pass through Heathrow and at peak periods there are up to 78 aircraft arrivals and departures per hour. More than 60,000 people are employed at Heathrow. A wide variety of planes are handled from Concorde and wide-bodied jets to small executive aircraft.

Stansted Airport is situated some 30 miles north of London and is also a standby airport for both Heathrow and London's second airport, Gatwick. At present only 500,000 passengers use the airport each year, but it has a capacity for four times this number and there are facilities for further expansion. Stansted is also the fourth biggest air cargo handler in Britain and caters to a complete range of aircraft.

The Disaster Planning for Stansted Airport, which' it is proposed will become London's third airport, with expansion to handle up to 50 million passengers per annum by the end of the decade, poses a unique problem because, unlike most other major airports, it is relatively isolated and some distance from the medical facilities required to handle a major disaster. The airport is situated about halfway between London and Cambridge, each 30 miles away, in the heart of the countryside in North Western Essex, close to its border with Hertfordshire.

In the past, the number of survivors from aircraft accidents involving narrow-bodied jets has been very small but, with the advent of the wide-bodied jets such as the Boeing 7k7, this has changed and survival rates in excess of 50% have been found. This gives a potential of more than 250 survivors from an aircraft with 500 seats, many of whom might be expected to have major injuries.

The nearest hospital is k miles away which, in the event of a major disaster, could take up to 6 seriously injured and 12 walking wounded within the first 4 h. Twelve miles away is another hospital which could take the same number, and 20 miles away is a further hospital which could handle up to 8 seriously injured and 20 walking wounded. The nearest hospitals with major accident departments are in North East London and Cambridge, each of which could take up to 10 seriously injured and 50 walking wounded initially.

Up to 1980, the important European airports and European airlines increased the number of their flights and passengers. As a result, it has been necessary to develop and launch airplanes with a high passenger capacity (e.g., Boeing 747, Jumbo, with 270 seats; Douglas DC 10 with 265 seats; and the Airbus A 300 with 249 seats). Simultaneously, the airports had to be enlarged or even rebuilt. After this substantial investment, the number of passengers began to decrease. In 1981, the French airline “Air France” expected a deficit of about 65 million DM (29.5 million US dollars), excluding the deficit by Concord. For the first time in 18 years, the Scandinavian airline “SAS” in 1980 had a deficit. The German airline “Lufthansa” expects no profits in 1981. This situation has been caused by rising oil prices, decreasing numbers of passengers, and a general recession. Many airlines have been reducing prices to attract more passengers. In spite of the high investments in new airplanes and modernizing airports, there has been little improvement in the necessary air- and ground-control-systems.

In April 1981, the International Associates of Pilots (IFALPA) graded the security of air- and ground-control-systems of German airports as follows: deficient — Frankfurt and Bremen; seriously deficient — Hamburg, Stuttgart and Saarbrücken. According to the security scale of the IFALPA, the most important airports in the Mediterranean area were surveyed and estimated in 1977/78 as follows: deficient — Los Rodeos (Canary Islands), Las Palmas (Canary Islands), Lisbon, Faro, Malaga, Alicante, Madrid, Gerona, Ibiza, Palma de Mallorca, Venice and Roma; and critically deficient — Alghero, Rimini, Naples.

During peak hours at Frankfurt Airport, approximately 10,000 employees of 300 different firms, organizations and services simultaneously handle more than 10,000 passengers and accompanying people. Most of them are not familiar with the airport facilities and speak several different languages.

Disaster management is the act of solving an organization problem under pressure of time. The leading role during the immediate action concerning major accidents or disasters is played by the Safety and Security Control Center of the airport operator, which alerts and controls all emergency services of the airport. Included in this organization are the fire-fighting, rescue and medical services of the airport operator, the U.S. Rhein Main Air Base and the emergency services of the City of Frankfurt. The immediate actions are exclusively based on the operation of professional task forces (without volunteer helpers). As far as possible, the emergency procedures, including personnel operations, are the same at all hours (working/holidays, day/night).

The basis for the emergency operation is the “Emergency Orders” manual. The manual consists of an alarm plan in the form of alarm checklists for the different emergency services and of emergency procedures which are activated through the alarm plan.

Command and control through the staff and communication system of the Safety and Security Operation Center, the on-scene Mobil Command Post and the operation centers of the airport services guarantee that the immediate response of the airport's and external task forces is fully coordinated without delay.