Crisis case studies of cascading and/or cross- border

Transcription

D3.1: Crisis case studies of cascading and/or cross-border disasters
Project acronym:
FORTRESS
Project title:
Foresight Tools for Responding to cascading effects in a
crisis
Call identifier:
FP7-SEC-2013-1
Contract type:
Capability Project
Start date of project:
01 April 2014
Duration:
36 months
Website:
www.fortress-project.eu
This project has received funding from the European Union’s Seventh Framework
Programme for research, technological development and demonstration under grant
agreement no 607579.
Deliverable D3.1:
Crisis case studies of cascading and/or crossborder disasters
Author(s):
Dissemination level:
Kim Hagen, Hayley Watson, Kush Wadhwa (TRI),
Meropi Tzanetakis, Reinhard Kreissl (IRKS), Gianluca
Pescaroli, David Alexander (UCL), Tom Ritchey
(RCAB)
Public
Deliverable type:
Draft
Version:
1
Submission date:
31 October 2014
D3.1 Crisis case studies of cascading and/or cross-border disasters
Change records
Issue
0.1
Date
19.09.2014
Description
30.09.2014
Chapters revised
0.3
28.10.2014
Partners’ review
0.4
30.10.14
Revisions
Chapter
Kim Hagen, Hayley Watson (TRI),
Yves Dien (EDF)
Internal review
0.2
Author (Company)
Meropi Tzanetakis, Reinhard Kreissl
(IRKS), David Alexander, Gianluca
Pescaroli (UCL), Hayley Watson, Kim
Hagen (TRI)
Massimo Migliorini (SiTi), Meropi
Tzanetakis (IRKS), Robert Pelzer,
(TUB), Gerke Spaling, Rob Peters
(VRK)
Kim Hagen (TRI), Meropi Tzanetakis,
Reinhard Kreissl (IRKS), Gianluca
Pescaroli, David Alexander (UCL)
Main authors responsible
Contributors
Chapter 1
Kim Hagen (TRI)
Hayley Watson, Kush Wadhwa (TRI)
Chapter 2
Kim Hagen (TRI)
Hayley Watson, Kush Wadhwa (TRI), Tom Ritchey
(RCAB)
Chapter 3
Kim Hagen (TRI)
Hayley Watson, Kush Wadhwa (TRI), Tom Ritchey
(RCAB)
Chapter 4
Hayley Watson (TRI)
Kim Hagen, Kush Wadhwa (TRI), Tom Ritchey
(RCAB)
Chapter 5
Meropi Tzanetakis (IRKS)
Reinhard Kreissl (IRKS), Tom Ritchey (RCAB)
Chapter 6
Chapter 7
Chapter 8
Gianluca Pescaroli, David Alexander (UCL)
Tom Ritchey (RCAB)
Chapter 9
Tom Ritchey (RCAB)
Chapter 10
Tom Ritchey (RCAB)
Chapter 11
Kim Hagen (TRI)
Hayley Watson, Kush Wadhwa (TRI)
2
TABLE OF CONTENTS
Executive summary.................................................................................................................... 7
List of acronyms ...................................................................................................................... 10
1
2
Introduction ...................................................................................................................... 13
1.1
Methodology ............................................................................................................ 13
1.2
Report outline .......................................................................................................... 18
Enschede fireworks factory disaster ................................................................................ 19
2.1
The event in more detail ......................................................................................... 20
2.2
Cascading effects and their triggers ...................................................................... 22
2.2.1
Box A: Malfunctioning of a pre-crisis legal and regulatory relation .......... 27
2.2.2
Box B: Malfunctioning of organisational relation ........................................ 27
2.2.3
Box C: Flaws in a supply relation ................................................................... 27
2.2.4
Box D: Disruption of an information relation ............................................... 28
2.2.5
Box E: Disruption of an organisation relation .............................................. 28
2.2.6
Box F: Disruption of an information relation ............................................... 28
2.2.7
Box G: Disruption of an information relation ............................................... 28
2.2.8
Box H: Disruption of an organisation relation .............................................. 28
2.2.9
Box I: Disruption of an information relation ................................................ 29
2.2.10 Box J: Malfunctioning of a supply relation ................................................... 29
2.3
2.3.1
What went wrong? ........................................................................................... 29
2.3.2
What went well? ............................................................................................... 30
2.4
3
Lessons learned........................................................................................................ 29
Conclusion ................................................................................................................ 30
2011 Japan earthquake, tsunami and fukushima disaster ................................................ 32
3.1
3.2
3.2.1
Box A: Malfunctioning of a pre-crisis legal and regulatory relation .......... 41
3.2.2
Box B: Malfunctioning of a pre-crisis legal and regulatory relation .......... 41
3.2.3
Box C: Pre-disaster condition ......................................................................... 41
3.2.4
Box D: Malfunctioning of a pre-existing backup supply relation ............... 41
3.2.5
Box E: Disruption of an organisation relation .............................................. 42
3.2.6
Box F: Disturbance relation ............................................................................ 42
3.2.7
Box G: Disruption of an organisation relation .............................................. 42
3.3
Lessons learned........................................................................................................ 42
3.3.1
What went wrong? ........................................................................................... 42
3.3.2
What went well? ............................................................................................... 43
3
3.4
4
Conclusion ................................................................................................................ 43
2005 London attacks ........................................................................................................ 45
4.1
4.2
4.2.1 Box A: Malfunctioning of information relation, the presence of a
disturbance (physical), and the disruption of an organisational relation ................. 56
4.2.2
Box B: Malfunction of a supply relation ........................................................ 57
4.2.3
Box C: Disturbance relation ........................................................................... 57
4.2.4
Box D: Disruption of an organisational relation ........................................... 57
4.2.5
Box E: Disruption of an information relation ............................................... 57
4.2.6
Box F: Disruption of an information relation ............................................... 58
4.2.7
Box G: Disruption of an organisation relation .............................................. 59
4.2.8
Box H: Disruption of an information relation ............................................... 59
4.3
4.3.1
What went wrong? ........................................................................................... 60
4.3.2
What went well? ............................................................................................... 60
4.4
5
Conclusion ................................................................................................................ 61
The Avalanche Disaster of Galtür.................................................................................... 62
5.1
5.2
Triggers of cascading effects .................................................................................. 66
5.2.1
Box A: Political relational condition .............................................................. 70
5.2.2
Box B: Physical disturbance relation ............................................................. 70
5.2.3
Box C: Disruption of information relation .................................................... 70
5.2.4
Box D: Physical disturbance relation ............................................................. 71
5.2.5
Box E: Disruption of supply relation (delivery) ............................................ 71
5.3
Lessons learned........................................................................................................ 71
5.3.1
What went wrong? ........................................................................................... 72
5.3.2
What went well? ............................................................................................... 72
5.4
6
Lessons learned........................................................................................................ 60
Conclusion ................................................................................................................ 72
The HeatWave of 2003 .................................................................................................... 73
6.1
6.2
6.2.1
Box A: Cultural relational condition ............................................................. 81
6.2.2
Box B: Disruption of an information relation ............................................... 81
6.2.3
Box C: Disruption of an organisational relation ........................................... 81
6.2.4
Box D: Disruption of a supply relation of physical media ........................... 82
6.2.5
Box E: Physical disturbance relation ............................................................. 82
4
6.3
6.3.1
What went wrong? ........................................................................................... 83
6.3.2
What went well? ............................................................................................... 83
6.4
7
Conclusion ................................................................................................................ 84
Malaysia Airlines MH17 plane crash .............................................................................. 85
7.1
7.2
7.2.1
Box A: Political relational condition .............................................................. 97
7.2.2
Box B: Economic relational condition ........................................................... 97
7.2.3
Box C: Disruption of an information relation ............................................... 97
7.2.4
Box D: Disruption of an organisational relation ........................................... 98
7.2.5
Box E: Disruption of a service supply relation .............................................. 98
7.3
Lessons learned........................................................................................................ 99
7.3.1
What went wrong? ........................................................................................... 99
7.3.2
What went well? ............................................................................................... 99
7.4
8
Lessons learned........................................................................................................ 83
Conclusion .............................................................................................................. 100
Floods of 2002 in The Prague Area, Czech Republic .................................................... 101
8.1
The event in more detail ....................................................................................... 101
8.2
Cascading effects and their triggers .................................................................... 105
8.2.1
Box A: Pre-Crisis Political Relational Condition ........................................ 111
8.2.2
Box B: Pre-crisis Cultural-Relational Condition ........................................ 111
8.2.3
Box C: Disturbance Relation (Geospatial and Physical) ............................ 111
8.2.4
Box D: Pre-Crisis Condition: Failures of Structural Defence ................... 113
8.2.5 Box E: Negligence in pre-Crisis regulatory relation and organisational
relation .......................................................................................................................... 113
8.3
8.3.1
What went wrong? ......................................................................................... 113
8.3.2
What went well? ............................................................................................. 114
8.4
9
Lessons learned...................................................................................................... 113
Conclusion .............................................................................................................. 114
Hurricane Sandy in The United States, 2012 ................................................................. 116
9.1
The event in more detail ....................................................................................... 117
9.2
Cascading effects and their triggers .................................................................... 121
9.2.1
Box A: Pre-Crisis Political-Relational Condition ...................................... 127
9.2.2
Box B: Disturbance Relation (Geospatial and Physical) ............................ 127
9.2.3
Box C: Disruption of a supply Relation (Physical Media) ......................... 127
9.2.4
Box D: Disruption of a supply Relation (Delivery Relation) ..................... 128
9.2.5
Box E: Disturbance Relation (Geo-spatial relation) ................................... 128
5
9.2.6
9.3
Lessons learned...................................................................................................... 129
9.3.1
What Went Wrong? ....................................................................................... 129
9.3.2
What Went Well? ........................................................................................... 129
9.4
10
Box F: Disruption of an information Relation (Telecommunication Relation)
.......................................................................................................................... 128
Conclusion .............................................................................................................. 130
2010 Eyjafjallajökul volcanic eruption and civil aviation crisis .................................... 131
10.1 The event in more detail ....................................................................................... 132
10.2 Cascading effects and their triggers .................................................................... 135
10.2.1 Box A: Pre-Crisis Political Relational Condition ........................................ 139
10.2.2 Box B: Disturbance Relation (Physical) ....................................................... 139
10.2.3 Box C: Disruption of a supply Relation (Delivery and Service) ................ 139
10.2.4 Box D: Disruption of an organisational relation ......................................... 140
10.2.5 Box E: Disruption of an information Relation ............................................ 140
10.3 Lessons learned...................................................................................................... 141
10.3.1 What went wrong? ......................................................................................... 141
10.3.2 What went well? ............................................................................................. 142
10.4 Conclusion .............................................................................................................. 142
11
Conclusion ..................................................................................................................... 144
11.1 Disruptions of relations......................................................................................... 145
11.2 Disturbance relations ............................................................................................ 146
11.3 Pre-disaster conditions.......................................................................................... 147
11.4 Less frequent triggers ........................................................................................... 147
11.5 Lessons learned...................................................................................................... 147
References .............................................................................................................................. 150
6
EXECUTIVE SUMMARY
Cascading effects in crisis situations refer to the sequence of events in a crisis resulting in
physical, social or economic disruptions far beyond the initial impacts of the crisis. The
analysis of cascading effects, and the identifications of their triggers, can contribute to
enhancing the understanding of the complexity of cascading crisis situations, which can in turn
aid in addressing cascading effects. In this report nine historical crisis case studies are analysed
with regards to their cascading effects. The case studies selected were the Enschede fireworks
factory explosion (the Netherlands), the London attacks (UK), the Fukushima nuclear disaster
(Japan), the Galtür avalanche (Austria), the European Heatwave (focus on France), the MH17
plane crash (Ukraine), the Eyafjallajökull volcanic eruption (Iceland, but with a focus on the
UK), Hurricane Sandy (USA), and the Central European floods (focus on Prague).
The chapters in which these case studies are analysed all present and discuss a visual overview,
of the unfolding of the crisis. In these overviews, six columns outline: A) what happened during
the event, B) the time scale of the event, C) what actions in crisis management were carried
out, D) the direct negative effects, E) the sectors (e.g., infrastructure, communication) directly
affected, and F) the sectors indirectly affected. By using different colour lines and arrows, the
overviews also provide an indication of how entries in the different columns relate to one
another (see the example in Figure i below), for instance, how actions in crisis management
affected the unfolding of the disaster. In a seventh column (the green column in Figure i)
triggers of cascading effects were identified and classified by using the following
categorisation:






disruption of information relations;
disruption of supply relations;
disruption of organisational relations;
malfunctioning of legal and regulatory relations;
disturbance relations;
pre-disaster conditions.
Triggers of cascading effects
time (on relevant
timescale)
Unfolding of events in crisis
management (incl category and level of
authority involved)
(unfolding of) physical event over time
(vertical cascasde)
Negative effects (horizontal
cascade)
Sectors directly affected
(horizontal cascade)
since 06.02.1999, 19:30
LWZ: avalanche warnings lavel 4 and 5 &
road blocks of whole Paznaun valley
bad weather: heavy snowfalls and snow
drifts
changes of shifts of holidaymakers
were not possible
Economic sector (local): loss of
revenues in the tourism sector
have to check the exact
date
crisis management groups were installed
in Innsbruck and Landeck
numerous avalanches were reported in
Austria, France and Switzerland
09.02. - 28.2.1999
BMI and BHeer: supply flights to Galtür
with foodstuffs and medicines &
exploratory flights on a regular base
A
Political relational condition:
Galtür being an avalanche-prone
village and having gone through a
transformation towards tourism
inevitably means that roads are
going to be cut off and
infrastructure is damaged if an
avalanche disaster happens.
B Physical disturbance relation: due
to extreme weather conditions
public transport system was
blocked, Galtür was accessible only
by air
Food: Galtür had to be supplied
with foodstuffs by air
Healthcare (hospitals&clinics):
Galtür had to be supplied with
medicines by air
temporary lifting of the road blocks
temporary improvement of the weather
condition
LWZ: blockages of whole public
transport system
weather conditions are worsening
22.02. - 28.02.1999
23 February 1999- 16:05
Police Landeck reported to LWZ that an
avalanche hit the local area of Galtür
an extreme avalanche hit the local area
of Galtür
LWZ: not possible to fly in assistants to
the scene of the accident
bad weather is continuing
10.02. - 17.02.1999
LWZ: avalanche rescue group, avalanche
search dogs, physicians, policeman and
Red Cross helpers waited in Landeck for
their assistance intervention
Galtür is cut off from the outside
world
C
Disruption of information relation:
rescue organisations involved did
not share a uniform telephone line
to communicate among
themselves
Ground transportation: blockages
of whole ground transport system
Air Transportation: all transport
helicopters in Austria were
aggregated
planned surgeries (mediacl) for the
upcoming days were cancelled
Helper teams in Galtür were on their
own, searching for survivors
journalists and relatives called the LWZ
continuously to get information
Sectors indirectly affected
Healthcare: hospitals were on
stand-by and high state of
alertness
Emergency service: Large-scale
operation to Galtür was not
possible
phone lines were temporarely disabled
and blackout in Galtür
landline and mobile phone
networks were threatened to fail
because of overload
different organisations involved in
rescue operation and crisis management
had no uniform telephone line to
communicate
Figure i Example of a visual overview
7
Public communication via
telephone was threatend to fail
The analysis of the nine case studies showed that three overarching categories of triggers were
most common. The first category was concerned with the disruptions of relations that should
have been functioning, including: the disruption of information relations, organisational
relations, and supply relations. Information relations were commonly disrupted by the
congestion of telecommunication networks, which created difficulties and delays in the
communication amongst crisis responders, or between crisis responders and the public.
Disruptions of organisational relations are often related to disruptions of information relations,
but are more than that. Rather, they refer to organising, making decisions, and making different
people or things function in emergency management. Confusion over responsibilities in crisis
management, or decisions taken that later turned out to be erroneous are examples of such
triggers. Disruptions of supply relations refer to the everyday supply of goods or services being
disrupted as part of the crisis. An example of this is the reduced supply of water as a result of
water used for firefighting.
A second category of commonly identified triggers was that of disturbance relations: the
unintended relations of interference that only come into being in a crisis. These are cases in
which the functioning of one system or actor becomes dependent on another system or actor,
whereas that was previously not the case. The Fukushima disaster provides an illustrative
example of disturbance relations as due to the failure of the pumps, seawater could not be used
to cool the reactors and firemen became charged with the task of providing water. The
firefighters’ new responsibility caused further disastrous impacts as they were not able to get
to the nuclear power station in a timely manner due to aftershocks.
A third category is that of pre-disaster conditions concerned with developments and the turn of
events prior to the crisis that lead to cascading effects during the crisis. This can be specific
decisions at a governmental level that cause changes in the behaviour of citizens. The case
study of the 2002 floods in Prague clearly illustrates this as political decisions led to changes
in settlement patterns, increasing citizens’ exposure to floods, and subsequently contributed to
the destruction of homes, goods and commercial properties during the 2002 floods.
The analysis of these triggers of cascading effects, presented several main findings:

Triggers of cascading effects can have their roots both in the turn of events during
crises, as well as in a pre-crisis context. The latter implies that crisis preparedness
cannot be viewed in isolation from the everyday life in a given society, country, or area.

Regulations and sanction in a pre-disaster stage have the potential to reduce cascading
effects in a crisis. However, the effectiveness of such regulations is dependent on how
they are implemented and whether those subject to the regulations comply with them.
Compliance is not only the responsibility of those being regulated, but also of the
regulator.

Pre-crisis conditions, such as economic and political developments, contributing to
cascading effects are more difficult to address by the means of preparedness measures.
Triggers related to pre-crisis conditions are frequently linked to gradual changes over
long periods of time and can rarely be pinned down to one single event or cause.

With regards to triggers that originate during a crisis, having separate communication
systems as well as pre-established plans of approach and clear divisions of
responsibilities could improve the organisational response to crises. This could
8
considerably reduce the cascading effects related to the disruption of information and
organisational relations, as well as those related to disturbance relations.

Cascading effects are not merely related to flaws in interdependent infrastructure
systems, but can be a result of various other factors such as human errors or a lack of
resources. In addition to physical or material solutions, strengthening human resources
plays a considerable role in planning for emergencies with the aim of reducing
cascading effects.
The approach used within this report may be of use to others in extending this type of analysis
of past-events. Such research could subsequently inform measures of preparedness aimed at
reducing the likelihood and/or intensity of cascading effects.
9
LIST OF ACRONYMS
AAIB
Air Accidents Investigation Branch
ACR
Armáda České Republiky (Czech Republican Army)
AMRS
Bergretungsdienst (Austrian Mountain Rescue Services)
AMUF
Association des Médecins Urgentistes de France (Emergency physicians)
ANSV
Agenzia Nazionale per la Sicurezza del Volo (National Agency for the Safety
of Flights)
ATSB
Australian Transport Safety Bureau
BEA
Bureau d'Enquêtes et d'Analyses pour la sécurité de l'aviation civile (Bureau
of Enquiry and Analysis for Civil Aviation Safety)
BFU
Federal Bureau of Aircraft Accident Investigation
BL
Bezirkshauptmannschaft Landeck (District authority Landeck)
BMI
Bundesministerium für Inneres (Federal Ministry of the Interior)
BHeer
Bundesheer (Austrian Armed Forces)
BRS
Bezpečnostní rada státu (National Security Council)
ICAO
Civil Aviation Organization
CHMI
Czech Hydrometeorological Institute
CNB
Ceska Narodni Banka (Czech National Bank)
COBRA
Cabinet Office Briefing Room
CPA
Centrale Post Ambulance Vervoer (Central Post Ambulances)
DCA
Department of Civil Aviation
DGS
Direction générale de la santé (French Directorate-General for Health)
DMKL
Directie Materieel Koninklijke Landmacht (Royal Armed Forces Materials
Directorate)
DSB
Dutch Safety Board
EAPC
Euro-Atlantic Partnership Council
EASA
European Aviation Safety Agency
10
EIA
Energy Information Agency
FATA
Federal Air Transport Agency
FEMA
Federal Emergency Management Agency
FEPC
Federation of Electric Power Companies of Japan
GřHZS
CR
Generální ředitelství Hasičského Záchranného Zboru ČR (General Directorate
of the Fire Rescue Brigades)
HZS CR
Hasičský záchranný sbor České republiky (Fire Rescue Service of the Czech
Republic
IAC
Interstate Aviation Committee
IATA
International Air Transport Association
ICAO
UN International Civil Aviation Organization
IFRCRCS
International Federation of the Red Cross and Red Crescent Societies
IMH
Inspectie Milieuhygiëne (IMH) (Environmental Hygiene Inspection)
INVS
Institut de Veille Sanitaire (French Institute for Public Health Surveillance)
IRS
Integrated Rescue System
LBKE
Lokale Brandweer Korps Enschede (local firefighters Enschede)
LFTO
National Forensic Investigation Team
LWZ
Landeswarnzentrale Tirol (National Warning Centre Tyrol)
ME
Mobiele Eenheid (mobile unit national police)
NAME
Numerical Atmospheric-dispersion Modelling Environment
NATO
North Atlantic Treaty Organisation
NATS
National Air Traffic Service
NBAAI
National Bureau of Air Accidents Investigation of Ukraine
NCTV
National Coordinator for Security and Counterterrorism
NHS
National Health Service
NDoJ
National Diet of Japan
NERH
Nuclear Emergency Response Headquarters
11
NISA
Nuclear and Industrial Safety Agency
NMOC
EUROCONTROL Central Flow Management Unit
NOAA
National Oceanic and Atmospheric Administration
NTSB
National Transportation Safety Board
NTSC
National Transportation Safety Committee
NSC
Nuclear Safety Commission
NWS
National Weather Service
OvD
Officier van Dienst (coordinator firefighters)
PCR
Policie České Republiky (Czech Police)
PE
Politie Enschede (local police Enschede)
PL
Gendarmerie Landeck (Police)
PPS
Public Prosecution Service
RAC
Regionale Alarm Centrale (Regional Control Room)
RMC
Regionaal Meld Centrum Twente (Regional Control Room)
RVI
Rijksverkeersinspectie (National transport inspection)
SE
Smallenbroek Enschede (SE Fireworks)
SPEEDI
System for Prediction of Environment Emergency Dose Information
SMM
OSCE Special Monitoring Mission
TEPCO
Tokyo Electric Power Company
TIRIS
Tiroler Raumordnungs-Informationssystem
UNEP
United Nations Environment Programme
UNESCO
United Nations Educational, Scientific and Cultural Organization
UNOCHA United Nations Office for the Coordination of Humanitarian Affairs
VAAC
Volcanic Ash Advisory Centre
12
1
INTRODUCTION
Investigating and analysing cascading effects in crisis situations is crucial in enhancing our
understanding of why certain hazards create extensive disastrous impacts whereas others do
not. How disastrous events unfold and what factors trigger cascading effects are important
elements to consider in such an analysis, especially when using it as a basis for developing
platforms and tools to respond to cascading effects. This report analyses cascading effects in
nine historical crisis situations that took place between 1999 and 2014 in various countries. By
doing so, the authors aim to create sufficient material to illustrate cascading and/or cross-border
effects in crises. This material serves to inform later work in this and other Work Packages of
the FORTRESS project. As defined in D1.1 (Interdependencies and cascading effects in crisis
situations), cascading effects are understood as the dynamics present in disasters when the
impact of a physical event, or the development of a principal technological or human failure,
generates a sequence of events that result in physical, social or economic disruption (Alexander
et al. 2014). It must be noted that as this report focuses on cascading effects, and therefore
largely on negative aspects in crises enabling cascading effects to occur, it does not present an
adequate picture of all features of each respective crisis.
1.1 METHODOLOGY
The selection of case studies was informed by an analysis of the Emergency Events Database
(EM-DAT)1 crisis data carried out as part of the COSMIC (The COntribution of Social Media
In Crisis management) project.2 As part of the latter project an overview of crises most
commonly occurring in Europe between 2003 and 2013 was developed. This list featured
floods as the most commonly occurring crisis, followed by extreme temperatures, storms, and
transport accidents. Whilst acknowledging the frequency of these events in selecting case
studies, the selection is not an exact representation of the most commonly occurring crises in
Europe. This is because partners working on this report did not want to exclude more recent
and/or non-European case studies that are important with regards to our understanding of
cascading effects. Additionally, partners wanted to account for case studies with a cross-border
component, as this commonly adds to the complexity of cascading effects. After careful
consideration and deliberation the case studies listed in Table 1 were selected.3
Table 1 List of crisis case studies
Crisis and location
Enschede fireworks factory explosion
The Netherlands
London bombings
UK
Fukushima nuclear disaster
Japan
Galtür avalanche
Austria
Heatwave
Europe- focus of analysis: France
MH17 plane crash
Year
2000
2005
2011
1999
2003
2014
1
EM-DAT was created with the initial support of the World Health Organisation and the Belgian Government. It
is maintained by the Centre for Research on the Epidemiology of Disasters since 1988.
2
COSMIC(http://www.cosmic-project.eu/) is a two-year project funded by the European Commission's Seventh
Framework Programme FP7-SEC-2012 under grant agreement no. 312737
3
The case studies are presented in the same order as they are presented in this report.
13
Ukraine
Floods
Central Europe- focus of analysis: Prague, Czech
Republic)
Hurricane Sandy
USA
Eyafjallajökull volcanic eruption
Iceland- focus of analysis: UK
2002
2012
2010
Considering FORTRESS’s focus on cascading effects, the analysis of these case studies was
limited to an investigation of such effects and their triggers. It is acknowledged that this at
times implies that rather complex events are presented in a simplified manner, and that the
time-frame of the analysis does not always account for changes in impacts that took place in
the long-term.
The analysis of the case studies is based on a study of existing academic literature, research
and evaluation reports, event reports and news articles. Each of the crisis situations were
analysed by the means of a visual overview, developed using Microsoft Excel (see the template
presented in Figure 1. Each overview consists of seven columns. One column addresses how
the crisis unfolded- it lists and briefly describes subsequent turns of events. For example, heavy
winds cause trees to fall onto power lines, causing power outages. Related to this is a column
in which steps in crisis management are detailed- it lists what actions were taken, and at times
the absence of steps taken. For example, when did first responders decide to intervene in the
situation, and how did they do so? A column indicating a time-scale aids in interpreting when
the aspects described in these two columns took place. Two other columns list sectors directly
and indirectly affected. Sectors directly affected are considered to be those sectors physically
impacted by the disastrous event itself. For example, the London attacks (see Chapter 4) caused
direct damage to London’s infrastructure network. Indirectly affected sectors are those that are
impacted as the result of something else being affected. An example of the latter is the impact
on the provision of drinking water after the Enschede fireworks factory explosion (see Chapter
2), as large amounts of water had been used during fire-fighting. Direct negative effects that
could not be listed as a ‘sector’ (i.e., casualties) are listed in a separate column. A final column
in the model is of a slightly different nature and therefore has another colour: green. This
column lists the identified triggers of cascading effects. Within each visual overview lines and
arrows of different colours (see Table 2) are used to indicate the relations between the various
elements of the analysis. In each chapter, the triggers of cascading effects listed in the cells in
the green column (Cell A, B, C etc.) are discussed in detail in the sub-sections that follow the
visual overview.
14
time (on relevant
timescale)
management (incl category and level
of authority involved)
(unfolding of) physical event over
time (vertical cascasde)
cascade)
X
xx
X
xx
X
xx
X
xx
Figure 1 Template of visual overview
Table 2 Arrows and lines used in the visual analysis of the case studies
Blue arrow
direct causal relation (e.g., A causes B)
Yellow arrow
of influence on (e.g., X influences how A causes B)
Green line
subsequent steps but not a causal relation
Red line
connects trigger in green column to the cascade it caused
To ensure a consistent approach of identifying triggers or cascading effects throughout this
study, a categorisation of triggers was developed. The varying natures of the case studies at
times resulted in the identification of new triggers, and the creation of categories was therefore
a process of discussions and revisions. Drawing on Becker et al. (2012), Rinaldi (2001), and
Voogd (2004), the final categorisation used to identify and label all case studies’ triggers of
cascading effects is presented in Table 3. Where possible sub-categories are identified - where
applicable these will be referred to in the discussion of cascading effects and their triggers.
Table 3 Categorisation of triggers of cascading effects
Categories of
triggers
Disruption of an
information relation*
Sub-categories
(where
applicable)
Further explanation and/or example
Face-to-face
The disruption of the exchange of information
between two or more people without the use of
technologies.
Telecommunication
The disruption of a relation between two actors
that takes place via technology such as the
internet or phone.
15
Disruption of a
supply relation**
Data involving
machines
The disruption of a relation between two
machines, or a machine and an actor, that
automatically share data.
Physical media
The disruption of a relation concerning the
dependency on the supply of a resource (e.g.,
water, gas, electricity, heating) through a
physical, permanent infrastructure (e.g., a
pipeline, grid, wire).
Delivery
relation
The disruption of a relation concerning the
dependency on the supply of resources though
transportation infrastructure (e.g., road, rail, ship,
air).
Service relation
The disruption of a relation wherein the
functioning of a system element or organisation
depends on a service provided by another
organisation or system element.
Disruption of an
organisational
relation***
Example: due to a lack of overview in the control
room, there are flaws in the coordination of the
first responders.
Malfunctioning of a
legal and regulatory
relation
When regulations are not respected or legal
responsibility are not acted upon. Triggers of
cascading effects that fall in this category largely
concern the malfunctioning of this relation in a
pre-disaster stage.
Geo-spatial
relation
Components are located in close proximity to one
another and therefore damage to one may affect
the other. Example: Water flowing from a
ruptured pipeline damages electrical wiring.
Physical
A mobile system element affects another. Of
particular relevance here is the system ‘weather,’
as adverse meteorological conditions can cause
systems (e.g., infrastructure) to malfunction.
Disturbance
relation****
Other
Political
Political conditions that contributed to the
occurrence of cascading effects. Example: a
government’s choice to increase the use of dams
on the upstream sections of rivers whilst the
downstream is heavily populated. This largely
concerns pre-crisis conditions.
Cultural
Cultural conditions that contributed to the
occurrence of cascading effects. This largely
concerns pre-crisis conditions. Example: an area
16
Conditions
subject to flooding has not experienced floods in
many years. As a result thereof, its citizens
gradually stopped adopting precautionary
behaviours.
Economic
Economic conditions that contributed to the
occurrence of cascading effects. This largely
concerns pre-crisis conditions.
*
refers to a relation in which system elements or actors are dependent on the
communication of information.
refers to a relation in which system elements or actors are dependent on supply
**
activities by other system elements.
*** refers to a relation of organising, making decisions, and making different people or
things work. It is the case when actor X is dependent on decisions made by actor Y
and not only on information.
**** refers to unintended relations of interference that only come into being in a crisis.
Unlike the categories above, where pre-existing relations were disturbed, disturbance
relations did not exist before.
In addition to the visual overview of the identification of triggers of cascading effects, each
chapter presents a simple problem space, developed as part of General Morphological Analysis
(GMA) (see the template presented in Figure 2). The column-headings used in the problems
space were identified and discussed during workshops part of Deliverable 1.3: Morphological
Analysis: Developing a conceptual model of the project problem space (Ritchey 2014).
Case
Types of hazard
Principal nature(s) of Scope of impact
impact
Onset of crisis
Cross border?
Principal involved
actors in CM
Directly affected
sectors
Indirectly affected
sectors
Triggers/ causes for
cascade
Global
Yes
Police
Transportation
GROUND
Transportation
GROUND
Disruption of
Information relation
No
Fire
Transportation AIRWATER
Disruption of supply
relation
Disruption of
organisational
relation
Malfunctioning of
relation
Disturbance relation
Tsunami-Fukushima, Natural
Japan, 2011
Physical
Firework factory
Social
explosion (2000) Netherlands
London attacks (2005) Technological
Social / Psychological National
Rapid (Hours/days)
International
Economic
Regional
Slow (Weeks)
National
Health
Energy production
Energy production
Heat wave 2003
(France)
Political
Local
Creeping
(months/years)
Regional
Local admin.
Municipal govt.
Energy transmission
and distribution
Energy transmission
and distribution
Local
National/central
government
Water provision
Water provision
Avalanche Disaster of
Galtür, AT (1999)
National security
Public communication Public communication Relational condition
(telecom)
Central European
floods (focus on
Prague) (2002)
Insurance companies Waste & biochem
Waste & biochem
Hurricane Sandy, USA
(2012)
Civil protection
authorities
Healthcare
(hospitals&clinics)
Healthcare
(hospitals&clinics)
Eruption of
Eyjafjallajokull in
Iceland (2010)
MACC, CMC, etc.
Emergency services Emergency services
and national security and national security
Civil society
organisation
Economic services
Economic services
Community based
organisations
Government sector
(Decision &
continuity)
Social
sector(Education,
aggregation, icon)
Government sector
(Decision &
continuity)
Social
sector(Education,
aggregation, icon)
Companies/ industry Residential housing
sector
Residential housing
sector
Antagonistic
International & cross Sudden
border
Scope of CM
Malaysia MH17 plane
crash (2014)
Intergovernmental
organisations
Natural environment Natural environment
Figure 2 Template problem space GMA
17
1.2 REPORT OUTLINE
The purpose of this report is to illustrate cascading effects whilst identifying their triggers. In
doing so, the remainder of this report has ten chapters: nine case study chapters followed by
the conclusion in which all case studies are analysed, compared, and concluding observations
are presented. To enhance comparison across case studies, each of the nine case study chapters
follows the same approach and structure. The conclusion analyses and discusses all triggers of
cascading effects listed in the nine case studies and provides recommendations for research
based on the insights gained.
18
2
ENSCHEDE FIREWORKS FACTORY DISASTER
Smallenbroek Enschede (SE) Fireworks was a major importer of fireworks, located in the city
of Enschede in the Netherlands. Situated in the eastern part of the country, Enschede lies six
kilometres from the German border (see Figure 3). Built in 1977, the factory was originally
located outside the city, but as the city expanded it became surrounded by residential housing.
On 13 May 2000, approximately 177,000 kilos of fireworks, of which 40,000 kilos could
potentially create mass explosions, were stored in the factory. This exceeded the maximum
kilos that was permitted to be stored. In addition, the fireworks were of a more explosive nature
than the company’s permit allowed, and not all was stored in adequate facilities (COV 2011,
60). That day, at 15:03, a patrolling police officer reported to the fire department’s regional
control room (regionale alarm centrale (RAC)) that explosions were heard at the factory. This
was followed by a call from local citizens reporting a fire one minute later. Within half an hour
of the fire first being reported, the factory’s containers and central depot exploded, resulting in
the death of 19 people, including four firemen. An additional three bodies were never found
again and have been presumed dead, making the total number of casualties 23. Around 950
people were injured, 205 houses completely destroyed, a further 293 houses were made
uninhabitable, and 1500 houses were damaged. 1250 people lost their homes (COV 2001, 27.
Additionally, almost 50 commercial buildings were heavily or irreversibly damaged (COV
2001, 18).
Enschede
e
Figure 3 Map (left) showing the location of the city of Enschede (source: ANWB), and photos taken during
(top right) and after (bottom right) the disaster (source: ANP).
19
2.1 THE EVENT IN MORE DETAIL
The Enschede fireworks factory disaster can be referred to as an industrial accident. It is
therefore classified as a ‘technological hazard’, opposed to incidents resulting from natural
hazards or being related to crises of a social nature, such as the 2005 London Bombings
discussed as part of this Deliverable. It is a disaster of a rapid-onset nature, and could even be
described as being instantaneous: there was little time for warning and precautionary measures.
Although the most adverse impacts of the disaster were confined to two square kilometres in
the city of Enschede (Voogd 2004), the disaster is not classified as a local or regional crisis.
First responders from across the Netherlands were called to the scene, and means of transport
(e.g., helicopters) from across the country were used. Additionally, German rescuers and
medics were present, emergency helicopters flew in from Germany, several casualties were
treated in a hospital in the German city of Gronau, and several first response units from the
German Osnabrück were on stand-by (Inspectie voor de Gezondheidszorg 2001). Considering
this international response, the disaster is classified as a ‘cross-border’ one. In addition to the
direct negative impacts this crisis had on the citizens living in the area surrounding the
fireworks factory, the crisis impacted on other sectors including the economic, housing,
transport, communication, energy, and the water (both drinking water and waste water) sector
(MINBZK 2000), as illustrated in Figure 5. Many of these sectors were associated with the
predominately residential nature of the affected area. Nearly eight years after the fireworks
factory disaster, the reconstruction of the residential area was completed and the area was
officially re-opened (Eén Vandaag 2008).
Figure 4 (below) provides a simplified representation of the complexity of the event, by
presenting important information in a simple problem space.
20
Case
Types of hazard
impact
Onset of crisis
Cross border?
Principal involved
actors in CM
Directly affected
sectors
Indirectly affected
sectors
cascade
Global
Yes
Police
Transportation
GROUND
Transportation
GROUND
Disruption of
No
Fire
relation
Disruption of
organisational
relation
Malfunctioning of
relation
Japan, 2011
Physical
Firework factory
Social
Rapid (Hours/days)
International
Economic
Regional
Slow (Weeks)
National
Health
Energy production
Energy production
Heat wave 2003
(France)
Political
Local
Creeping
(months/years)
Regional
Local admin.
Municipal govt.
Energy transmission
and distribution
Energy transmission
and distribution
Local
National/central
government
Water provision
Water provision
Galtür, AT (1999)
National security
(telecom)
Central European
floods (focus on
Prague) (2002)
Waste & biochem
(2012)
Civil protection
authorities
Healthcare
(hospitals&clinics)
Healthcare
(hospitals&clinics)
Eruption of
Eyjafjallajokull in
Iceland (2010)
MACC, CMC, etc.
Civil society
organisation
Economic services
Economic services
Community based
organisations
Government sector
(Decision &
continuity)
Social
sector(Education,
aggregation, icon)
Government sector
(Decision &
continuity)
Social
sector(Education,
aggregation, icon)
sector
Residential housing
sector
Malaysia MH17 plane
crash (2014)
Antagonistic
border
Scope of CM
Intergovernmental
organisations
Figure 4 Problem space overview of the Enschede fireworks factory explosion
21
2.2 CASCADING EFFECTS AND THEIR TRIGGERS
This section provides an analysis of the cascading effects that occurred in the Enschede
fireworks factory explosion, along with identifying the triggers of these effects. Figure 5
(below) presents a visual overview of the unfolding of events in the Enschede fireworks factory
disaster. The first column indicates the main triggers or interdependencies that caused
cascading effects to occur. The remaining columns illustrate what happened at certain times
and what effects are associated with this. The second column indicates the time timescale on
which the unfolding of the crisis (column 4) and the actions in crisis management associated
with that (column 3) occurred. Direct negative effects that occurred are described in column 5
and sectors directly and indirectly affected in column 6 and 7. It must be noted that the impact
of the crisis described here is largely concentrated on those impacts associated with cascading
effects as well as those related to the cross-border nature of this crisis. Each of the following
sub-sections, address one of the boxes listed in the green column of Figure 5. For each box it
is illustrated what type of trigger it concerns, along with describing what kind of cascading
effects it caused.
22
time (on relevant
timescale)
A Malfunctioning of a pre-crisis legal
and regulatory relation due to
negligence: local (muncipality of
Enschede) and national (IMH, DMKL,
RVI) governmentshould carry out
inspections in SE Fireworks. They had
not done so, which enabled SE
Fireworks to avoid meeting legal
obligations.
B Malfunctioning of an organisational
relation: pre-crisis preparations with
regards to the organisational
response to crisis showed
considerable flaws.
Fire in fireworks factory
13 May 2000- 15:03
C Malfunctioning of a supply relation
(service relation): due to a shortage
of firemen present, firetrucks going
to the site were equipped with only
a small number of firemen
15:08
Dutch regional: RAC and RMC are
notified of fire by patrolling police
officer and citizens
Dutch Local: Notified by RAC, local
firefighters (Korps Enschede) and
OvD go to site
D Disruption of information relation
due to witholding of information:
Despite being asked, S.E. Fireworks
(industry) did not inform the fire
fighters of the illegal, heavy
explosive fireworks stored on site.
Dutch Local: Firefighters arrivethey think they’re able to control the
fire and that there is no risk of
explosion
E Disruption of organisation relation
due to information being witheld: SE
Fireworks witheld information which
resulted in inadequate
decisionmaking and operational
planning by firefighters.
Dutch local: firefighters focus on
factory alone
23
cascade)
A Malfunctioning of a pre-crisis legal
and regulatory relation due to
negligence: local (muncipality of
Enschede) and national (IMH, DMKL,
governmentshould
carry
out
F RVI)
Disruption
of organisation
relation
inspections
in SE Fireworks.
They had
due to information
being witheld:
not
donebeing
so, which
SE did
Despite
askedenabled
SE Fireworks
Fireworks
to avoidtomeeting
legal that
not communicate
the firemen
obligations.
the firesafety of the factory did not
time (on relevant
timescale)
Dutch Local : Firemen therefore think
the situation is controllable and take
actions based on that.
15:27
Fire in fireworks factory
13 May 2000- 15:03
C Disruption of information relation
due to witholding of information:
Despite being asked, S.E. Fireworks
(industry) did not inform the fire
fighters of the illegal, heavy
explosive fireworks stored on site.
cascade)
Fire expands
meet the regulations. Incorrect
emergency response decisions were
made based on that.
B Malfunctioning of a supply relation
(service relation): due to a shortage
of firemen present, firetrucks going
to the site were equipped with only
a small number of firemen
Dutch regional: RAC and RMC are
notified of fire by patrolling police
officer and citizens
15:28
Dutch Local: Fire brigade tries to
extinguish the fire, but fails
15:33
Dutch Local: Notified by RAC, local
firefighters (Korps Enschede) and
OvD go to site
15:08
Two containers outside the factory
catch fire
Container 1 explodes
Windows, roof-tiles of nearby
houses scatter
Dutch Local: Firemen, policemen
(and general public) evacuate en
masse (stop trying to extinguish the
fire) Local: Firefighters arriveDutch
15:34
they think they’re able to control the
fire and that there is no risk of
explosion
Pieces of the container hit other
containers. Chain reaction of
exploding containers: a fireball with
a diameter of 85m
Fire in main factory expands
D Disruption of organisation relation
due to information being witheld: SE
Fireworks witheld information which
resulted in inadequate
decisionmaking and operational
planning by firefighters.
Dutch local: firefighters focus on
factory alone
15:35
Main factory explodes: a fireball with
a diameter of 135 meters
casualties and fatalities
Transportation ground:
roads damaged/inaccesible due
to debrees
200 houses destroyed
Housing: 1250 people become
homeless
300 houses heavily damaged
24
50 commercial buildings heavily
damaged
Economic sector (local)
mental health: PTSD, anxiety
disorder (short- and long-term)
Energy transmission: gas pipes
time (on relevant
timescale)
15:35
Main (vertical
factory explodes:
time
cascasde)a fireball with
a diameter of 135 meters
casualties
cascade) and fatalities
Transportation
ground:
roads damaged/inaccesible due
to debrees
200 houses destroyed
Housing: 1250 people become
homeless
300 houses heavily damaged
50 commercial buildings heavily
damaged
Economic sector (local)
mental health: PTSD, anxiety
disorder (short- and long-term)
Energy transmission: gas pipes
damaged, power lines damaged
Telecommunication: phone
lines damaged
Waste/biochem: sewarage
systems damaged
15:38
Commander fire-department notifies
RAC asking for all aid possible
G Disruption of information relation
(telecommunication) due to
increased volume of calls: phone
lines are overloaded. This impaired
the telecommunication between the
RMC and first responders.
H Disruption of organisation relation
due to shortage of staff: RMC does
not have enough manpower to deal
with all incoming calls and develop
accurate emergency management
actions.
These two factors resulted in RMC
(Dutch local) not communicating
properly with RAC, CPA and OvD, and
not giving priority to the event, and
not rapidly asking for assistance,
which caused a delay in the arrival of
further assistance. When the
assistance arrived there was little
overview of the crisis between 15:35
and 17:00 as phonelines were still
overloaded.
RAC does not respond adeqautely to
this: very minimal (almost none)
firefighting takes place until 16:10
Fire expands
25
time (on relevant
timescale)
cascade)
Fire expands
These two factors resulted in RMC
(Dutch local) not communicating
properly with RAC, CPA and OvD, and
not giving priority to the event, and
not rapidly asking for assistance,
which caused a delay in the arrival of
further assistance. When the
assistance arrived there was little
overview of the crisis between 15:35
and 17:00 as phonelines were still
overloaded.
I Disruption of information relation
(telecommunication) due to
sustained high volume of calls:
phone lines are still overloaded.
16:05
German local firefighters arrive,
followed by Dutch regional and
national firefighters. Dutch national
& German regional medical
assistance arrives after this. Limited
coordination and communication as a
resutl of phone lines being
overloaded.
Water provision: reduction in
(drinking)water
Emergency response activities are
carried out
J Malfunctioning of a supply relation:
the use of water for firefighting led
to a reduction in water provision.
All fires are extinguished
14 May 2000, 02:00
Figure 5 Visual overview of Enschede fireworks factory disaster
26
2.2.1 Box A: Malfunctioning of a pre-crisis legal and regulatory relation
This box addresses the malfunctioning of a pre-crisis legal and regulatory relation between
local government, national government and industry, as a result of negligence. Voogd (2004:
9) refers to the relation between the national government, local government and industry (SE
Fireworks) as a ‘problem of interplay’ in the form of ‘functional interdependencies’. He argues
that the fact that there was a dependency between these actors and institutions impacted on the
ways SE Fireworks operated. The box differs from the following boxes in the sense that it
addresses certain pre-crisis developments which, as argued by Voogd (2004), enabled the
Enschede fireworks factory disaster to escalate and unfold the way it did. Nevertheless, the
interdependencies described in this box can be analysed in a manner similar to the analysis of
interdependencies of influence during the crisis. The following points illustrate the
malfunctioning of the pre-crisis legal and regulatory relation:

Prior to the Enschede fireworks factory disaster, SE Fireworks (industry) did not meet
its legal obligations: the fireworks stored were of a more explosive nature than was
permitted, fireworks were present in the area where the fire started but were not
permitted to be there for safety reasons, the terrain was not sufficiently kept clean to
prevent fire from spreading, and two sea containers used for storing fireworks were
illegally present and wrongly positioned- they were difficult to access (Voogd 2004).

SE Fireworks was able to get away this as inspections were not sufficiently carried out
by the municipality of Enschede (local government), the Environmental Hygiene
Inspection of the Ministry of Environment (IMH) (national government) and the Royal
Armed Forces Materials Directorate of the Ministry of Defence (DMKL) (national
government).
These factors combined enabled the fire that started in the factory to spread rapidly.
2.2.2 Box B: Malfunctioning of organisational relation
There were several flaws in the crisis management plans that existed for the region in which
Enschede. These flaws largely concerned the procedures for the firefighters and the medical
personnel. In 1998 the province of Overijssel (in which Enschede is located) asked consultancy
AVIV to carry out a risk analysis of objects/buildings in the province of Overijssel. In the report
AVIV drew attention to the LBKE’s absence of plans of approach with regards to how to
operate in case of fires in several large buildings, amongst which the fireworks factory. The
LBKE did not work with such plans of approach, but with maps of the buildings on which basic
details such as the location of dangerous substances were noted. However, such a map had not
yet been developed for the fireworks factory (COV 2001, 110). Additionally there were flaws
in the procedures for the medical response, such as the absences of tasks that need to be carried
out and the lack of clarity with regards to who should carry out tasks that are addressed in the
procedure. Also responsibilities between actors and organisations were not always clear.
Hence, the flaws in the pre-crisis planning for emergencies are considered a malfunctioning
of an organisational relation, and concern ‘critical shortcomings which could lead to a less
adequate crisis management (COV 2001, 110).
2.2.3 Box C: Flaws in a supply relation
Box C addresses flaws in a supply relation: the delivery of manpower in the form of
firefighters from the LBKE to the site. Two different types of fire engines were sent to the
factory. According to national standards the larger type should have been equipped with six
27
firemen, the smaller with two. However, the number of firemen that arrived on the scene
totalled five, not eight (COV 2001, 116). As a consequence, too few firemen were present to
adequately operate the fire engines.
2.2.4 Box D: Disruption of an information relation
Box B concerns the intentionally withholding of information that affected the information
relation between industry (SE Fireworks) and local government (firefighters of the LBKE)
based on not having the correct information. In conversations with the firemen on site,
personnel of SE Fireworks did not specify the degree of the danger that the stored fireworks
represented. This is likely due to the heavy explosive fireworks being partly illegal. The owner
of SE Fireworks rapidly left the factory around 15:21. COV (2001, 119) concludes this should
have been interpreted as a warning that the situation could get drastically out of hand. The two
directors of SE Fireworks were each sentenced to a year in prison (OM 2003).
2.2.5 Box E: Disruption of an organisation relation
Related to Box D is Box E. Due to the incorrect information given by SE Fireworks, the
firefighters of the LBKE took incorrect actions. It is important to acknowledge the dependency
between the explosive nature of the fireworks and the explosion it caused, but if information
on the explosive nature of the fireworks and the amount of fireworks stored was not withheld,
this dependency could have been undermined. Hence it is important to note that the withholding
of information discussed in Box D relates to the disruption of an organisation relation: the
local government (LBKE)’s plan of approach was based on incorrect information provided by
industry (SE Fireworks) and was therefore not well-suited to the situation.
2.2.6 Box F: Disruption of an information relation
Box F addresses how withholding information shaped the information relation between
industry (SE Fireworks) and the local government (OvD). The coordinator of the firefighters
(OvD) spoke to one of the owners and an employee of SE Fireworks at approximately 15:27.
He asked about the state of the fire prevention of the compartments of the factory. The
employee of SE Fireworks answered that everything was up to standards and met the
regulations (COV Annex A 2001, 431). The firemen based their actions based on this
information, which later turned out to be incorrect.
2.2.7 Box G: Disruption of an information relation
Box G addresses the fact that an increased volume of calls disturbed an information relation.
After the factory and the containers exploded a large number of calls to the RMC caused phone
lines to be overloaded. As a result, the communication system via phone became unreliable,
which in this case affected the communication between first responders on the site and the
RMC. The local government (police officer on site) could not reach the regional government
(RMC) for several minutes, which contributed to a delay in the first response organisation and
operation (COV 2001, 127).
2.2.8 Box H: Disruption of an organisation relation
In addition to the flaws in the communication system, as addressed in Box G, the RMC did not
have the resources, in the form of manpower, to deal with the high number of incoming calls.
On the day of the explosion, they were understaffed. Additionally, they had no experience with
handing over control of the crisis situation to the national level, which should happen in the
case of large unexpected incidents and/or when there is a need for multidisciplinary
coordination during incidents (COV 2001 127-128). Box H therefore addresses how a lack of
manpower disturbed the organisation relation within the regional government (RMC) as a
28
result of the sudden high demand for these resources. In combination with the communication
relation described in Box G, this led to flaws in the communication within the regional
government (between the RMC and the RAC and CPA) and between the regional government
(RMC) and local government (OvD).
2.2.9 Box I: Disruption of an information relation
Due to the high number of calls to the RMC, the communication system via phone continued
to be unreliable. Various crisis managers could not communicate with one another, which in
turn resulted in limited coordination of actions. Hence Box I addresses the disruption of an
information relation which in this case affected all crisis managers on site.
2.2.10 Box J: Malfunctioning of a supply relation
Box J addresses the malfunctioning of a supply relation (water) between regional/provincial
government (WMO) and various sectors, but predominately the general public. As the problem
was the lack of water due to the high volume of water used by firefighters, and there was
nothing wrong with the means of supplying water, this relations is not further described by
listing a sub-category. Due to the large amounts of water used to extinguish all fires, the water
level in the region’s clean water reservoir was critically low. Waterleiding Maatschappij
Overijssel (WMO), the water supplier for the province in which Enschede is located, solved
the problem by 18 May 2000, five days later (Doorn 2001). Due to this timely intervention no
further negative consequences resulted from the low water level.
2.3 LESSONS LEARNED
The analysis of the Enschede fireworks factory disasters presents several opportunities for
identifying lessons learned that can contribute to the understanding of the unfolding of
cascading events in crises. The most important lessons on what went wrong and what went
well are discussed in the sub-sections below.
2.3.1 What went wrong?
An analysis of the boxes addressed in the sub-sections of section 2.2 illustrates the importance
of the flow of information and resources, and draws attention to the role pre-crisis happenings
played in enabling cascading effects to occur the way they did. These three points are discussed
here as unfortunate turns of events from which lessons learned can be drawn, and that can
contribute to the understanding of the evolution of cascading effects.
First, the nature of information used to inform operational decisions in emergency management
played a role of tremendous importance in the cascading nature of the crisis. In one case this
was the accidental provision of incorrect information by the RAC to firefighters, but in two
other cases it was the presentation of incorrect information by employees of SE Fireworks
(COV Annex A, 431), which very likely contributed to inadequate emergency management.
Due to the rapid-onset nature of the crisis, first responders did not have the time to triangulate
the information given to them by the personnel of SE Fireworks, who very likely knew they
would face punishment if it became public knowledge that safety regulations were not met.
These findings support Comfort et al.’s (2004) emphasis on the quality of information rather
than the quantity and uncertainty of information in assessing the magnitude of a crisis. The
findings further develop Comfort et al.’s (2004) argument by not only drawing attention to the
uncertainty of information, but also to the presumed certainty of incorrect information in trying
to assess the potential magnitude of a crisis.
29
A second major point contributing to the cascading effects of this crisis, were the insufficient
resources to deal with a crisis of this magnitude, and the ways these resources were organised.
As Box C indicated, too few firemen were sent to the site. Box H referred to the incapacity of
the RMC to deal with all incoming phone calls and prioritise actions and assistance. This
illustrates the need for plans and guidelines to deal with crises beyond the magnitude of
‘common’ crises. This could take the form of back-up communication systems but also having
first responders on stand-by.
Thirdly, what must be considered here is the legacy of the lack of inspections carried out in a
pre-crisis situation. The negligence on local and national level enabled SE Fireworks to get
away with not abiding laws and regulations, which, in combination with SE Fireworks
personnel not being upfront about this during the crisis, facilitated the crisis to infold in the
way it did. Also of relevance with regard to a pre-crisis level were the flaws in crisis preparation
as outlined in Box B.
2.3.2 What went well?
With regards to the development of the crisis management operations after the major
explosions at 15:34 and 15:35, some strong points can be identified. Considering the lack of
communication and coordination in the first few hours following the explosions, it is
remarkable that first response organisations did not wait for commands to take actions but acted
largely on their own initiative. The high visibility of the crisis strongly contributed to these
initiatives: many first responders rushed to the scene after seeing the smoke plumes (COV
2001, 128).
In this context, it is worth noting that the first emergency responders present at the scene after
the large explosions were German firefighters from Gronau who rushed to the scene without
being asked to do so by the Dutch emergency responders (Woltering & Schneider 2002). At
the time of the fireworks factory disaster there was no agreement on cooperation between
Dutch and German emergency services. In fact, German first responders providing their
services during the disaster were officially not allowed to do so (Trouw 2001). One year after
the disaster, an agreement for cross-border emergency response was signed between the Dutch
regions of Twente and de Achterhoek and the German regions Borken and Grafschaft Bentheim
(Trouw 2001). Also, the personnel of the second Dutch ambulance to arrive after the explosions
immediately took the initiative to create a local first aid point to treat victims who could not be
transported immediately. The mobile unit of the Dutch national police (ME) was contacted by
one of the first responders who did not have the authority to do so. Nevertheless, this initiative
proved to be of considerable value; 132 people of the ME arrived quickly and had pagers,
which considerably aided the response operations as the phone network was still overloaded
and could therefore not be relied upon (COV 2001, 127).
2.4 CONCLUSION
This case study demonstrates that the triggering factors causing cascading effects were mainly
related to human interventions and decisions rather than being caused by physical
interdependencies between infrastructures. The provision of information, or the lack thereof,
and the distribution of resources, mainly manpower, played prominent roles in the unfolding
of cascading effects in this event. It shows the importance of not only focusing on physical
connections between infrastructures but also on more dynamic relations that develop as the
crisis unfolds. What can also be concluded from this case study is that the pre-crisis situation
cannot be overlooked when analysing cascading effects, as pre-crisis relations, particularly
30
those concerning legal and regulatory issues, were of influence on the event evolving the way
it did.
31
3
2011 JAPAN EARTHQUAKE, TSUNAMI AND FUKUSHIMA DISASTER
On Friday 11 March, 2011 at 14:46 Japan Standard Time, an earthquake with a magnitude of
9.0 occurred 129 kilometres east of the city of Sendai, Japan. The earthquake occurred at a
depth of 30 kilometres, shallow enough to trigger a tsunami. Fifty minutes later the first tsunami
waves hit the east coast of Japan. The earthquake and tsunami combined resulted in the death
of 16100 people, of which approximately 14308 people as a result of the tsunami. A year after
the devastating events occurred, 3061 people were still reported missing (CADAT 2012).
The tsunami’s impact was intensified by the fact that it caused extensive damage to the
Fukushima Daiichi Nuclear Power Plant (see Figure 6). The supply of power to the plant was
cut off, and emergency generators were destroyed. Without power the cooling systems of the
plant stopped working, resulting in the overheating of the fuel rods in three units (unites 1, 2,
and 3) - the other three units (units 4, 5, and 6) had been shut down for maintenance.
Consequently, the fuel rods in units 1, 2 and 3 melted down. Radioactive materials were
released into the air and contaminated water continued to spill from the plant’s storage facilities
for many months (BBC 2013). Power to the site was restored in September 2011.
This analysis of the events resulting from the 2011 Japan earthquake focuses largely on the
crisis at the Fukushima nuclear power plant.
Fukushima
Figure 6 Map (left) showing the location of Fukushima (source: Google Maps), the Fukushima nuclear
disaster (top right) (source: ABC News), and the deserted street of the town of Namie, which inhabitants
all left the town (source: EPA/Franck Robichon).
32
The principal event causing the disaster was an earthquake, which falls into the category of
natural hazards. It was of an instantaneous onset: there was no warning for the earthquake. The
tsunami was also a natural hazard. As there were minutes of warning it was a hazard of a rapidonset nature. Although related to the earthquake and tsunami, the Fukushima nuclear crisis is
not commonly referred to as being ‘natural’ in nature. The Fukushima Nuclear Accident
Independent Investigation Commission (chartered by The National Diet of Japan (NDoJ)), who
produced the main Japanese report on the crisis, states that the Fukushima reactor meltdowns
were not the unavoidable result of the earthquake and tsunami. The report analyses several
errors and cases of negligence that resulted in the Fukushima power plant being ill-equipped
to deal with disasters such as the events of 11 March 2011. It concludes:
The TEPCO Fukushima Nuclear Power Plant accident was the result of collusion
between the government, the regulators and TEPCO, and the lack of governance
by said parties. They effectively betrayed the nation’s right to be safe from nuclear
accidents. Therefore, we conclude that the accident was clearly “manmade.” We
believe that the root causes were the organisational and regulatory systems that
supported faulty rationales for decisions and actions, rather than issues relating to
the competency of any specific individual (NDoJ 2012: 16).
Hence, partners chose to categorise the Fukushima nuclear crisis as a ‘man-made’ or
‘technological’ event.
With regards to the impacts of the events, the area instantaneously affected by the earthquake
and tsunami was mainly Japan, its east coast in particular. Tsunami warnings were issued in
other countries, but no damage was reported. The Fukushima nuclear disaster’s main impacts
were national, but were not restricted to Japan alone; nuclear contamination of the seawater
affected much larger areas on a global level. The response to the events was of an international
level: ninety-one countries and nine international organisations offered to assist with relief
efforts (The Guardian 2011). Hence the event is considered to be of a global level.
The impacts of the Fukushima disaster include the evacuation of approximately 150,000 people
(NDoJ 2012: 19) - they had to leave their homes because of radiation leaks into the air, soil and
sea. More than 90.000 people still lived in evacuation shelters three months after the events
(Rianovosti 2011). Energy production and energy transmission were directly affected, but the
foremost effects of the Fukushima nuclear disaster were related to the release of radioactive
material into the environment outside of Fukushima via water and wind. Main sectors indirectly
affected by this were:
 Transportation ground, air and water: due to the high radiation levels in areas surrounding
Fukushima many areas are inaccessible from a safety point of view. All transport systems
in these areas are therefore not being used.
 Energy production: nuclear reactors exited service, both in Japan and in other countries
(CNN 2014). Japan increased its dependence on natural gas, oil, and renewable energy (U.S.
Energy Information Administration 2014).
 Water provision: radiation affected the quality of drinking water in several areas
(Bloomberg 2011). Other sources of water need to be relied on.
 Waste processing: the large amounts of radioactive wastewater at the plant pose a problem.
Contaminated water has been released into the sea to make storage space for water with
much higher radioactivity (Voice of America 2011).
33
 Economic sector: various sectors within the economic sector were affected by nuclear
contamination. Agriculture (including, but not limited to crops, beef, fish) is a main example
as the contamination of soil restricts its use.
 Government sector: executed and pending political and policy changes in post-Fukushima
Japan are described by Al-Badri and Berends (2013).
 Housing (residential): many towns and villages surrounding Fukushima have been deserted.
Their former inhabitants need to be re-housed elsewhere, which therefore impacts the
nation’s housing sector.
 Environment: Radioactive soil and water contamination. This is not limited to Japan and its
surrounding areas, but affects much larger areas due to the distribution of radioactive
materials by sea and air.
These affected sectors are presented in Figure 7 below, which provides a simple problem space
of the Fukushima disaster.
34
Case
impact
Onset of crisis
Scope of CM
Cross border?
Principal involved
actors in CM
Directly affected
sectors
Indirectly affected
sectors
cascade
Japan, 2011
Physical
Sudden
Global
Yes
Police
Transportation
GROUND
Transportation
GROUND
Disruption of
Firework factory
Social / Psychological International & cross Rapid (Hours/days)
border
International
No
Fire
relation
Economic
National
Slow (Weeks)
National
Health
Energy production
Energy production
Heat wave 2003
(France)
Political
Regional
Creeping
(months/years)
Regional
Local admin.
Municipal govt.
Energy transmission
and distribution
Energy transmission
and distribution
Local
National/central
government
Water provision
Water provision
Disruption of
organisational
relation
Malfunctioning of
relation
Galtür, AT (1999)
National security
(telecom)
Central European
floods (focus on
Prague) (2002)
Waste & biochem
(2012)
Civil protection
authorities
Healthcare
(hospitals&clinics)
Healthcare
(hospitals&clinics)
Eruption of
Eyjafjallajokull in
Iceland (2010)
MACC, CMC, etc.
Civil society
organisation
Economic services
Economic services
Community based
organisations
Government sector
(Decision &
continuity)
Social
sector(Education,
aggregation, icon)
Government sector
(Decision &
continuity)
Social
sector(Education,
aggregation, icon)
sector
Residential housing
sector
Malaysia MH17 plane
crash (2014)
Types of hazard
Social
Antagonistic
Global
Local
Intergovernmental
organisations
Figure 7 Problem space overview of the Fukushima disaster
35
This section provides an analysis of the cascading effects that occurred in the Fukushima
nuclear disaster along with identifying the triggers of these effects. Figure 8 (below) presents
a visual overview of the unfolding of events in the Fukushima nuclear disaster. The first column
shows the main triggers or interdependencies that caused cascading effects to occur. The
remaining columns illustrate what happened at certain times and what effects are associated
with this. The second column indicates the time timescale on which the unfolding of the crisis
(column 4) and the actions in crisis management associated with that (column 3) occurred.
Direct negative effects that occurred are described in column 5 and sectors directly and
indirectly affected in column 6 and 7. It must be noted that the impact of the crisis described
here is largely concentrated on those impacts associated with cascading effects as well as those
related to the cross-border nature of this crisis. Each of the following sub-sections, address one
of the boxes listed in the green column of Figure 8 (box A, B, C etc). For each box it is
illustrated what type of trigger it concerns, along with describing what kind of cascading effects
it caused. In addition to impacts being related to particular events there are also impacts that
are related to the nuclear disaster as a whole, and that cannot be linked to particular aspects of
it. To place these impacts in the overview, the yellow cell in Figure 8 sums up the main events
of the nuclear crisis and lists the impacts related to this event as a whole.
36
37
38
39
Figure 8 Visual overview of the Fukushima nuclear disaster
40
3.2.1 Box A: Malfunctioning of a pre-crisis legal and regulatory relation
The Nuclear and Industrial Safety Agency (NISA) of the Ministry of Economy, Trade and
Industry (METI), the Nuclear Safety Commission (NSC) and other regulatory authorities had
relaxed their activities due to pressure from the Federation of Electric Power Companies
(FEPC), of which Tokyo Electric Power Company (TEPCO) is a central player. What
complicates this issue is that NISA had a conflict of interests: on the one hand they had to
ensure nuclear safety, on the other hand they were to promote nuclear energy in Japan. The
NDoJ (2012: 43) states that the FEPC lobbied on behalf of the electricity companies and
scrutinized the relationship between operators and regulators. Additionally, both NISA and
TEPCO were aware that there was a risk of core damage from a malfunctioning of seawater
pumps if tsunami levels rose beyond the assumptions made by the Society of Civil Engineers.
Yet they did not attempt to amend the existing regulations with regards to this, or bring them
in line with international standard; NISA gave no orders to do so and TEPCO did not make
changes themselves (The National Diet of Japan (NDoJ) 2012, 43). The failure of the pumps
is exactly what happened, and the possibility of this happening could have been addressed by
actions in the pre-disaster stage. The choice for not doing so therefore disturbs the functioning
of the pre-crisis legal and regulatory relation of dependency between NISA and NSC, and
TEPCO, and is therefore a trigger of a cascading effect.
3.2.2 Box B: Malfunctioning of a pre-crisis legal and regulatory relation
Guidelines for anti-seismic design for nuclear reactor facilities had been set by the NSC in
1981. In 2006 the NSC announced revisions to these guidelines. NISA instructed TEPCO to
assess the anti-seismic safety of their sites in relation to these revised guidelines. This is also
referred to as ‘conducting anti-seismic’ (NDoJ 2012, 27). No significant anti-seismic safety
assessments were carried out by TEPCO. NISA, as the regulator, failed to demand TEPCO to
do so. In the analysis of the damage caused as a consequence of the 2011 earthquake, both
TEPCO and NISA confirmed that the safety of some of the piping and support did not meet
the standards of the new guidelines. The negligence in the pre-crisis legal and regulatory
relation of dependency between NISA and TEPCO was therefore a cause in the cascade of
the event. TEPCO argues there was no damage to the pipes and supports, but the Fukushima
Nuclear Accident Independent Investigation Commission places questions around the
plausibility of this claim, as inspections are not yet completed (NDoJ 2012, 27).
3.2.3 Box C: Pre-disaster condition
Over the years prior to the 2011 events, nuclear power had become less profitable in Japan.
TEPCO had begun to place more emphasis on reducing the costs, which happened at the
expense of investing in safety. Appropriate diagrams and instruments related to safety protocols
had not been developed or were not in place, which contributed to the delay in venting at a
crucial time of the accident (NDoJ 2012, 44). Hence this is a pre-disaster condition: a
sequence of events that contributed to the cascade of the disaster.
3.2.4 Box D: Malfunctioning of a pre-existing backup supply relation
As the earthquake had disturbed the electricity supply between TEPCO and the Fukushima
Daiichi Nuclear Power plant, electricity had to be generated in alternative ways to keep the
cooling systems at the nuclear power plant going. The back-up 66V transmission line should
have been able to do so, but failed to feed Unit 1 due to mismatched sockets (NDoJ 2012, 12).
It is not clear how the other units should have been provided with electricity. Hence this
concerns the malfunctioning of a pre-existing backup relation of the supply of physical
media (power). This malfunctioning did not happen as a result of the disasters, but had to do
41
with the negligence of checking if this backup system worked or not, prior to the occurrence
of the event.
3.2.5 Box E: Disruption of an organisation relation
During the disaster TEPCO received information on what was happening from plant workers
present at the nuclear plant. As these people witnessed what was going on this information
should have been taken into account in the subsequent emergency response activities.
However, TEPCO ignored this information and gave priority to instructions from NISA and
the Kantei as they did not want to take responsibility for the outcomes of its emergency
response (NDoJ 2012a, 30). It is not known exactly how ignoring the on-site information
influenced the emergency response, but the fact that this information was ignored in decisionmaking altered the decisions made and emergency response carried out. Hence this is labelled
as the disturbance of an organisation relation, due to intentionally disregarding information.
3.2.6 Box F: Disturbance relation
As the reactors could not be cooled in the normal way (see Box D), alternative water injections
had to be generated, and firefighters were charged with providing water for cooling the
reactors. The fact that firefighters became responsible for the cooling of nuclear reactors,
whereas this was not a relation of dependency present in an everyday situation, shows that this
is a disturbance relation: it is a relation that originated during the crisis. This relation was
further problematized as the aftershocks as a result of the earthquake hindered the access to the
site. Due to this, fire trucks could not deliver water to the site, and alternative water injections
to cool the reactors could not be carried out (NDoJ 2012, 14).
3.2.7 Box G: Disruption of an organisation relation
The NEHR did not provide local municipalities with information on radiation. The NEHR
claimed communication and measurement tools had been damaged by the earthquake, and that
for this reason they had not been able to gather and spread information on the radioactivity.
However, using mobile monitoring systems, the NEHR had observed higher radiation doses in
the environment within a few days after the events, but did not share this information (Tanaka
2012). Additionally, SPEEDI did not deliver the predictive movements of radioactive clouds
based on the weather forecast to municipalities (Tanaka 2012). The NSC should have used the
information of SPEEDI to aid the evacuation, but failed to do so. The reason for this remains
unclear. Hence not sharing information was the trigger of cascading effects, as this influenced
the evacuation activities as part of the organisation of emergency response.
3.3
LESSONS LEARNED
The analysis of the Fukushima nuclear crisis presents a case from which lessons on the
importance of having well-established pre-crisis regulatory relations and enforcing regulations
can be drawn. The most important lessons on what went wrong and what went well are
discussed in the sub-sections below.
An analysis of the boxes addressed in the sub-sections of section 3.2 shows that in the case of
Fukushima, many of the cascading effects were related to actions and decisions taken prior to
the crisis, and to a much lesser extent to those taken during the crisis. Official regulatory
relations between institutions were not respected in various ways during the pre-crisis stage.
This largely had to do with a lack of authoritative powers; advice and instructions were ignored
or not followed up in time, and no sanctions were in place for this behaviour. It illustrates that
whilst laws can in theory use regulation to reduce disaster risk, what really matters is how they
42
are enacted in practice. The NDoJ (2012, 46) expressed the need for ‘sweeping, fundamental
reform of laws and regulations to bring them into line with international standards. (…) A
mechanism for monitoring the resulting infrastructural implementations must be devised.’
Not only were the legal and regulatory relations of dependency malfunctioning in a pre-crisis
stage, also the malfunctioning of a supply relation in a pre-crisis stage contributed to the
cascading effects. The fact that this regarded a back-up supply relation adds an interesting angle
to the analysis of the crisis. The back-up supply relation of electricity was in place as a measure
of disaster preparedness: if the main power supply would fail, this back-up system should take
over. The very fact that this back-up system was made inaccessible illustrates the importance
of the thorough development of probable disaster scenarios, possibly combined with drills and
exercises. Providing a back-up system without checking whether it functions or not can cause
more harm than good, especially if people assume they can rely on this system. As argued by
Adachi and Ellingwood (2008), the utility of backup systems should be considered when
analysing system vulnerability. The fact that the (lack of) functioning of pre-disaster relations
had such an impact on the development of cascading effects is what makes the Fukushima
nuclear disaster an event that deserves attention in its own right. Unlike many crisis situations
the cascade of many of the effects could not have been prevented once the first signs of the
disaster presented itself.
In addition to the pre-disaster relations of dependency, the case of Fukushima also shows that
pre-disaster conditions can contribute to cascading effects occurring. Considering the
economic developments in the nuclear sector, TEPCO had invested more in the reduction of
costs, and fell short on investing in and implementing safety measures. This is not so much a
relation of dependency in the sense of actions of one institution being dependent on those of
another institution, but is related to long-term processes and developments on a large scale.
Such processes cannot be traced back to the actions of one actor or institution, but are macrolevel conditions that shaped behaviour and actions on a very local level, eventually leading to
cascading effects. It can therefore be concluded that decisions to invest in cost-reduction at the
expense of safety were wrongfully taken, especially as other ways of enhancing the safety at
the plant, as described in the previous paragraph, were lacking.
A final point to be emphasised here is that relations of power and the responsibilities associated
with this can stand in the way of the correct use of vital information. On-site information was
ignored, despite it being more important for decision-making than information external to the
site.
As the focus of the analysis presented here is mainly on the cascading effects and not so much
on the management of the crisis, it is more difficult to state what went well. However, what
can be addressed in this context are the efforts of the workers present at Fukushima at the time
of the crisis. They did all they could to try to reduce the cascading effects, despite constraining
factors such as the flawed manuals, needing to work with torches as there was no electricity,
and not to forget that they largely carried out their work whilst their efforts were not being
acknowledged by TEPCO as the company prioritised other information over that of the workers
on site (as discussed in Box E).
3.4
CONCLUSION
The Fukushima disasters is a clear example of an extensive disaster flowing from another
disaster, namely that of the earthquake and tsunami. It is also an example of an event that
43
affected various sectors, many in the (very) long term and of which the exact consequences are
still unknown. The impact of the cascading effects is therefore much larger, both over space
and time, than those discussed in the Enschede case study in Chapter 1 of this Deliverable.
Similar, however, was the fact that certain cascading effect might have been preventable if
legal and regulatory relations were functioning adequately. The analysis of the Fukushima
disaster illustrated the importance of respecting regulatory relations in disaster preparedness,
and emphasises that crisis managers have limited capacities of controlling a crisis if the triggers
of cascading effects are outside of their powers. Additionally, this analysis brought to the
foreground a point that is not addressed in most of the case studies in this Deliverable: that of
the importance of functioning back-up systems. Having back-up systems in place provides a
sense of security, which, if the backup systems are actually malfunctioning, is largely an
illusion. However, if people are under the impression that these systems will work, alternative
preparations may be reduced to a minimum, which could cause further disastrous effects.
44
4
2005 LONDON ATTACKS
The UK’s capital, London, fell victim to several acts of domestic terrorism on 7 July 2005
(07/07). At 08:50 British Summer Time (BST) on 07/07, London’s transportation network was
purposefully attacked by four individuals. Within minutes of each other, three attacks occurred
on the London underground
system: at Russell Square via
the Piccadilly line, by
Germaine Lindsay, aged 19; at
Aldgate via the Circle line, by
Shehzad Tanweer, aged 24;
and at Edgware road also via
the Circle line, by Mohammad
Sidique Khan, aged 30. A
fourth attack took place an
hour later, targeting a London
public
bus
service
at
Tavistock Square and was
committed by Hasib Hussain,
aged 18 (BBC no date) (see
Figure 9 and Figure 10).
Figure 9 Picture of the blast – Source: BBC (no date)
Figure 10: The site of the bomb attacks – Source: House of Commons (2006, 6)
The attacks resulted in direct impacts on the security of citizens, resulting in 52 fatalities and
770 injuries (London Assembly 2006, 6). They also affected critical infrastructure in the form
of the provision of public transportation. This chapter will draw on findings from the London
45
Review Committee, who, following the attacks, were tasked with identifying lessons learnt
from the emergency services’ response to the attacks - in order to improve future response
capabilities. It will also examine news articles, and other publications that go some way to
informing us about the unfolding of the attacks.
The London attacks consisted of a deliberate, sudden-onset, man-made terror attack on the
public transportation network in the UK. The term ‘terrorism’ is notoriously difficult to define
(Furedi 2007). Within this chapter partners will draw upon a widely accepted definition, as
provided by Hoffman (2006, p40-41):
…the deliberate creation and exploitation of fear through violence or the threat of violence
in the pursuit of political change. All terrorist acts involve violence or the threat of violence.
Terrorism is specifically designed to have far-reaching psychological effects beyond the
immediate victim(s) or object of the terrorist attack. It is meant to instil fear within, and
thereby intimidate, a wider ‘target audience’ that might include a rival ethnic or religious
group, an entire country, a national government or political party, or public opinion in
general. Terrorism is designed to create power where there is none or to consolidate power
where there is very little. Through the publicity generated by their violence, terrorists seek
to obtain the leverage, influence, and power they otherwise lack to effect political change
on either a local or an international scale.
Understanding how terrorism is defined assists us to understand the potential cascading effects
that may arise as a result of an attack, particularly as the effects of an attack are not restricted
to those who may be initially, physically harmed in an attack, as with other types of crises. By
its very nature, terrorism is often an unexpected, rapid crisis with little or no warning, and this
was certainly the case with those that took place in London. In the first instance, the
geographical level of the attack can be considered a local, urban incident, as it predominantly
affected London. In this incident, 52 individuals were killed and 700 were physically injured,
however, ‘many more hundreds of people were direct affected by the attacks, including
passengers who were uninjured but potentially traumatised by the experience’ (London
Assembly 2006, 12). Furthermore, transportation (Ground) and transportation (AIR-WATER)
were both affected; the provision of transport services such as flights in and out of London
were disrupted, along with heavy congestion and disruption to the roads around London, thus
causing disruption outside of the immediate local vicinity of the incidents (The Guardian
2005a). Healthcare, and the social sector (e.g., schools and local businesses within the
surrounding areas) also faced disruption (The Guardian 2005a; 2005b; Ford 2005). In this
chapter the analysis of cascading effects is focused on the immediate aftermath of the attacks.
It is worth noting, that the official response to the London attacks was applauded and by no
means exacerbated the crisis (London Assembly 2006, chair’s forward). Rather, for
FORTRESS, the attacks are a useful way of demonstrating the importance of relations between
information, supply and organisations and how these relations can impact response to a crisis
with the potential for cascading effects.
Figure 11 provides a simple problem space of the 2005 London attacks.
46
Case
Types of hazard
impact
Onset of crisis
Scope of CM
Cross border?
Principal involved
actors in CM
Directly affected
sectors
Indirectly affected
sectors
cascade
Global
Yes
Police
Transportation
GROUND
Transportation
GROUND
Disruption of
No
Fire
relation
Japan, 2011
Physical
Firework factory
Social
Rapid (Hours/days)
International
Economic
Regional
Slow (Weeks)
National
Health
Energy production
Energy production
Disruption of
organisational
relation
Heat wave 2003
(France)
Political
Local
Creeping
(months/years)
Regional
Local admin.
Municipal govt.
Energy transmission
and distribution
Energy transmission
and distribution
Local
National/central
government
Water provision
Water provision
Malfunctioning of
relation
Galtür, AT (1999)
National security
(telecom)
Central European
floods (focus on
Prague) (2002)
(2012)
Waste & biochem
Civil protection
authorities
Healthcare
(hospitals&clinics)
Healthcare
(hospitals&clinics)
Eruption of
Eyjafjallajokull in
Iceland (2010)
MACC, CMC, etc.
Civil society
organisation
Economic services
Economic services
Community based
organisations
Government sector
(Decision &
continuity)
Social
sector(Education,
aggregation, icon)
Government sector
(Decision &
continuity)
Social
sector(Education,
aggregation, icon)
sector
Residential housing
sector
Malaysia MH17 plane
crash (2014)
Antagonistic
border
Intergovernmental
organisations
Figure 11: Problem space overview of the 2005 London attacks
47
This section provides an analysis of the cascading effects that occurred in the London attacks.
Figure 12 provides information on the sectors impacted by the attacks, the nature of the impact
and over what period of time the impacts occurred. The first column indicates the main triggers
or interdependencies that caused cascading effects to occur. The remaining columns show what
happened at certain times and what effects are associated with this. The second column
indicates time timescale on which the unfolding of the crisis (column 4) and the actions in crisis
management associated with that (column 3) occurred. Direct negative effects that occurred
are described in column 5 and sectors directly and indirectly affected in column 6 and 7. It
must be noted that the analysis presented in Figure 12 is largely focused on those impacts
associated with cascading effects.
The sub-sections following Figure 12 contain further information on the boxes included in its
first column. Each of these boxes addresses a trigger that contributed to cascading effects.
48
49
50
51
52
53
54
Figure 12: Visual overview of the 2005 London attacks
55
4.2.1 Box A: Malfunctioning of information relation, the presence of a disturbance
(physical), and the disruption of an organisational relation
Box A provides an overview of the primary causes of the delay in the initial response to the
attacks, and thus relates to three inter-connected relations; information, disturbance and
organisational relation. Whilst these relations will be discussed (together) here to provide a
broader understanding of inter-relational disturbances, they will be individually discussed in
greater detail in the remaining sub-sections.
From the outset of the three attacks on the underground, conflicting reports of what was
unfolding led to the initial response by the London Underground Control Centre based upon
there being a power surge (London Assembly 2006). Conflicting reports were also witnessed
by the emergency services and the news media. In order for these organisations to understand
unfolding events, and coordinate their response, they were dependent on the flow of
information from train drivers to the London Underground Control Centre, as well as between
the control centre and the emergency services, and the public and the emergency services.
These conflicting reports were identified by the London Assembly (2006, 7) in their report of
the attacks:
The task of establishing what had happened was in itself complicated and difficult, given
the location of the first three explosions in tunnels. It took some time before the
emergency and transport services were able to establish accurately what had happened
and where, and how many people were involved. In the minutes following the explosions
at Aldgate, King’s Cross/Russell Square and Edgware Road, there were unclear,
conflicting reports from the scenes a within London Underground’s Network Control
Centre: reports of loud bangs, signs of power surge on the Underground, and reports of a
train derailment and a body on the track.
This transmission of information is ordinarily based upon the use of functioning
telecommunication systems. As such we see an information, disturbance and organisational
relation present from the onset.
The malfunctioning of the information relation can be understood via the sub-category telecommunication relation. As the attacks took place underground, members of the public on
the trains were unable to have access to their mobile phones due to the lack of mobile network
coverage. This meant that they were unable to call for help to the emergency services (Ibid.,13).
This network failure was not due to the attacks, but is a routine consequence of using the tube
in London, where mobile network coverage is often lacking.
In addition to the existing information relation, there was also a disturbance relation present
in the physical form. As a result of the attacks, at Russell Square, the radio service between the
drivers of the trains and the London Underground Control Centre was severed due to the
damage of a “leaky feeder cable” (Ibid., 15). It is also worth noting, that passengers on the
trains were also unable to communicate with drivers and thus has no idea of what was
happening or what actions they should take (Ibid., 62).
Lastly, there was a disturbance of an organisational relation present. This relation took place
as a result of the culmination of the other relations that were present (as discussed above). As
a consequence, the ability of the emergency services to declare a major incident, and therefore
enforce the official major incident response according to the Major Incident Procedure Manual
(London Emergency Services Liaison Panel 2004), was delayed and somewhat varied across
incidents and emergency services (London Assembly 2006). As noted by the findings of the
review panel, in future incidents, it would be; “common sense that one declaration of a major
incident, by whichever service is first at the scene, ought to automatically mobilise units from
‘all three’ services – police, fire and ambulance – and activate major incident procedures within
all services” (Ibid., 39).
4.2.2 Box B: Malfunction of a supply relation
Box B consists of a malfunctioning of a supply relation in the form of the sub-category,
physical media. This supply relation was not a result of the attacks, but rather, a relation of a
dependency that existed prior to the crisis. In responding to all three attacks underground,
throughout the immediate response phase, the abilities for emergency services to report back
to their line commanders were severely affected due to their radios not yielding the capacity to
function underground. Findings from the London Assembly revealed that only the British
Transport Police were equipped with suitable radios. This was not a new problem for the
emergency response organisations to deal with, but had been recognised as an issue and an area
for major concern since the Kings Cross Fire in 1988 (London Assembly 2006, 17). It was
found that the CONNECT project, run by Transport for London was in fact two years behind
schedule at the time of the attacks. The CONNECT project was in the process of installing
facilities for underground radio coverage which would significantly improve communications
underground, as well as facilitating interoperable communications between emergency services
(Ibid., 16-17). However, regardless of this delay, the project was not due for completion until
2006/07.
4.2.3 Box C: Disturbance relation
Box C consists of a disturbance relation in the form of the sub-category physical. Following
the attacks at Russell Square, a leaky feeder antennae cable was damaged. This cable was
responsible for providing “two-way radio traffic inside tunnels and buildings” (Ibid., 143). The
damage contributed to difficulties in communication between the train drivers and the London
Underground Control Centre, as well as to members of the British Transport Police who were
attempting to respond to the attack. As noted by Tim O’Toole, (then) Managing Director of
London Underground, this led to significant delays in response: “The way we obtained
information was from station staff running down to the sites and then using their radios to call
indirectly to the operations centre that something was wrong” (Ibid., 15). Although a
replacement cable was supplied, this was not fitted until 9pm.
4.2.4 Box D: Disruption of an organisational relation
Box D addresses the disruption of an organisational relation, as a result of changes made to
the meeting location for members of the Gold Coordination Group to assemble. The group,
chaired by the Metropolitan Police, originally met at New Scotland Yard at 10:30 BST. This
location was changed to Hendon (North London). The location was deemed more suitable due
to its good facilities and prior use for running emergency preparedness (Ibid., 42). As a
consequence of congestion on the roads, and the closure of the underground as a result of the
attacks, senior officials experienced difficulties in gaining access (in a timely manner) to the
new location. As a consequence, this impacted the strategic coordination to the attacks. Upon
reflection, the Metropolitan Police claimed they would review meeting locations for the Gold
Coordinating Group for future incidents, and that in future, Hendon would be avoided due to
its remote location.
4.2.5 Box E: Disruption of an information relation
As a result of the combination of failures with communication following the attacks, the
collection of information by emergency services was disrupted, which subsequently disturbed
57
the dissemination of information to other audiences, particularly the media – resulting in the
disruption of an information relation. As a consequence, during a press briefing at 11:15
BST the Commissioner of the Metropolitan Police Service, Sir Ian Blair, inaccurately informed
the media that there had been six attacks, when in actuality there had been four (Ibid., 13). Such
an error, led to on-going misinformation throughout the day, as such, recommendations have
since been made by the London Assembly to have a single police representative responsible
for press announcements (Ibid., 81). As noted by the London Assembly, it is of utmost
importance that the media are kept appraised of accurate and timely information during a major
incident so that they are able to further communicate updates to the public (Ibid., 79).
4.2.6 Box F: Disruption of an information relation
Box F relates to the disruption of an information relation as a result of the congestion of the
mobile communications networking in London. The high profile nature of the attacks (1. the
attacks being in the UK’s capital city and 2. the attack being an act of terror which, following
the events of September 11 2001 received considerable attention) resulted in the extensive use
of mobile telephones, resulting in extensive congestion to the networks. For instance, Vodafone
experienced a 250% increase in the volume of calls, O2 experiences 60% increase in call traffic
(Ibid., 43). When considering the impact of this congestion on the functioning of the emergency
services, mixed reports were provided. For some, the congestion resulted in an “inconvenience”
rather than a “problem”. Representatives from the Metropolitan Police and the London
ambulance service, argued that as those at the scenes were equipped with radios, it did not
cause a great deal of trouble. Representatives from London Fire brigade and London
Ambulance also argued that they were reliant on mobile phones at the scene and due to issues
with communication, Incident Commanders felt “isolated” from Gold Support (Ibid., 43). Due
to problems with communication, this also affected the abilities of the ambulance service to
organise response efforts with local hospitals (Ibid., 50). Furthermore, this prevented the
allocation of additional resources at the scene of the attacks, including the deployment of
“vehicles, personnel, equipment and supplies” (Ibid., 51).
In responding to the difficulties faced with the mobile network, the Gold Coordinating Group
could have implemented a system, Access Overload Control (ACCOLC) that would restrict
mobile network access to the emergency services in a specified area. However, this would
deemed a last resort (Ibid., 44). In their first meeting, the Gold Coordinating Group decided
against implementing ACCOLC, following a request by the London Ambulance service. This
was decided as they were concerned about the consequence of implementing the system in
relation to inciting public panic, and questioned whether emergency personnel would have the
correct equipped mobile devices (ACCOLC enabled phones) (Ibid.).
Despite this decision, the City of London Police implemented ACCOLC in collaboration with
O2 in a one-kilometre (km) area around Aldgate (see Figure 13). The network was shut down
from 12 noon until 4:45pm; “During that period of time, O2 estimates that ‘Several hundred
thousand, possibly maybe even more than a million’ attempted calls by members of the public
were lost.” (Ibid., 45). When explaining their reasoning for going against the decision made by
the Gold Coordinating Group, James Hart, Commissioner of the City of London Police claimed
that at the time the decision made, the City of London Police were not aware of the decision.
As such, their decision was based upon their assessment of their needs during the on-going
situation (Ibid., 46).
58
Figure 13: Implementation of AOCC (London Assembly 2006, 45)
4.2.7 Box G: Disruption of an organisation relation
Box G concerns the disruption of an organisation relation. The lack of a coordinated,
systematic establishment of a survivor reception area was extremely problematic to the ongoing response efforts to the attacks (Ibid., 69). As outlined by the London Assembly,
following a major incident, the Major Incident protocol dictated that a reception area should be
set up, in the first instance by the emergency services and then taken over the relevant local
authorities. By doing so, there is a systematic way of recording personal information about
those caught up in an incident, which can be used for subsequent enquiries and support (Ibid.).
The lack of a coordinated effort at the scene was also deemed to have had consequences for
the efforts of the casualty bureau. The sub-section below (4.2.8) illustrates how the casualty
bureau experienced additional difficulties.
4.2.8 Box H: Disruption of an information relation
Lastly, Box H relates to the disruption of an information relation. Following a major incident
there is a need for the emergency services to initiate a casualty bureau. This bureau is
responsible for setting up a telephone line for friends and families of those potentially caught
up in an incident to be able to call to find out further information and to register a person as
missing (Ibid., 84). On the day of the attacks, the telephone line was organised by the
Metropolitan Police Service Casualty Bureau (Ibid.). The bureau also serves as an official
mechanism for the first stage of a criminal investigation and formal identification process
(Ibid.). A decision was made to initiate a bureau at 09:30 am, however, due to a problem with
the connection at the switchboard at New Scotland Yard, the establishment of the casualty
bureau was delayed until 16:00 (Note: the bureau should have been operational within four
hours of a decision being made to initiate one, and thus should have been implemented by
14:30). The bureau experienced an extremely high volume of calls (42,000 within the first
59
hour), placing it under extensive pressure, and the recognisable need for technology to support
such an operation in future. Lastly, rather than a toll-free number being used for people to call,
an 0870 (based on national rates) was implemented, however, all profits were donated to
charity; in future a toll-free number would be utilised (Ibid., 85).
4.3 LESSONS LEARNED
The analysis of the unfolding events on 7 July 2005 in London presents several opportunities
for identifying lessons that can contribute to the understanding of the unfolding of cascading
events in crises. The most important lessons are discussed in the sub-sections below.
The 07/07 attacks were met with a comprehensive response by London’s emergency services
and other contributing organisations and authorities. It was clear that the procedures in place
prior to the attacks taking place were, for the most part, of use to coordinating response efforts.
However, multiple issues relating to communication and information added to the (already)
complex situation emergency responders were forced to deal with. This yielded the potential
to contribute to the evolution of cascading effects.
The analysis conducted here revealed that the primary pre-disaster factor contributing to the
complexity surrounding the management of the attacks concerns the availability of effective
radio communication systems that would work in an underground setting (primarily due to the
on-going roll out of communication facilities that would work underground). As three out of
the four incidents occurred on the London underground network, this yielded great difficulties
in those responding to the incidents being able to communicate with one another. Due to
problems with communications, this had subsequent impacts on the speed with which a major
incident could be declared. Subsequently, delays and on-going difficulties were faced with the
organisation and deployment of resources to the scene to respond to the incident.
As response efforts developed, further communication challenges were experienced with
coordination due to mobile network congestion. Subsequently, staff that were already facing
difficulties in communicating below ground were also having trouble above ground. It
illustrates that the circulation of information during an incident of this magnitude is pivotal to
on-going response efforts and that reliable and resilient communication systems are imperative.
Lastly, organisational difficulties relating to the care and organisation of those not in need of
immediate attention were also lacking. The failure to set up a systematic and coordinated
survivor reception centre, along with delays and challenges experienced by the establishment
of the casualty bureau, caused difficulties in managing the care for vast numbers of individuals
that were caught up in the attacks, and addressing the concerns of their friends and families.
The lapse in the establishment of a survivor reception centre also had consequences for
subsequent criminal investigations into the attacks and the delivery of support in the long-term
response and recovery efforts to the attacks.
The analysis of the London attacks in this chapter has demonstrated the importance of effective
major incident plans being in place, particularly in the pre-event organisation of coordinate
efforts between emergency services. The emergency services response efforts were
commendable, particularly under the challenging circumstances they were forced to work
amongst. Crucial to the response to the attacks were also the efforts of the members of the
public, transport and hospital staff whom assisted in managing and caring for those caught up
60
in the attacks. Such emergent and spontaneous efforts were critical in assisting the official
sources of crisis management and should be recognised in further developing major incident
procedures.
4.4
CONCLUSION
The analysis of 07/07 provides a useful case study for understanding the complexities
surrounding communication and the circulation of information in a crisis and therefore the
importance of resilient communication systems to managing a crisis. Furthermore, from a crisis
management perspective, the London attacks demonstrate the importance of coordinating
efforts for recording information of those people not in urgent medical assistance. To do so,
there is a need for the establishment of quick, coordinated and comprehensive methods of
managing survivors and being able to communicate with the wider networks of those involved
in a crisis in order to keep the public informed and up-to-date with unfolding events.
61
5
THE AVALANCHE DISASTER OF GALTÜR
Snow avalanches pose a frequent risk to settlements, tourism and infrastructures like traffic
routes, communication and power lines in the European Alps. Therefore, organising protection
to mitigate the effects of natural hazards has a long tradition (Keiler et al. 2006, 637). During
the winter of 1998/99 extreme weather conditions prevailed in the Austrian Alps according to
the Amt der Tiroler Landesregierung (2009, 144-165). That winter the Austrian state of Tyrol
was characterised by both-long lasting, persistently heavy precipitation, fluctuating
temperatures, extreme snow drifts and heavy snowfalls which led to a snow accumulation of
up to 400 cm. In one month the amount of fresh snow was more than would normally fall
during a whole winter. Furthermore, the snow layering was extremely stable which hindered
avalanches from setting off and subsequently led to an accumulation of huge amounts of snow.
This triggered an avalanche of unforeseen dimension on February 23, 1999 (see Figure 14).
On this day at 4:05 pm an enormous powder avalanche struck the Tyrolean village of Galtür
burying approximately 100 people and leaving 31 people dead (Thaler 1999, 117-137). The
path of the disastrous avalanche was sub-divided into the so-called “Wasserleiter” and “Weiße
Riefe” avalanches. Together they reached a width of approximately 400 meters and deposited
roughly 130,000 tons of snow (Mair 2000, 107-109). Heumader (2000, 399-400) mentioned
that the avalanche, that can be regarded as extreme due its physical characteristics, also affected
60 residential and business buildings, among which six were completely destroyed and seven
heavily damaged. The material damage on buildings and facilities was estimated at 5.27 million
Euros by a Commission of the Tyrolean state (Heumader 2000, 400). This estimation does not
include both security measures for avalanche control and indirect damages that are difficult to
calculate like loss of revenue in the tourism sector or a damage to the image of the ski resort
Galtür.
Galtür
62
Figure 14 Map (top) showing the location of the small alpine village of Galtür (Austria) (source:
Tangient LLC), and photos showing the avalanche track (bottom left) (source: Rudi Mair) and disaster
aid workers searching buried persons (source: Austrian Armed Forces Photograph).
5.1
THE EVENT IN MORE DETAIL
The avalanche disaster of Galtür in 1999 can be classified as a natural hazard. It is therefore
assigned to the type avalanche in contrast to other natural hazards like earthquakes, floods,
volcano eruptions, storms or extreme temperatures which are also discussed as part of this
document. A snow avalanche is a sudden movement of snow down a slope. There are various
classifications of snow avalanche forms, the most common distinguishing between powder
snow avalanches - like in Galtür - which break away from a certain point, and slab avalanches
whereby a cohesive plate of snow slides as a unit on the snow underneath. Avalanches can
occur due to the following triggers: precipitation, temperature, wind, and overall snowpack
condition and human activity (Embleton-Hamann 2007, 47-48). Referring to the onset of the
disaster of Galtür it can be described as a slow event: there was time for indirect precautionary
measures in the Austrian state of Tyrol due to extreme weather conditions several weeks prior
to the disaster, but the release of the avalanche itself was of a sudden-onset nature. When the
disaster struck the local area of Galtür on 23 February 1999, the village was cut off from the
outside world. However, prior to the Galtür avalanche wide areas of Tyrol (along with the
Paznaun valley where Galtür is located) were already only accessible by air due to both
snowdrifts and heavy snowfalls lasting for days (Thaler 1999, 117-132). The weather
conditions worsened and numerous avalanches were reported in the European Alps, especially
in Austria, France and Switzerland. For the affected region of Tyrol, crisis management groups
were installed in Innsbruck and Landeck and were on alert. These groups had their first
meetings days before the extreme avalanche was triggered. Hence, exploratory flights and
supply flights to the Paznaun valley with food and medicine had been taking place since 9
February, two weeks prior to the avalanche.
In terms of geographical areas directly affected by the avalanche disaster of Galtür it can be
classified as a local or regional crisis. However, two conditions must be taken into account
when pigeonholing this particular event. Firstly, many of the 31 people that were killed were
not Austrian citizens: 17 were from Germany, six from the Netherlands and two were citizens
of Denmark. Secondly, when managing the crisis, international response was requested and
received from the USA, Germany, France and Switzerland. During the airlift 28 helicopters
from these countries were used in addition to 41 Austrian helicopters (Droessler 2002). To
conclude, considering the international fatalities and response, the Galtür disaster is classified
as a cross-border one.
63
In addition to the direct negative effects this avalanche disaster had on the lives of both the
residents of Galtür and the tourists, the natural hazard affected ground transportation, public
communication, healthcare, emergency services, energy transmission and the economic sector.
Many of these effects were associated with the fact that the village of Galtür was cut off from
the outside world and accessible only by air days before and after the avalanche was triggered
(Thaler 1999, 135). The rescue operation in the aftermath of the Galtür avalanche disaster
lasted until February 27, 1999. The Austrian Armed Forces carried out clean-up work of streets,
buried houses, forest etc. which lasted until 17 June 1999.
The Figure below provides a basic representation of the complexity of the event, by presenting
important information in a simple problem space.
64
Figure 15 Problem space overview of the 1999 Galtür avalanche
5.2
TRIGGERS OF CASCADING EFFECTS
This section provides an analysis of the cascading effects that occurred in the avalanche. Figure
16 below provides information on the sectors impacted, the nature of the impacts and over what
period of time the impacts occurred. While the first column indicates the main triggers that
caused cascading effects to occur, the remaining columns show what happened at certain times
and what effects are associated with this. The second column indicates the timescale of the
unfolding crisis (column 4) and the actions in crisis management associated with it (column 3).
Direct negative effects that occurred are described in column 5 and sectors directly and
indirectly affected in column 6 and 7. It must be noted that the impact of the crisis described
here is largely concentrated on those impacts associated with cascading effects as well as those
related to the cross-border nature of this crisis.
The subsections following this Figure analyse each of the boxes listed in its first column. As
these boxes address the exact triggers responsible for the cascading effects, the sub-sections
provide a detailed analysis of the cascading effects in the avalanche disaster of Galtür.
time (on relevant
timescale)
authority involved)
(vertical cascasde)
cascade)
since 06.02.1999, 19:30
LWZ: avalanche warnings lavel 4 and 5 &
road blocks of whole Paznaun valley
drifts
were not possible
date
09.02. - 28.2.1999
A
by air
medicines by air
temporary lifting of the road blocks
condition
transport system
22.02. - 28.02.1999
23 February 1999- 16:05
of Galtür
the scene of the accident
10.02. - 17.02.1999
search dogs, physicians, policeman and
world
C
themselves
had no uniform telephone line to
communicate
aggregated
Helper teams in Galtür were on their
alertness
possible
because of overload
D
A
Physical disturbance relation: due
to extreme weather conditions it
was difficult to provide a reliable
situation picture to LWZ in the first
place
time (on relevant
timescale)
authority involved)
(vertical cascasde)
cascade)
BHeer:
first debriefing
session
LWZ:
avalanche
warnings
lavel with
4 and 5 &
emergency
involved:
road
blocks organizations
of whole Paznaun
valley
unclear situation of the scope of the
avalanche in Galtür
drifts
were not possible
Energy transmission
andloss of
Economic
sector (local):
distribution
temporarily
affected
revenues
in the
tourism sector
17:43
09.02. - 28.2.1999
Mayor of Galtür gave the first situation
report to the LWZ, which later on it
turned out to be wrong
Mayor reported no fatalities, still
unclear how many persons were buried
24 February 1999- 6:45
10.02.
- 17.02.1999
until 7:45
LWZ: first helicopters started with
helper teams
(avalanche
rescue
group,
temporary
lifting
of the road
blocks
avalanche search dogs, physicians,
policeman and Red Cross helpers) from
Landeck to Galtür
condition improvement of the weather
temporary
condition
transport system
Galtür
is cut off from the outside
people with severe injuries were
world
flown to a hospital
LWZ: technicians,
powerto
sets
and
fuelan
Police
Landeck reported
LWZ
that
was carried
Galtür
ensure
avalanche
hittothe
localtoarea
of Galtür
communication
of Galtür
number of casulities and fatalities
were updated constantly
LWZ: not
psychologists
LWZ:
possible towere
fly intransfered
assistants to
Landeck
affected people and
the
scenetoofsupport
the accident
emergency services
since 06.02.1999, 19:30
17:00
date
22.02.
07:15 - 28.02.1999
23 February 1999- 16:05
LWZ: about 300 media representatives
LWZ:
avalanche rescue
avalanche
and photographer
weregroup,
informed
by a
search
dogs, physicians, policeman and
press spokesman
Federal Government of Austria:
requested large transport helicopters
from neighbouring states and NATO
Helper
teams
in because
Galtür were
on their
member
states
Austrian
own,
searching
fornumerically
survivors not able to
helicopters
were
E
Disruption of delivery supply
by air
relation: Federal Government of
Austria requested international
assistance for evacuation through
diplomatic channels because
transport helicopters were limited
in number and capacity
15:30
C
themselves
bring helper teams to Galtür and
evacuate people at the same time
US Army sent the first large transport
helicopters which landed at the airport
in Innsbruck
different
organisations involved in
medicines by air
aggregated
alertness
possible
bad weather conditions
because of overload
immediate use of these helicopters was
had
no uniform telephone line to
not possible
communicate
16:00
25 February 1999- 8:00
until 22:00
rescue flights had to be cancelled
LWZ: evacuation of 200 tourists and
locals with first priority started
Galtür is again cut off from the
outside world
best flight weather conditions
about 1200 people wanted to be
flown out and evacuated from
Galtür
68
time (on relevant
timescale)
since 06.02.1999, 19:30
date
09.02. - 28.2.1999
10.02. - 17.02.1999
A
26 February 1999- 16:00
22.02. - 28.02.1999
23 February 1999- 16:05
17:30
by air
27 February 1999- 12:00
authority involved)
(vertical cascasde)
cascade)
warnings
and 5 &
aLWZ:
crisisavalanche
intervention
centrelavel
was 4installed
road
blockswith
of whole
Paznaunand
valley
in
Landeck
psychologists
psychotherapists for relatives and
emergency
servicesgroups were installed
crisis management
drifts
were not possible
LWZ: additionally to Austrian helicopters
German,
andsupply
Swiss helicopters
were
BMI and US
BHeer:
flights to Galtür
used
for evacuation
purposes &
with foodstuffs
and medicines
C
themselves
18:00
17 June 1999
number of casulities and fatalities
were updated constantly
LWZ:
a list of
flown
was
temporary
lifting
of out
the persons
road blocks
publised on the internet
condition
LWZ: French helicopters were used for
evacuation
porposes,
too public
LWZ: blockages
of whole
transport system
fatalities were taken to Innsbruck by
helicopters
LWZ: all transport flights for evacuation
purposes ended successfully
of Galtür
the scene
of the accident
LWZ:
200 emergency
services were still
looking for missing persons
world
upcoming
were
cancelled
100 peopledays
were
buried
by the
buses and spezial trains were offered to
Helper
teams to
in their
Galtürhome
weretowns
on their
bring
tourists
for
free
60 buildings were affected, among
which six were completely
destroyed and seven heavily
damaged
LWZ: with approval of BHeer the flying
ban was lifted
LWZ:
roads
and public
transport
had no
uniform
telephone
line toroutes
were
re-opened
communicate
avalanche, 31 people died, 11 had
severe injuries
medicines by air
aggregated
search operation
dogs, physicians,
and
rescue
in the policeman
aftermath of
RedGaltür
Cross avalanche
helpers waited
in Landeck
the
disaster
finishedfor
28 February 1999- 12:00
because of overload
alertness
Emergency
Large-scale
revenues inservice:
the tourism
sector
operation
to Galtürinfrastructure
was not
because damaged
possible
(roads, hotels) had to be rebuilt to
be usable for tourists again
revenues in the tourism sector and
damage to the image of the ski
resort Galtür
Austrian Armed Forces finished clean-up
process
Figure 16 Visual overview of 1999 avalanche disaster in Galtür
69
5.2.1 Box A: Political relational condition
Box A addresses a political relational condition which enabled the avalanche disaster to
unfold and escalate the way it did. Galtür with its almost 800 inhabitants (Stötter et al. 2002,
169) is located at an altitude of 1583m (Amt der Tiroler Landesregierung 2009, 146) and has
always been avalanche-prone due to its exposed position in the mountainous Paznaun valley.
The political condition as a pre-crisis condition plays a role as Galtür was a farming village
since the mid-twentieth century that was transformed to a tourism winter resort as Keiler et al.
(2005, 50) point out. This transformation was a political decision that was agreed upon by the
municipal council. Due to this transformation, deforestation for settlement, tourism and
infrastructure (e.g., transport routes) proceeded and led to the spatial extension of endangered
areas as the trees prevented large snow masses from accumulating. Furthermore, with Galtür
relying on tourism the number of persons exposed to the risk of avalanches increased as during
winter season a multiple of its visitors stay in endangered areas (Keiler et al. 2005, 57). To sum
up, Galtür being an avalanche-prone village and having gone through a transformation towards
tourism inevitably meant that roads were going to be cut off and infrastructure was going to be
damaged if an avalanche would happen.
5.2.2 Box B: Physical disturbance relation
Unlike box A, box B addresses triggers that did not exist prior to the disastrous event, namely
a physical disturbance relation. Heavy snowfalls, snowdrifts and the avalanche disaster itself
caused damage to roads (ground transportation), which meant that Galtür was accessible only
by air (air transportation). Therefore, according to Thaler (1999, 117-130) the
Bundesministerium für Inneres (Federal Ministry of the Interior) and Bundesheer (Austrian
Armed Forces) had to operate supply flights to Galtür with food and medicine as well as
exploratory flights on a regular bases between 9 and 28 of February, 1999. When the extreme
avalanche hit the local area of Galtür on February 23 the weather conditions had worsened and
the village was completely cut off from the outside world. For this reason the LWZ was not
able to fly in assistance to the scene of the accident and a large-scale operation could not be
sent to Galtür (emergency service). First responders in Galtür were searching for survivors on
their own, until the weather conditions improved temporarily. Only during the early morning
hours of February 24 the LWZ was able to send helicopters with emergency responders
(avalanche rescue group, avalanche search dogs, physicians, policemen, and Red Cross
personnel) from Landeck to Galtür. Furthermore, because roads were still impassable until
February 28 an airlift was established to both fly out the seriously injured, supply the isolated
village of Galtür with food and medicine, and evacuate tourists and locals. To sum up, due to
severe weather conditions the whole ground transportation system was blocked which impacted
indirectly on air transportation: transport helicopters were aggregated. Moreover, when the
avalanche hit the local area of Galtür it was completely cut off from the outside world, not
accessible by any means of transport and a large-scale emergency operation could not reach
the accident site immediately (emergency services).
5.2.3 Box C: Disruption of information relation
Box C refers to a disruption of an information relation by the means of telecommunication.
During the disaster, the communication of relevant information from and to Galtür was difficult
as both landline and mobile phone networks were overload and threatened to fail (Thaler 1999,
133) and because different organisations involved in rescue operation and crisis management
had no common telephone line to communicate among themselves (Thaler 1999, 146). It was
challenging for rescue organisations as well as police in Landeck to communicate with
emergency personnel in Galtür since radio and telephone systems could not be relied upon
(public communication) (Parlamentarische Anfragebeantwortung 1999b). The communication
problem between Landeck and Galtür was solved successfully by improvising and installing a
quite stable connection via a radio network (Thaler 1999, 143).
Furthermore, due to severe weather conditions and avalanche warnings journalists and relatives
were not able to get to Galtür. For this reason, media representatives and relatives called the
LWZ in Landeck continuously to get the latest information. The crisis management group was
not prepared for this enormous media interest with about 300 journalists and photographers
continuously requesting information on what happened (Thaler 1999, 134). There were two
telephones, a fax machine and one mobile phone available for press relations which turned out
to be insufficient (Österreichischer Städtebund 2001). For dealing with this challenge a press
spokesman was installed on February 24 to inform and support media representatives in
Landeck, which proved successful.
5.2.4 Box D: Physical disturbance relation
Box D addresses a second physical disturbance relation. Although the same category of
dependency is touched upon in 5.2.2, this cascade is different content wise. When the extreme
avalanche hit Galtür the weather conditions were severe and the village was cut off from the
outside world. Therefore, emergency personnel in Galtür were on their own while searching
for survivors. According to Thaler (1999, 132), one hour after the avalanche was triggered the
first debriefing session with emergency organisations involved took place in Landeck. The
LWZ, however, could not provide a clear picture of the situation because essential information
was lacking. In addition, the Mayor of Galtür gave the first situation report to the LWZ at 17:43
the same day and reported that it was unclear how many persons were buried, but that no deaths
had occurred. Later on, this information turned out to be wrong. The flaws in this physical
disturbance relation were not man made but could be traced back to the extreme weather events.
However, these flaws impacted on the organisation of the rescue operation for the following
reason: when a person is buried by an avalanche the chance to survive decreases from 92% in
the first 15 minutes to 3% after 90 to 130 minutes (Nairz 2000, 112). When being buried by an
avalanche the probability of surviving decreases rapidly. Therefore, it is very important to
rescue people buried as soon as possible which, however, was very difficult at the disaster of
Galtür. It therefore contributed to the unfolding of the crisis the way it did.
5.2.5 Box E: Disruption of supply relation (delivery)
Box E addresses a supply relation of dependency in the sense of the delivery of helicopters.
This relation covers the dependency on the aircrafts for airborne operations. When the rescue
operation started on February 24, all Austrian transport helicopters were aggregated and in use
in the Tyrolean region (air transportation). However, Austrian helicopters lacked the capacity
to bring emergency personnel to Galtür and evacuate people at the same time. Thus, the Federal
Government of Austria requested large transport helicopters from neighbouring states and
NATO member states through diplomatic channels (Parlamentarische Anfragebeantwortung
1999c). In total, the USA, Germany, Switzerland and France sent 28 helicopters to Austria to
aid the airlift in Galtür and other avalanche prone villages in Tyrol as referred to in section 1.2
(Droessler 2002).
5.3
LESSONS LEARNED
While in the previous sub-sections triggers or disruptions of dependency enabling cascading
effects at the avalanche disaster of Galtür in 1999 were identified, this section will address
some opportunities for identifying lessons that can contribute to the understanding of the
unfolding of cascading events in disasters. The most relevant lessons on what went wrong and
what went well are discussed in sub-sections below.
71
An analysis of triggers of cascading effects in the previous section showed that most relations
were intertwined in the sense that they are linked to each other. Four different types of triggers
caused cascading effects, namely political relational conditions, physical disturbance relation,
information relation, and a supply relation. Certain pre-crisis conditions, like Galtür having
gone through a transformation towards tourism, increased both the residual risk of a disastrous
event and the uncertainty regarding its extent. As a consequence of the avalanche various
measures were taken in Galtür to both minimise risks of avalanche hazards, improve the
avalanche warning service and prevent triggering of avalanches: hazard zone plans were
adapted and the most dangerous red zone was extended, an automatic weather station was
installed, preventive and protective walls as well as avalanche breakers were built and the
starting zones of the “Wasserleiter” avalanche was protected by supporting structures
(Heumader 2000, 404-405). However, regardless of all protective measures taken in avalancheprone villages like Galtür, a residual risk remains with this type of natural hazard.
With regards to the development of the rescue operation and crisis management of the
avalanche disaster in Galtür at 16:05 o’clock, some strong points can be identified. Despite the
meteorological circumstances, the overall rescue operation, crisis management, and
cooperation between different organisations and public authorities went smooth as pointed out
by the Austrian Minister of the Interior (Parlamentarische Anfragebeantwortung 1999a).
Problems that occurred during the rescue operation, such as the communication problem
between Landeck and Galtür were solved as quickly as possible (Thaler 1999, 143).
5.4
CONCLUSION
The case study on the avalanche disaster of Galtür showed that the triggering factors causing
cascading effects were largely not human decisions but rather caused by severe weather
conditions. Four out of five triggers of cascading effects discussed above related in one way or
another to extreme weather conditions. Considering this, the rescue operation, crisis
management, cooperation between different organisations and public authorities worked very
well. As in other case studies discussed in this deliverable, the Galtür avalanche demonstrates
that pre-disaster conditions were of influence on the event evolving the way it did. In this case
this refers to the transformation to tourism Galtür had undergone, despite it being an avalancheprone village.
72
6
THE HEATWAVE OF 2003
Several European countries including France, Switzerland, Portugal, Germany, and the UK
experienced anomalously high mean surface temperature as well as extremely dry conditions
during the summer of 2003 (Garcia-Herrera et al. 2010). According to the UNEP (2004, 1)
extreme maximum temperatures of 35°C to 40°C were recorded across Europe in July and
August. These record high temperatures were 20 to 30% higher than the seasonal average
temperatures in most European countries. The unusually warm summer of 2003 in terms of
both intensity and duration was the hottest in Europe since more than half a millennium
(ProClim 2005, 5; Garcia-Herrera et al. 2010, 275). Garcia-Herrera et al. (2010, 276-283) list
several meteorological conditions that contributed to this historic European heatwave. One
factor was that the average precipitation was reduced by more than 50% between February and
May 2003 leading to a soil moisture deficit. Furthermore, extremely hot and dry summer
months especially between June and August were caused by an intense meridional airflow and
contributed to the intensity and persistence of the heatwave.
The temperature anomalies of the summer 2003 had an impact on both human health and
ecosystems. Numbers of heatwave related casualties vary between 70,000 deaths for the
summer 2003 in Europe according to a publication that was produced within an EU funded
project (Robine et al. 2007, 8) and 30,000 people (mostly elderly) (UNEP 2004, 2). The
difference in estimates can be explained by their sensitivity to the method used to calculate the
excess mortality (Kovats et al. 2004). Regardless of this, the estimated death toll made the
heatwave one of the deadliest European natural disaster in the last 100 years (UNEP 2004, 2).
Furthermore, the UNEP (2004, 2-3) reported that the productivity of vegetation was negatively
affected by the drought, particularly crops and fodder. In addition, water stress weakened trees
and encouraged forest fires. Moreover, more than 25,000 forest fires were recoded all over
Europe and a total amount of about 650,000 hectares of forest were burned (UNEP 2004, 4).
Further, due to extreme weather conditions a large proportion of harvests was threatened to fail
and production costs increased, affecting especially the green fodder supply, the arable sector,
livestock sector and forestry. Moreover, the Alpine glaciers lost an estimated 5-10% of the total
remaining ice cover (UNEP 2004, 3). The degradation of mountain permafrost also resulted in
small but widespread Alpine rock falls. Furthermore, nuclear power plants in France suffered
from overheating. The risks of this have been made clear in the Fukushima case study. Several
nuclear power plants had to shut down, which led to a cut in power exports by more than 50%
(UNEP 2004, 3). Overall, the economic losses due to drought and the forest fires were
estimated to exceed 13 billion Euro (UNEP 2004, 4).
The following analysis of the heatwave focuses in detail on one particular European country:
France. France experienced some of the highest temperature anomalies in 2003 (see Figure 17)
with temperatures exceeding 40°C (WHO 2004, 18). Nationwide, 14,082 excess deaths were
estimated for August 2003, more than that of any other European country (UNEP 2004, 2). The
National Institute for Public Health Surveillance (INVS) in France as well as the WHO
estimated that total mortality increased by 60% between August 1 and 20 in the relevant year
(INVS 2004, 19; WHO 2004, 21).
73
France
Figure 17 Map (top left) showing the differences in surface temperatures collected in the two years by the
Moderate Resolution Imaging Spectroradiometer (MODIS) on NASA’s Terra satellite (source: NASA).
Areas highlighted deep red (mainly in France) are showing where temperatures were 10 degrees Celsius
hotter in 2003 than in 2001. In a photo (top right) taken during summer 2003 the Parisian Eiffel Tower
was barely visible due to heavy air pollution (source: Jack Guez/AFP). Photo (bottom right) shows elderly
population which was most vulnerable to excessive heat (source: AFP/Getty Images).
6.1
The heatwave of 2003 is an extreme temperature event, and can therefore be classified as a
natural hazard. The time scale of the heatwave in France can classified as slow onset, reaching
a peak during the first two weeks in August 2003 with anomalously high mean surface
temperatures. This peak of the heatwave corresponded with a peak in excess mortality (INVS
2004, 2; Garcia-Herrera et al. 2010, 287). In fact, the disaster could even be described as
creeping, evolving during the summer months of 2003 (from June to September) (Robine et al.
2007). However, the geographical distribution of the heatwave of 2003 includes Europe and
the Mediterranean Sea with regional and seasonal variations (Garcia-Herrera et al. 2010).
Therefore, the heatwave of 2003 was of a cross-border nature. Furthermore, international
emergency response was offered to deal with the impacts of the heatwave but not in France on
which the present case study will focus on. Additionally to the direct negative effects the
heatwave had on the lives of 14,082 people who died and others in France, it severely affected
the healthcare, emergency services, social sector, energy production, residential housing sector
and the natural environment (INVS 2004, 2-4). The heatwave of 2003 is not characterised as
an isolated event; extreme temperature events are expected to occur more frequently in the
74
future due to global warming, which is connected to climate change (WHO 2004; GarciaHerrera et al. 2010).
Figure 18 below provides a representation of the complexity of the event, by presenting
75
Case
Types of hazard
Principal nature(s) of
impact
Scope of impact
Onset of crisis
Scope of CM
Cross border?
Principal involved
actors in CM
Directly affected
sectors
Indirectly affected
sectors
cascade
Tsunami-Fukushima,
Japan, 2011
Natural
Physical
International & cross
border
Sudden
Global
Yes
Police
Transportation
GROUND
Transportation
GROUND
Disruption of
Firework factory
Social
Social / Psychological
National
Rapid (Hours/days)
International
No
Fire
relation
London attacks (2005)
Technological
Economic
Regional
Slow (Weeks)
National
Health
Energy production
Energy production
Disruption of
organisational relation
Heat wave 2003
(France)
Antagonistic
Political
Local
Creeping
(months/years)
Regional
Local admin. Municipal Energy transmission
govt.
and distribution
Energy transmission
and distribution
Malfunctioning of legal
and regulatory relation
Local
National/central
government
Water provision
Water provision
Galtür, AT (1999)
National security
(telecom)
Central European
floods (focus on
Prague) (2002)
Insurance companies
Waste & biochem
Waste & biochem
(2012)
Civil protection
authorities
Healthcare
(hospitals&clinics)
Healthcare
(hospitals&clinics)
Eruption of
Eyjafjallajokull in
Iceland (2010)
MACC, CMC, etc.
Emergency services
and national security
Emergency services
Civil society
organisation
Economic services
Economic services
Community based
organisations
Government sector
Government sector
(Decision & continuity) (Decision & continuity)
Intergovernmental
organisations
Social
sector(Education,
aggregation, icon)
Residential housing
sector
Social
sector(Education,
aggregation, icon)
Residential housing
sector
Natural environment
Natural environment
Malaysia Airlines MH17
plane crash (2014)
Companies/ industry
Media
Figure 18 Problem space overview of the 2003 heatwave
6.2
The Figure below provides information on the sectors impacted by the heatwave, the nature of
the impacts and over what period of time the impacts occurred. While the first column indicates
the main triggers that caused cascading effects to occur, the remaining columns show what
happened at certain times and what effects are associated with this. The second column
indicates the timescale of the unfolding crisis (column 4) and the actions in crisis management
associated with it (column 3). Direct negative effects that occurred are described in column 5
and sectors directly and indirectly affected in column 6 and 7. It must be noted that the impact
of the crisis described here is largely concentrated on those impacts associated with cascading
effects.
The subsections following Figure 19 analyse each of the boxes listed in its first (green) column.
As these boxes address the exact triggers responsible for the cascading effects and dependency
relations, the sub-sections provide a detailed analysis of the cascading effects during the 2003
French heatwave.
time (on relevant
timescale)
authority involved)
unusually high temperatures and dry
weather
04.08.-13.08.2003
extreme weather conditions: mean
temperatures were higher than average,
small variation between day and night
termperatures, long period of both high
mean temperatures as well as no
cooling during nights
longest sequence of consecutive
hot days in the French
meteorological history
general holiday period: many managers,
politicians, senior staff of emergency
services, and general practitioners were
on holidays
many managers, politicians, senior
staff of emergency services, and
general practitioners were not
available
Aug.03
01 August 2003
Météo-France: published press release
informing about risk of drought and
weather conditions
300 deaths above the average for a
single day (compared with the
same period in 2000-2002 ) were
observed
04 August 2003
B Disruption of an information
relation: information was not
passed on in time to hierarchically
higher authorities because the
seriousness of the situation was as
not appropriately valued.
cascade)
June to September 2003
A Cultural relational condition: Due
to the cultural tradition of going
on annual leave in August,
managers, politicians and senior
staff of emergency services were
on holidays when the heat wave
struck France.
(vertical cascasde)
04 August 2003
06 August 2003
Météo-France: temperatures above
35°C were recorded in two-thirds of
meteorological sites, and above 40°C in
15% of these sites
Emergency services such as ambulance,
fire crew and emergency doctors
reported higher than average number of
emergency calls and hospital admissions
06 August 2003
InVS and DGS received first report of a
health alert by a physician, InVS and DGS
was not aware of the seriousness of the
situation
07 August 2003
informing about health risks of the
population (especialy elderly) due to
weather conditions
higher than average number of
emergency calls and hospital
admissions were reported
C Disruption of an organisational
relation: poorly coordinated
services, insufficient alerts, lack of
efficient mitigation measures and
action plans with emergency and
health care services as well as
politicians in charge.
time (on relevant
timescale)
authority involved)
08 August 2003
08 August 2003
Hospital emergency services reported
being overwhelmed
04.08.-13.08.2003
Funeral services and morgues reported
higher than average number of bodies
struck France.
09 August 2003
Aug.03
11 August 2003
01 August 2003
(vertical cascasde)
cascade)
weather
1200 excess deaths were observed
extreme weather conditions: mean
hospital
services
hot daysemergency
in the French
reported
being overwhelmed
meteorological
history
general holiday period: many managers,
media
reports
started
up the
politicians,
senior
staffby
ofpicking
emergency
concerns
of the
emergency
and funeral
services, and
general
practitioners
were
services
on holidays
general practitioners were not
available
04 August 2003
13 August 2003
06 August 2003
13 August 2003
13 August 2003
06 August 2003
16 August 2003
07 August 2003
18 August 2003
After a meeting with the members of
Météo-France:
temperatures
the French government
'Whiteabove
Plan'(Plan
35°C
in two-thirds
Blanc)were
was recorded
applied because
of theof
meteorological
sites,
and
above
conclusion that a major epidemic40°C
wasin
15%
of thesea sites
developing:
set of previously designed
procedures to deal with unusual
circumstances where the general wellbeing is seriously threatened
French government
it was
now of
reported
higher thanstatet
average
number
clear that these
were occurring
emergency
calls deaths
and hospital
admissions
largely among the elderly populatio
Météo-France: announced progressive
ending of the heat wave
situation
French government:
of heat
population
(especialypeak
elderly)
due wave
to
was overconditions
and extent of disaster was
weather
now apparent
Healthcare: hospitals were
overwhelmed by treating the
growing number of patients, 42%
of excess deaths occurred in
hospitals
Emergency service: hospital
emergency services struggled to
cope with the growing number of
people at risk
300 deaths above the average for a
single
day (compared
withobserved
the
2200 excess
deaths were
same period in 2000-2002 ) were
observed
higher than average number of
3000 excesswere
deaths
were observed
admissions
reported
confusion concerning the full extent of
the disaster, little information on victims
was available
79
Social sector: funeral homes
received more dead bodied than
they could cope with and
therefore used provisional storing
methods
number of deaths was higher then
average
A meeting with the members of the
French government has held to discuss
Météo-France:
published
pressasrelease
implications of the
heat wave
well as
informing
about riskthat
of drought
and
technical problems
EDF were
weather
conditions
experiencing
in managing energy
supplies
04
12 August 2003
time (on relevant
timescale)
authority involved)
weather
(mostly elderly) suffered from
people
hyperthermia, heatstroke, dehydration,
extreme weather
disorders
respiratorymean
andconditions:
cardiovascular
04.08.-13.08.2003
01.08.-20.08.2003
lowered
in rivers
levels
water
general
holiday
period:
many managers,
politicians, senior staff of emergency
around
generate
stations
power
nuclear
services, and general practitioners
were
of France's electricity; water levels
75%
on holidays
in rivers dropped low, water
temperatures after the cooling process
have exceeded safety
levels, cooling process became
impossible
D Disruption of a physical media
E
Physical disturbance relation:
extreme weather conditions
impacted widely on environmental
sector.
Aug.03
01 August 2003
informing about risk of drought and
weather conditions
2003
04 August 2003
04 August 2003
2003
cascade)
supply relation: due to lower
water levels in rivers the cooling
process of power plants became
impossible. Several nuclear power
struck France.
stations shut down.
(vertical cascasde)
Météo-France: temperatures above
35°C were recorded in two-thirds of
meteorological sites, and above 40°C in
15% of these sites
reported higher than average number of
emergency calls and hospital admissions
situation
07 August 2003
population (especialy elderly) due to
weather conditions
plants suffered
nuclear
generalpower
practitioners
were notfrom
overheating
available
80
Energy production: several (six)
nuclear power plants had to shut
down or operate at reduced
capacity, which led to a cut in
power exports by more than 50%
Maize grain crop was reduced by
30%, fruit harvests declined by
25%, wheat had nearly achieved
the heatfor a
ofaverage
time
by the
maturity
300 deaths
above
the
forage
by 21%,
wave
singleand
daydeclined
(compared
with the
reduced on) were
was
production
same period
in 2000-2002
by 30%
average
observed
Natural environment: Agricultural
production (food): the quantity
and quality of harvests decreased,
economic losses for agriculture
were estimated at 4 billion Euros
Forest fires (73,000 ha) destroyed
many areas of land and damaged
the environment, high levels of high
air pollution, vegetation growth
was reduced by about 30 %, Alpine
glaciers lost an estimated 5-10% of
the total remaining ice cover,
of mountain
degradation
higher than average
number of
permafrost
Natural environment was affected
by forest fires, reduction in
vegetation, degradation of
mountain permafrost, increased air
pollution
admissions were reported
August 2003
Figure 19 Visual overview of06the
2003 French heatwave
06 August 2003
hot days in the French
meteorological history
14,082 excess deaths in France,
with elderly population above 75
years mainly affected
6.2.1 Box A: Cultural relational condition
Box A addresses a certain pre-crisis condition that enabled the 2003 French heatwave to
unfold and escalate the way it did, namely a cultural relational condition. Due to a cultural
tradition in France, managers, politicians, general practitioners and senior staff of emergency
services go on annual leave in August (WHO 2004, 31; Stephenson 2009, 302). As a result,
when the heatwave struck France, personnel shortages were immanent in these sectors
(Lagadec 2004, 162; Ogg 2005, 8). Moreover, the shortage of staff during the traditional
holiday period in August that is part of annual leave in summer in general had negative effects
on information and organisational relations, which will be described below. Another dimension
of the French tradition of going on vacation during August was addressed by Evin et al. (2004),
who emphasised that people without financial capacities to going on vacation, especially
elderly, were left behind. Therefore, the elderly people left behind were not in the position to
call their relatives on holiday during the heatwave spontaneously and ask for help.
6.2.2 Box B: Disruption of an information relation
Box B addresses a disruption of an information relation that pre-dated the heatwave and
could be either face-to-face or via telecommunication. Because of not passing on available
information in time to hierarchically higher authorities basically communication between
emergency and health care services was poor. This not only had consequences for the
transmission of information, but also for the organisational response to the heatwave. The
failure in coordination of both services and public authorities as well as by the French
government as described in the box C ‘disruption of an organisational relation’ were closely
related to not quickly enough passing on available information to hierarchically higher
authorities because the seriousness of the situation was as not appropriately valued (Evin et al.
2004; WHO 2004, 30). For example, while InVS and DGS received a first report of a health
alert by a physician on August 6, both public authorities were not aware of the seriousness of
the fast-approaching disaster and therefore did not pass on the information to other public
health authorities in due time (INVS 2004, 18). Thus, poor communication and a lack of
information sharing between emergency and health care services led to a slowness of services
and public authorities involved (Ogg 2005, 13). The inadequate exchange of information is
summarised by Lagadec (2004, 161) as the following: ‘in a nutshell, organisations and people
in charge did not have the intellectual and practical frameworks to respond adequately to the
2003 heat episode’. Furthermore, services and public authorities were understaffed as already
elaborated in Box A, and responsibilities were not clearly defined because a heatwave plan was
missing in 2003 (WHO 2004, 27).
6.2.3 Box C: Disruption of an organisational relation
Another dependency relation is addressed in Box C, namely disruption of an organisational
relation, which is closely and inherently connected to the information relation. The
organisational relation of actors involved in emergency management was disrupted because
there was no heatwave response plan in place during the disaster of 2003 (Stephenson 2009,
299). Therefore, it was an additional challenge for services and public authorities to classify
the event happening as an “emergency situation” since it did not fit to any already existing
format (Leger et al. 2004, 162). Due to the missing heatwave response plan emergency
management (public authorities and politicians in charge) did not realise and classify the
ongoing disaster as such for many days while the death toll was increasing rapidly (Evin et al.
2004; Leger et al. 2004; Lagadec 2004; WHO 2004). This delay in classification led to a lack
of efficient mitigation measures, poorly coordinated emergency services, insufficient alerts on
risk and mistrust in political decision makers occurred (WHO 2004, 30).
The coordination of services for elderly people, for example, was not sufficient both prior to,
and during the heatwave (Leger et al. 2004). Therefore, nursing homes lacked of air
conditioning or and provided inadequate ventilation (Ogg 2005, 28). Nursing homes were also
slow to realise that the excess death rate was above the average although they were used to deal
with deaths.
An example of the lack of raising alert that occurred during the heatwave is the press release
by Météo-France (INVS 2004, 18). It provided information on the health risks of the population
(especially the elderly) due to extreme weather conditions. However, when the press release
was issued, about 1200 excess deaths had already been reported (WHO 2004, 21). These alerts
on risk aimed at increasing awareness of the heatwave, however, they turned out to be
insufficient because they were raised too late. Additionally, this corresponds with the fact that
there was no heatwave plan in place which would have enabled emergency services and public
health authorities to proceed systematically and timely (WHO 2004, 21; Lagadec 2004, 162).
Moreover, the investigations in the aftermath of the heatwave disaster also disclosed the role
of the French Ministry of Health and it`s administrative institutions, which failed to fulfil their
role of monitoring the health status of the population and respond adequately to the disaster
(Lagadec 2004; Evin et al. 2004). Furthermore, in several articles it was stressed that most
actors involved in emergency management became aware of the extent of the heatwave via
media reports which draw a direct line between the death of many people and the unusually
high temperatures that occurred in August 2003 without being asked to do so by public health
authorities (Leger et al. 2004; Lagadec 2004; Ogg 2005).
6.2.4 Box D: Disruption of a supply relation of physical media
Box D addresses a disruption of a supply relation of physical media, water, as a resource
through a physical, permanent infrastructure - namely nuclear power stations. During the
French heatwave of 2003 the water levels in rivers became critically low, leaving insufficient
water to be used for the cooling of power plants (UNEP 2004, 3). The French prime minister
agreed to shut down several nuclear power stations because they experienced overheating
(UNEP 2004, 3). Therefore, nuclear power stations which generate around 75% of France's
electricity operated at reduced capacity and electricity exports to other European countries were
reduced by more than 50% to ensure energy supply for the French population (UNEP 2004, 3).
Furthermore, the French government gave a specific authorisation to EDF that allowed some
nuclear power stations to be running under temporarily loosened regulations; the power plants
were permitted to ‘pump their cooling water into nearby rivers at a higher temperature than
usual to allow them to continue generating electricity’ (Gentleman 2003). ‘Water temperatures
after the cooling process exceeded safety levels’ (Gentleman 2003).
6.2.5 Box E: Physical disturbance relation
In contrast to the other relations discussed, box E addresses a relation that was not previously
there, namely a physical disturbance of dependency. Anomalously high temperatures and
drought affected the natural environment massively. Temperatures above 35°C were recorded
in two-thirds of meteorological measuring points in France, and above 40°C in 15% of these
sites (WHO 2004, 18). These severe weather conditions were mainly responsible for a
reduction of maize grain crop by 30%, a decline of fruit harvests by 25% in 2003 (compared
to 2002), a reduction of 21% in earning made through selling wheat, and forage production
was reduced by 30% on average (Parry et al. 2007, 846). The combined losses in agriculture in
2003 totalled roughly were estimated to be 4 billion Euros (Parry et al. 2007, 846).
82
Additionally, the vegetation and ecosystem were affected by the anomalously high
temperatures and drought. In France, forest fires burned 73,000 ha of land (Garcia-Herrera et
al. 2010, 288) as well as high ground-level ozone were reported leading to high levels of air
pollution and negatively effecting human health. Furthermore, drought impacted on vegetation
and vegetation growth was reduced by about 30% in Europe (Garcia-Herrera et al. 2010, 289;
Parry et al. 2007, 846), while Alpine glaciers in the Alps lost an estimated 5-10% of the total
remaining ice cover (UNEP 2004, 3). Furthermore, long-term impacts are expected on
vegetation, e.g., increased occurrence of highly flammable, shrubby vegetation as well as
reduction in species richness and overall biodiversity losses (Parry et al. 2007, 846).
6.3
LESSONS LEARNED
The analysis of the French heatwave disaster of 2003 presents various possibilities for
identifying lessons that can contribute to the understanding of the unfolding of cascading events
in crises. The most important lessons on what went wrong and what went well are discussed in
the sub-sections below.
An analysis of the sub-sections presented in section 6.2 reveals the importance of taking into
account cultural traditions, information sharing, good coordination of services, the dependency
on the supply of water for nuclear energy production and environmental effects of extreme
weather conditions. These five relations are discussed here as triggers or dependency relations
from which lessons learned can be drawn, and that can contribute to the understanding of the
evolution of cascading effects.
What can be learned from the heatwave disaster of 2003 is the need to be better prepared for
future extreme weather events. In the aftermath of the disaster, several studies were
commissioned by public health authorities and the French Ministry of Health to better
understand and meet the needs of most vulnerable people, especially elderly, disabled and
isolated individuals (INVS 2004). As a consequence, a couple of preventive measures were
implemented by the French government: national and local heatwave plans were both
developed and implemented, a registration system was introduced for vulnerable older people,
environmental surveillance was enhanced, architectural improvements were made in nursing
homes by financially supporting the installation of air conditions as well as having ‘cool rooms’
where residents could take shelter in the event of a heatwave (WHO 2004; Ogg 2005). These
were some measures taken to mitigate adverse health effects of future heatwaves in France.
With regard to crisis management operations during the response phase of the 2003 French
heatwave, not many strong points can be identified. However, one action contributing to
informing the general public before public health authorities does deserve attention. When the
media started reporting about the direct connection between increasing death rates and the
heatwave, the French health minister made an effort to appease the public by stating
‘everything’s under control’ (Lagadec 2004, 161). The President of the Association des
Médecins Urgentistes de France (Emergency physicians) did not agree with the official
appeasing policy and raised alarm about health impacts arising from the extreme heat by giving
a couple of media interviews after he unsuccessfully tried to alarm public health authorities
(Lagadec 2004, 161; Ogg 2005, 9). As a reaction the French government announced on August
11 that the alarming of the public would be ‘politically motivated polemics’ (Lagadec 2004,
160). To sum up, although not intended by public health authorities, media reports were of
83
importance for raising awareness about the lethal effects of the heatwave among the general
public.
6.4
CONCLUSION
The case study on the French heatwave disaster of 2003 showed that the triggering factors
causing cascading effects were wrong human decisions taken by emergency services, public
health authorities and politicians in charge because they were totally unprepared for the event.
Although two out of five triggers of cascading effects discussed above relate to extreme
weather conditions, three triggers relate to the unpreparedness for a heatwave in France. This
resulted partly from the fact that previous to the disaster of 2003, heatwaves were not
considered as a serious risk for human health in Europe (Kovats et al. 2004). Furthermore, the
emergency actors and organisations involved in crisis management were not able to invent ad
hoc solutions to tackle the disaster resulting from the extreme weather (Lagadec 2004, 169).
Such capacity would have increased the crisis management as a heatwave plan, which would
have determined who makes decisions and who is obliged to do what and when, was not in
place in France. The analysis of the French heatwave of 2003 also brought to light major
deficits in the French public health system, vulnerabilities of the nuclear energy sector, which
France is mainly dependent on, as well as vulnerabilities of the environmental sector. As in
some of the case studies previously discussed, the 2003 French heatwave demonstrates that
pre-disaster conditions once again were of influence on the event evolving the way it did. In
this case this refers to efficient mitigation measures and information sharing lacked, alerts were
insufficient and crisis management was poorly coordinated by emergency services, public
health authorities and politicians in charge. These (human) deficits mentioned contributed to
the unfolding of cascading effects in this heatwave that claim lives of 14,082 people in France
(UNEP 2004, 2).
84
7
MALAYSIA AIRLINES MH17 PLANE CRASH
On Thursday 17 July 2014 at 13:20 Greenwich Mean Time, Dnipropetrovs`k air traffic control
centre (Ukraine) lost contact with flight MH17 which had departed from Amsterdam’s
Schiphol airport and was heading to Kuala Lumpur International Airport (DSB 2014a, 14). As
it later turned out Malaysian Airlines (MA) Boeing 777-200 was at 30 km from Tamak
waypoint, approximately 50 km from the Russia-Ukraine border, when it crashed (Malaysian
Airlines (MA) 2014b). The last radio transmission made by the crew of the plane ended
abruptly at 13:19:59 (DSB 2014a, 14). All 283 passengers and 15 technical and cabin crew
died (MA 2014b). The people on board of MH17 were of different nationalities, some had dual
citizenship: 193 Dutch (including one dual Netherlands/USA citizen), 43 Malaysian, 27
Australian, 12 Indonesian, ten UK (including one dual UK/South African citizen), four
German, four Belgian, three Filipinos, one Canadian and one New Zealander (MA 2014b).
According to Eurocontrol, the European Organisation for the Safety of Air Navigation, the
aircraft was flying at Flight Level 330 (approximately 10,000 metres or 33,000 feet) when it
disappeared from radar (Eurocontrol 2014). This route had been closed by the Ukrainian
authorities from ground to Flight Level 320 but was open at the level at which the aircraft was
flying (Eurocontrol 2014; Dutch Safety Board (DSB) 2014a, 13). Therefore, flight MH17 was
flying in unrestricted airspace when it crashed (DSB 2014a, 14; MA 2014b, IATA 2014a). In
their preliminary report the DSB, which is leading the international investigation, concluded
that preliminary findings indicated that the aircraft broke up in the air probably as a result of
structural damage caused by a large number of high-energy objects that penetrated the aircraft
from outside (DSB 2014a, 24-28). Flight MH17 crashed during on-going civil warfare between
Ukrainian armed forces and armed forces of the self-declared Donetsk People's Republic as
well as the self-declared Lugansk People’s Republic (OSCE 2014).
85
Figure 20 Map (top left) showing the route of the Malaysia Airlines Flight 17 (source: Geordie Bosanko
and cmglee [CC-BY-SA-3.0], via Wikimedia Commons). A photo of the MH 17 plane (top right),
presumably taken moments before boarding and uploaded on social media (source: Facebook user Cor
Pan). The satellite imagery (bottom left) (source: Dutch National Forensic Investigation Team) shows the
crash site. Areas, coloured orange were examined by Ukrainian State Emergency Service, green areas
were searched by the international investigation team and red coloured areas were those where access
was denied. Yellow spots mark impacts on the ground. Another photo (bottom right) showing Malaysia
Airlines’ aircraft Boeing 777-200 (flight MH17) after it crashed in Donetsk region of Ukraine (source:
Jeroen Akkermans/RTL News Berlin).
7.1
The Malaysia Airlines MH17 plane crash can be referred to as an antagonistic disaster. It is a
disaster of a sudden-onset nature: the flight recorders indicated no aural warnings or alerts of
86
any aircraft system malfunctions and therefore no precautionary measures were possible (DSB
2014a, 19). Although the aircraft wreckage consisted of many large and small pieces distributed
over an area of approximately 10 km by 5 km near the villages of Rozsypne and Hrabove in
Eastern Ukraine (see Figure 20) (DSB 2014a, 21), the disaster is not classified as a local or
regional crisis. The scope of impact of the disaster is rather international and has a cross border
dimension due to the international crisis management involved in the investigation as well as
due to the fact that the aircraft crashed in Eastern Ukraine and belonged to the Malaysian
Airlines which departed in the Netherlands where two thirds of the victims originated (MA
2014b). Since the independent international investigation into the cause of the MH17 disaster
was formally transferred from Ukraine (as the state of occurrence) to the Netherlands, the DSB
is leading the international investigation that involves experts from several countries (Ukraine,
Malaysia, Australia, Germany, the United States, the United Kingdom, Russia, France,
Indonesia, Italy), as well as the Interstate Aviation Committee (IAC) and European Aviation
Safety Agency (EASA) (DSB 2014, 8). The investigation is carried out in accordance with
regulations of Annex 13 (Aircraft Accident and Incident Investigation) to the Convention on
International Civil Aviation (ICAO 2010). Furthermore, the ICAO had advised the DSB in
procedural matters to ensure full compliance with Annex 13 (DSB 2014, 8). In addition to the
lethal consequences this disaster had on the lives of 298 people on board of flight MH17, the
crisis impacted on other sectors including the healthcare, economic and air transport which will
be analysed in section 7.2.
Figure 21 (below) provides a representation of the complexity of the event, by presenting
87
Case
Types of hazard
impact
Scope of impact
Onset of crisis
Scope of CM
Cross border?
Principal involved actors Directly affected sectors Indirectly affected
in CM
sectors
Tsunami-Fukushima,
Japan, 2011
Natural
Physical
border
Sudden
Global
Yes
Police
Transportation GROUND Transportation GROUND Disruption of
Firework factory
Social
National
Rapid (Hours/days)
International
No
Fire
relation
Technological
Economic
Regional
Slow (Weeks)
National
Health
Energy production
Energy production
Disruption of
organisational relation
Political
Local
Creeping (months/years) Regional
Local admin. Municipal
govt.
Energy transmission and Energy transmission and Malfunctioning of legal
distribution
distribution
and regulatory relation
National/central
government
Water provision
Water provision
Galtür, AT (1999)
National security
Public communication
(telecom)
Public communication
Relational condition
Central European floods
(focus on Prague) (2002)
Insurance companies
Waste & biochem
Waste & biochem
(2012)
Civil protection
authorities
Healthcare
(hospitals&clinics)
Healthcare
(hospitals&clinics)
Eruption of
Eyjafjallajokull in Iceland
(2010)
MACC, CMC, etc.
Emergency services and
national security
Emergency services and
national security
Heat wave 2003 (France) Antagonistic
Malaysia Airlines MH17
plane crash (2014)
Local
Civil society organisation Economic services
Economic services
Community based
organisations
Government sector
(Decision & continuity)
Government sector
(Decision & continuity)
Intergovernmental
organisations
Social sector(Education, Social sector(Education,
aggregation, icon)
aggregation, icon)
Companies/ industry
Residential housing
sector
Residential housing
sector
Natural environment
Natural environment
Figure 21 Problem space overview of the 2014 MH17 disaster
cascade
7.2
This section provides an analysis of the cascading effects that occurred in the MH17 plane
crash. The Figure below provides information on the sectors impacted, the nature of the impact
and over what period of time the impacts occurred. The first column indicates the main triggers
that caused cascading effects to occur, the remaining columns show what happened at certain
times and what effects are associated with this. The second column indicates the timescale of
the unfolding crisis (column 4) and the actions in crisis management associated with it (column
3). Direct negative effects that occurred are described in column 5 and sectors directly and
indirectly affected in column 6 and 7.
The subsections following Error! Reference source not found. analyse each of the boxes
listed in its first column. As these boxes address the exact triggers responsible for the cascading
effects, the sub-sections provide a detailed analysis of the cascading effects in the Malaysia
Airlines MH17 plane crash.
time (on relevant
timescale)
Unfolding of events in crisis management (incl
category and level of authority involved)
since November 2013
8 March 2014
A
B
Political relational condition: due to the
political and armed conflict in Eastern
Ukraine some military and transport
planes crashed in the same region prior
to the air disaster.
Economic relational condition: For
Malaysia Airlines the disappearance of
MH370 and the crash of MH17, both
events happening within six months, had
very sensitive economic effects.
21 March 2014
Disruption of an information relation:
The states provide information on
where and when it is safe to fly. On this
information operational decisions of air
traffic control authorities are based
which turned out to be wrong for flight
MH17
cascade)
political and armed conflict in Eastern Ukraine
ongoing
political and armed conflict in
Eastern Ukraine ongoing
Malaysia Airlines Flight MH370 vanished with 239
passengers and crew on board, inexplicably
diverting from its course between Kuala Lumpur
and Beijing.
The OSCE Special Monitoring Mission (SMM) to
Ukraine is being deployed following a request to
the OSCE by Ukraine’s government and a
consensus agreement by all 57 OSCE participating
States. The monitors are to contribute to
reducing tensions and fostering peace, stability
and security.
Malaysia airlines flight MH370
disappeared with 239 people
on board.
6 June 2014
An Antonov plane of Ukrainian Air Force crashed
in eastern Ukrainian Donetsk Region
14 June 2014
An Ilyushin 76 transport plane of the Ukraine Air
Force crashed near Lugansk, Ukraine
17 July 2014, 10:31 GMT
departure of Malaysia Airlines flight MH17 from
Amsterdam’s Schiphol airport (NL) to Kuala
Lumpur International Airport (MA).
17 July 2014, 13:20 GMT
Malaysia Airlines flight MH17 abruptly stopped
sending messages to air traffic control as well as
recording voice and flight data.
17 July 2014
Malaysia Airlines confirms it received notification
from Ukrainian air traffic control that it had lost
contact with flight MH17 at 30km from Tamak
waypoint, approximately 50km from the RussiaUkraine border. MH17 went down due to external
causes.
Sectors directly
affected (horizontal
cascade)
Sectors indirectly
affected (horizontal
cascade)
Economic sector:
Two air disasters for
Malaysia Airlines
within six months had
very sensitive
economic effects.
An Antonov 26 transport plane of the Ukrainian
Air Force crashed near the Ukraine-Russian
border in an area were heavy fighting was going
on.
14 July 2014
17 July 2014, 14:15 GMT
C
(unfolding of) physical event over time (vertical
cascasde)
Notification of lost contact with MH17.
283 passengers and 15
technical and cabin crew died a total number of 298 people
from ten countries across four
continents were on board
Flight route: MH17’s flight plan was approved by
Eurocontrol (European Organisation for the
Safety of Air Navigation), who are solely
responsible for determining civil aircraft flight
paths over European airspace. Eurocontrol is the
air navigation service provider for Europe and is
governed under ICAO rules.
international laws, standards
and conventions have been
violated
Air transport sector:
new regulations for
overflight of conflict
zones will be
imposed
Air transport sector:
more clear and
accurate
information will be
needed in future on
where and when it is
safe to fly.
17 July 2014
Flight route: International Air Transportation
Association (IATA) has stated that the airspace
the aircraft was traversing was not subject to
restrictions.
17 July 2014
Flight route: International Civil Aviation
Organisation (ICAO) earlier declared the usual
flight route from Amsterdam to Kuala Lumpur
was safe.
17 July 2014
IATA, ICAO: Airlines need clear and accurate
information on which to base operational
decisions on where and when it is safe to fly. In
the case of MH17 airlines were told that flights
above 32,000 feet that traverse Ukraine would
not be in harm’s way. This guidance turned out to
be wrong.
17 July 2014
17 July 2014
National Bureau of Air Accidents Investigation of
Ukraine (NBAAI) is officially in charge of the
MH17 accident investigation by virtue of being
the state of occurrence according to Annex 13 of
the Convention on Aircraft Accident and Incident
Investigation.
Investigation
Ukrainian NBAAI and local citizens at crash site
were the first to recover human remains shortly
after the crash. Short visits of NBAAI to the crash
site between July 19 and 21.
Investigation
17 July 2014
Altitude: According to Malaysia Airlines MH17
filed a flight plan requesting to fly at 35,000ft
throughout Ukrainian airspace. This is close to
the ‘optimum’ altitude. However, an aircraft’s
altitude in flight is determined by air traffic
control on the ground. Upon entering Ukrainian
airspace, MH17 was instructed by Ukrainian air
traffic control to fly at 33,000ft.
17 July 2014
Altitude: According to Eurocontrol the aircraft
was flying at Flight Level 330 (approximately
10,000 metres/33,000 feet) when it disappeared
from the radar. This route had been closed by the
Ukrainian authorities from ground to flight level
320 but was open at the level at which the
aircraft was flying.
18 July 2014, 07:30 GMT
Flight route: With immediate effect, all European
flights operated by Malaysia Airlines took
alternative routes avoiding the usual route.
Following this incident, Malaysia Airlines now
avoids Ukrainian airspace entirely, flying further
south over Turkey.
91
Flight route: With immediate effect, all European
flights operated by Malaysia Airlines took
alternative routes avoiding the usual route.
Following this incident, Malaysia Airlines now
avoids Ukrainian airspace entirely, flying further
south over Turkey.
18 July 2014, 07:30 GMT
18 July 2014, 07:30 GMT
Malaysia Airlines started notifying the next-of-kin
of the passengers and crew.
Members of UN Security Council called for a full,
thorough and independent international
investigation into the incident in accordance with
the international civil aviation guidelines and for
appropriate accountability.
18 July 2014
18 July 2014
18 July 2014
Government of Ukraine officially requested the
ICAO for assistance with the official accident
investigation into the downing of MA Flight MH17
and ICAO sent a team on July 21 to assist the
NBAAI.
Investigation
Ukrainian NBAAI requested the Dutch Safety
Board to participate in the international
investigation. The focus is on the following
elements: the cause of the accident, the
passenger list and the plane's flight path.
Investigation
Families, friends and loved ones: A constant
stream of massages of sympathy are being
posted on social media. Almost everyone knows
1 of the victims, or knows someone who did.
There is a strong sense of solidarity in the
Netherlands.
18 July 2014
18-27 July 2014
Notification of the next-of-kin
OSCE's SMM together with Dutch and Australian
experts obtained very limited access to the crash
site on July 18. On 19 July, access to the site was
limited, but greater than it had been on the
SMM’s first visit the previous day. On 20 July, the
SMM was given full access to the main crash site,
which was on this occasion properly cordoned
off.
Getting access to the crash site
92
Healthcare:
psychosocial care is
offered to support
the next of kin and
friends of the
victims
19 July 2014
19 July 2014
Deployment of the Dutch National Forensic
Investigation Team (LFTO) to help identify the
victims. LTFO, which coordinated the
international identification operation, consists of
a team of the Dutch police (Royal Netherlands
Marechausee and Dutch National Police) and
partners responsible for the forensic investigation
of victims, which had first priority.
forensic investigation
Malaysia Airlines deploys its “Go Team” with 212
personnel from various government and media
bodies and its staff to Amsterdam and Kiev.
Malaysian team's onsite investigation between
July 22 and 24.
Investigation
21 July 2014
Unilateral ceasefire announced by President of
Ukraine and by Prime Minister of the selfdeclared Donetsk People's Republic in a 40 km
radius around the crash site. However, there was
no general ceasefire throughout the conflict
area.
21 July 2014
The UN Security Council Resolution 2166 was
adopted unanimously and supports efforts to
establish a full, thorough and independent
international investigation into the incident in
accordance with international civil aviation
guidelines and calls on all States to provide any
requested assistance to civil and criminal
investigations related to this incident.
22 July 2014
Agreement between Prime Minister of Malaysia
and Prime Minister of the self-declared Donetsk
People's Republic to move remains of MH17'
passagers and crew to Kharkiv, hand over black
boxes, and guarantee save and full access to
crash site for international investigarots.
22 July 2014, 9:00 GMT
Self-declared Donetsk People's Republic's Militia,
DSB, OSCE SMM, Malaysian "Go Team": First train
with the remains of victims of flight MH17 arrives
in Kharkiv; later on (23 July) transported by
military aircraft to Eindhoven, the Netherlands,
for identification. Other transport flights with
remains of victims and belongings are progressed
during the following days and weeks.
93
22 July 2014
23 July 2014
D Disruption of an organisational
relation: due to both the political and
armed conflict in Eastern Ukraine as
well as the tense security situation at
the crash site the Dutch government
(leading the international investigation)
decided not to deploy an international
military mission but rather to give the
repatriating of the victims first priority
and to do everything that prevents an
escalation in the area.
23 July 2014
Self-declared Donetsk People's Republic's Militia,
Malaysian authorities, DSB: Black boxes were
handed over to Malaysian authorities in Donetsk
and passed on to the international investigation
team (DSB).
Black boxes
Black boxes: UK's Air Accidents Investigation
Branch (AAIB) in Farnborough has downloaded
the recordings. Forensic analysis was carried out
by the international investigation team.
Black boxes
Memorandum of Understanding signed between
Ukraine and the Netherlands that formally
transferred the responsibility of the international
investigation to the Netherlands. DSB is leading
the international investigation that involves
experts several countries (Ukraine, Malaysia,
Australia, Germany, the United States, the United
Kingdom, Russia, France, Indonesia, Italy) and
Interstate Aviation Committee (IAC) and
European Aviation Safety Agency (EASA) as
organisations. The investigation is carried out in
accordance with rules of ICAO (Annex 13).
technical investigation
Malaysia Airlines: A multi-faith prayer session
was organized in Petaling Jaya (MA) for families
of the passengers and crew on board MH17,
embassy representatives and invited guests.
25 July 2014
Agreement between Prime Minister of Malaysia
and Prime Minister of the self-declared Donetsk
People's Republic that allows a group of
international police personnel to enter the area
in order to provide protection for international
crash investigators.
27 July 2014
27 July 2014
Security of LFTO for working on crash site is
accessed by 1) security analysis by the Dutch
Ministry of Defence (National Coordinator for
Security and Counterterrorism (NCTV)); 2) OSCE’s
advice by consulting all the parties involved; 3)
field commander. If one of the signals is negative
on a daily basis, the search teams did not
proceed.
assessment of security situation at crash site
94
E
Disruption of a service supply relation:
forensic, criminal and technical
investigations are depended on the
security situation of the crash site and
could not be completed up to 29
September 2014.
27 July 2014
Malaysia, Netherlands and Australia agreed to
work closely together in deploying police
personnel to secure the site.
Collaboration between Malaysia, Netherlands
and Australia
Criminal investigation is being carried out under
the leadership of Dutch Public Prosecution
Service.
criminal investigation
28 July 2014
Due to ongoing fighting the OSCE SMM, Dutch and
Australian experts were not able to visit the crash
site.
no access to crash site
28-29 July 2014
since 30 July 2014
OSCE SMM successfully reached the crash site for
investigating. However, on August 5 an escort
provided by the self-declared Lugansk People’s
Republic did not allow access to the experts’
target area, which is 78km east of Donetsk city,
saying it had been mined.
access to crash site
1-6 August 2014
Repatriation mission (about 400 Dutch, Australian
and Malaysian experts) worked at the MH17
crash site, with the aim of recovering as many
human remains and personal belongings as
possible and returning them to the Netherlands.
Not all of the chosen areas were searched,
because in some cases the experts were not
granted access or the security risks were too
great. Some of the areas had also been
completely burnt out.
03.Aug.14
Head of repatriation mission thankful for help of
local citizens at the crash site, who did not only
recover victims shortly after the crash but also
continue to participate in the search for victims.
06.Aug.14
14.Aug.14
After consulting Australia, Malaysia and OSCE the
Dutch government decided that MH17 recovery
mission (police personnel and experts) will leave
the crash site for the time being because the
investigators' safety was not guaranteed. A small
team stayed behind in the region.
recovery mission left the crash site for the time
being
Bilateral Agreement ratified between Prime
Minister of Malaysia and President of Ukraine
which formally authorizes the deployment of
Malaysian personnel at the MH17 crash site.
95
the investigators from DSB were so far not able
to visit the site of the crash and conduct their
investigation under safe conditions.
20.Aug.14
08.Sep.14
Dutch Ministry of Security and Justice identified
victims
A total of 193 victims of the MH17 air disaster
have been identified.
Dutch Safety Board: Preliminary report on the
investigation into the crash of MH17 with
information from various sources, such as the
cockpit voice recorder and the flight data
recorder (the black boxes), air traffic control data,
radar and satellite images.
Dutch Safety Board: Final report on the
international investigation expected to be
published within one year of the date of the
Preliminary report released
09.Sep.14
Final report expected within one year
Figure 22 Visual overview of Malaysia airlines MH17 plane crash
96
7.2.1 Box A: Political relational condition
Box A addresses a political relational condition that existed prior to the disaster and enabled
the MH17 plane crash to unfold and escalate the way it did. In Eastern Ukraine where the
MH17 crashed, there is an on-going political and armed conflict between Ukrainian armed
forces and armed forces of the self-declared Donetsk People's Republic as well as self-declared
Lugansk People’s Republic (OSCE 2014). Therefore, all 57 participating States of the OSCE
took a consensus decision on 21 March 2014 to deploy a Special Monitoring Mission (SMM)
to Ukraine following a request by Ukraine’s government (OSCE 2014). The mission aims to
contribute to reducing tensions and fostering peace, stability and security. However, as part of
the on-going armed conflict some military and transport planes of the Ukrainian Air Force
crashed in the same region months and days prior to the airplane disaster. According to the
Aviation Safety Network, an Ilyushin 76 transport plane of the Ukraine Air Force with 40
people on board crashed near Lugansk, Ukraine on 14 June 2014 (ASN 2014a). Likewise, an
Antonov 26 transport plane of the Ukrainian Air Force crashed on July 14, 2014 near the
Ukraine-Russian border in an area were heavy fighting was going on (ASN 2014b). However,
no commercial flight crashed prior to the disaster in July 2014 in the conflict area. To sum up,
plane MH17 overflew a conflict zone where military planes crashed as part of the on-going
political and armed conflict in Eastern Ukraine. This on-going civil warfare can be understood
as a political condition which contributed to the cascading effects because of increased security
risks in Eastern Ukraine.
7.2.2 Box B: Economic relational condition
Box B deals with an economic relational condition which existed only partly prior to the
crash. A previous transport disaster of Malaysian Airlines and the MH17 crash contributed to
severe financial losses of the airline. For Malaysia Airlines the disappearance of flight MH370
between Kuala Lumpur and Beijing with 239 passengers and crew on board in March 2014
(MA 2014a) and the crash of flight MH17 with 298 passengers and crew on board in July 2014
(MA 2014b), both incidences occurred within six months, implicates very sensitive economic
effects. In this regard Malaysia Airlines reported a 305.7 million Malaysian ringgit ($97.2
million) loss in the April-June 2014 quarter (MA 2014c, 21). The loss nearly doubled in the
second quarter 2014 and is being directly referred to the disappearance of flight MH370 and
therefore following a decline in bookings (MA 2014d). However, Malaysia Airlines Group
Chief Executive Officer stated that “the full financial impact of the double tragedies of MH370
and MH17 is expected to hit Malaysia Airlines in the second half of the year” (MA 2014d)
because the impact of flight MH17 disaster is not being reflected by financial results of
Malaysia Airlines up to 29 September 2014.
7.2.3 Box C: Disruption of an information relation
Box C addresses the disruption of an information relation that by means of
telecommunication pre-dates the MH17 disaster. As it turned out later on, the information on
where and when it was safe to fly was wrong (IATA 2014b). It is stated in Article 9 of the
Convention on International Civil Aviation that “each contracting State may, for reasons of
military necessity or public safety, restrict or prohibit uniformly the aircraft of other States
from flying over its territory” (ICAO 2006, 5-6). In the light of the flight MH17 disaster, the
UN International Civil Aviation Organisation (ICAO) reminded the contracting States “of their
responsibilities to address any potential risks to civil aviation in their airspace” (ICAO-IATAACI-CANSO 2014). In a press conference, the Director General and CEO of the International
Air Transport Association (IATA) stressed that “airlines need clear and accurate information
on which to base operational decisions on where and when it is safe to fly” and “even sensitive
information can be sanitised” in a way that remains operationally relevant (IATA 2014b). The
preliminary report of the Dutch Safety Board (DSB) mentions that flight MH17 was flying at
approximately 33,000 feet or 10,000 kilometres in unrestricted airspace (DSB 2014a, 13; MA
2014b). Furthermore, the European Organisation for the Safety of Air Navigation
(Eurocontrol), Malaysia Airlines, and IATA declared that both the flight route from
Amsterdam to Kuala Lumpur and the altitude of flight MH17 were approved and not subject
to any restrictions (Eurocontrol 2014; MA 2014b; IATA 2014a).
Box D concerns a disruption of an organisational relation. The political relational condition
described in Box A led to a tense security situation at the crash site. This civil warfare interfered
with the approach of the Dutch government leading the international investigation on flight
MH17 crash. Therefore, they decided not to deploy an international military mission but rather
to give the repatriating of the victims first priority and to do everything to prevent an escalation
in the area (Dutch government 2014c). The Dutch Prime Minister declared on 19 July 2014
that the recovery of the victims’ remains is absolutely necessary and should be given highest
priority (Dutch government 2014a). Regarding this matter the Dutch Minister of Foreign
Affairs stated that “for the Netherlands, one priority clearly stands out above all others: bring
the victims’ remains home. It is a matter of human decency that remains should be treated with
respect and that recovering victim’s remains should be done without any delay” (Dutch
government 2014b). Therefore, the Dutch National Forensic Investigation Team (LFTO) was
deployed to the crash site in Eastern Ukraine to collect evidence aiding in identifying the
victims. Furthermore, according to the Dutch government (2014d) the repatriation mission
which consists of about 400 Dutch, Australian and Malaysian experts worked at the MH17
crash site for three weeks with the aim of recovering as many human remains and personal
belongings as possible and returning them to the Netherlands.
However, sometimes the experts were not granted access or the security risks were too great
due to the on-going operations of heavily armed forces. Therefore, not all areas of the accident
site were searched. Additionally, some of the areas had been burnt out completely.
Nevertheless, based on its main priority – the recovery and identification of victims – the Dutch
government (2014c) made the decision not to send an international military mission to secure
the crash site. It was believed that this kind of mission would have created the risk of becoming
directly involved in the armed conflict and therefore risking its escalation to an international
dimension. “The success of the repatriation mission depends on preventing an escalation in the
area”, argued the Dutch government (2014c). Under these circumstances, a cooperation with
self-declared Donetsk People's Republic in searching for and recovering the victims’ remains
was unavoidable for achieving the goal of repatriating the victims (Dutch government 2014f).
7.2.5 Box E: Disruption of a service supply relation
Box E addresses the disruption of a service supply relation. This relation covers the
dependency on the Self-declared Donetsk People's Republic which controls large areas of the
crash site. Therefore, the three investigations - forensic, criminal and technical - into the flight
MH17 crash are dependent on the security situation of the crash site and could not be completed
up to 29 September 2014. Firstly, the technical investigation is examining the cause and
circumstances of the crash based on factual information and is being led by the Dutch Safety
Board (DSB 2014b). Secondly, the forensic investigation of victims is coordinated by the
Dutch National Forensic Investigation Team (LTFO) and consists of a team of the Dutch police
(Royal Netherlands Marechausee and Dutch National Police) and partners responsible for the
forensic investigation of victims (Dutch government 2014e). The third investigation is a
criminal investigation under the leadership of the Dutch Public Prosecution Service (DSB
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2014b). These three investigations depend on the security situation that can be described as
very unstable. Although unilateral ceasefire was announced by the President of Ukraine and by
the Prime Minister of the self-declared Donetsk People's Republic in a 40 km radius around
the crash site, there was no general ceasefire throughout the conflict area (Dutch government
2014f). Thus, the security situation in Eastern Ukraine is assessed on a daily basis by a) security
analysis by the Dutch Ministry of Defence (National Coordinator for Security and
Counterterrorism (NCTV)); b) OSCE’s advice by consulting all the parties involved; c) field
commander (Dutch government 2014g). If one of the signals is negative, the search teams
would not proceed. After consulting Australia, Malaysia and the OSCE, the Dutch government
decided on 6 August 2014 that the MH17 recovery mission (police personnel and experts)
would leave the crash site for the time being because the investigators' safety was not
guaranteed. A small team stayed behind in the region (Dutch government 2014h).
7.3
LESSONS LEARNED
The analysis of the Malaysia Airlines MH17 plane crash presents various possibilities for
identifying lessons that can contribute to the understanding of the unfolding of cascading events
in crises. The most important lessons on what went wrong and what went well are discussed in
the sub-sections below.
An analysis of triggers of cascading effects in section 3.2 shows that most triggers were related
to each other. Four different types of triggers caused cascading effects, namely a relational
condition, a disruption of an information relation, a disruption of an organisational relation and
a disruption of a supply relation. With exception of disruption of an organisational relation all
other named triggers existed prior to the disaster and are mainly related to the on-going civil
warfare Eastern Ukraine (relational condition). Consequently, the security situation on the
crash site in Eastern Ukraine was unstable and thus on-site international investigations were
limited regarding the collection of evidence (disruption of a supply relation). Additionally, the
information provided on where and when it is safe to fly turned later on out to be wrong (IATA
2014b) and therefore, the information relation was disrupted. Moreover, the loss of two
aircrafts within six months has severe economic impacts for Malaysia airlines (relational
condition).
The disruption of an information relation as described in Box C consequences for the whole
air transport industry. In this regard, the IATA stated that the MH17 plane crash “exposed a
gap in the system” (IATA 2014b). In the aftermath of the MH17 disaster the UN International
Civil Aviation Organization (ICAO), the International Air Transport Association (IATA),
Airports Council International (ACI) and the Civil Air Navigation Services Organisation
(CANSO) stressed in a Joint Statement on Risks to Civil Aviation Arising from Conflict Zones
the need for “fail-safe channels for essential threat information to be made available to civil
aviation authorities and industry” (ICAO-IATA-ACI-CANSO 2014). Therefore, a “Task Force
on Risks to Civil Aviation arising from Conflict Zones” had been established to revise the roles
and procedures relating to the mitigation of risks arising from conflict zones in civilian airspace
and therefore to elaborate a system that allows the share of urgent, accurate, timely and critical
information of conflict zone risks (ICAO 2014).
It is striking that most triggers causing cascading effects already existed prior to the disaster
and therefore came not into being during the disaster. The only trigger that came into play after
the occurrence of the MH17 crash - a disruption of an organisational relation - was related to
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the decision by the Dutch government (2014f) not to send an international military mission to
secure the crash site. This decision was based on the circumstance that heavy fighting in Eastern
Ukraine was on-going. Instead of being directly involved in the armed conflict, the Dutch
government (2014f) rather decided to cooperate with the self-declared Donetsk People's
Republic which controls the area to ensure that remaining bodies and belongings of the victims
of the plane crash disaster were “repatriated and handed over to their families, without
irresponsible risks being taken at the crash site” (Dutch government 2014f). This decision even
included the fact that recovery mission had to leave the crash site for the time being because of
the unstable security situation on-site (Dutch government 2014h). With its decisions the Dutch
government demonstrated their ability to cope carefully with a highly complex and politically
sensitive area for both examining the cause and circumstances of the crash, for the prosecution
in a criminal case and for examining the crash site to recover the victims and their personal
belongings. To sum up, what went well was the prevention of further escalation of the on-going
armed conflict in Eastern Ukraine. This was due to cautious approaches of both the Dutch
government and the intergovernmental organisations and companies involved in the
international management of the investigation of the MH17 plane crash.
7.4
CONCLUSION
The case study on the Malaysia Airlines MH17 plane crash in 2014 is an example of an aviation
disaster that took place in an area of civil warfare. Therefore, many of the triggers of cascading
effects were related to these initial conditions and thus, the unstable security situation that
limited the international investigation of the crash site in Eastern Ukraine. Furthermore, in view
of the violent circumstances of this case there was little that could have been done to prevent
cascading effects from materializing. Having said that, the Dutch government leading the
independent international investigation into the MH17 crash prevented further escalation of the
armed conflict by sending unarmed experts to the crash site. Another important point that will
be further analysed in D3.3 ‘Stakeholder interview findings, decision trees and prevention
analysis’ is the role of psychosocial care that is being offered in the Netherlands to support the
next of kin and friends of the victims. Furthermore, it must be noted that the case study on the
MH17 plane crash included relevant information publicly available up to 29 September 2014.
Additionally, the official and independent investigation of the DSB is still ongoing and
therefore the extent of impact of the disaster has not yet been finally clarified. However,
regarding the processes for overflight of conflict zones and the need for unequivocal
information, a “Task Force on Risks to Civil Aviation arising from Conflict Zones” had been
established which will elaborate ways to make air transport system safer and more secure to
ensure that this kind of disaster is not repeated (IATA 2014b). If new regulations for flights
over conflict zones will be elaborated within this task force, it will probably imply sensitive
economic costs for airline companies as the flight path would have to be extended for certain
air routes.
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8
FLOODS OF 2002 IN THE PRAGUE AREA, CZECH REPUBLIC
The 2002 floods were part of a cross border event of extreme magnitude that involved several
states in Central Europe. Heavy rainfall during early August triggered sequential waves of
flooding. Main rivers, such as the Oder, Neiss, Elbe, Mulde, Danube and Vltava, broke their
banks and severely inundated the Czech Republic, Germany, Austria, and Slovakia. Physical
impacts were visible also in Poland, Hungary, Romania and Croatia. The floods caused
hundreds of lives to be lost, economic losses on the scale of billions of euros, and significant
damage to cultural heritage and unique historical sites. The main cascades were visible in the
cessation of activity of two large power stations along the Danube River in Slovakia, a chlorine
gas cloud released by the Spolana chemical plant outside Prague, and the thousands of
inhabitants of Prague and Dresden who had to be vaccinated against hepatitis (Ekengren et al.
2006). The impact on the capital of the Czech Republic was particularly strong (see Figure 23),
and it necessitated a strong commitment on the part of the international community. For this
reason, the analysis of the floods presented in this chapter focuses on Prague.
Figure 23 Clockwise order: Karlin District in Prague, Vltava River flooded in Prague, Troja Castle flooded,
and mobile flood protection in Prague city centre (Source: Ministry of the Environment of the Czech
Republic, 2004)
The 2002 floods in Prague can be defined as effects of natural and technological hazards. It
was a slow onset event, with clear amplification points and the presence of subsidiary disasters.
It was part of a major cross-border event that that required mobilization at the global level. In
the Czech Republic it required a major commitment of all available human, physical and
economic resources.
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The floods were caused by two main rainfall periods in sequence: the first occurred from 6th to
7th August 2002 and was contained; a second one occurred between 11th and 14th August. As
the risk of flooding increased, on Monday 12th August at 10 a.m. co-ordination of crisis
management was taken up by the Ministry of the Interior and the General Directorate of the
Fire and Rescue Brigades. Part of Prague was closed and phased evacuation started in area at
higher risk. On Tuesday 13th August the City Council was evacuated, which affected the public
communication of warnings (United Nations Environment Programme/GRID 2002). Between
13th and 15th August 2002, the Vltava River submerged parts of the capital of the Czech
Republic, with peak flooding on Wednesday 14th August, when banks overflowed by an
estimated 5,000-6,000 m3/sec. Flood defences were inadequate or insufficient in many parts of
the city. Fire fighters and volunteers were sent in to limit the damage and protect items of
cultural heritage, such as the Charles Bridge (Crosby 2004). Evacuation involved as many as
40,000 citizens in Prague and more than 200,000 in the whole of the Czech Republic (NATO
2002a).
By 14th August international assistance was required. The President of the European
Commission, Mr Romano Prodi, received an emergency call during his holidays. A formal
request was made to the Monitoring and Information Centre to activate the European Civil
Protection mechanism (Ekengren 2006). The same day, the Czech Republic also involved the
Euro-Atlantic Partnership Council (EAPC), through the Euro-Atlantic Disaster Response Coordination Centre of NATO (2002b). In the following days, collaboration took place at different
levels simultaneously. For example, the Polish, German and Czech authorities practised
bilateral as well as international co-ordination (Ekengren et al. 2006).
On 15th August, in the district of Karlin, near the 'Old Town' of Prague, flooding to a depth of
nearly three meters overwhelmed emergency sandbags, while, despite the emergency
barricades, several metres of water and mud swamped valuable historical buildings and cultural
heritage sites (Christian Science Monitor 2002). Secondary disasters originated from the
interaction of floods with critical facilities and contributed to the escalation of the emergency,
as follows:

The Spolana chlorine and mercury chemical spill (Agence France-Presse 2002). It was
possible to prevent loss of life, but this required a large commitment. Water
contamination. The damage to wastewater treatment plants and industrial sites
contaminated water supply and due to high humidity, the mosquito population
increased. Risk of epidemics required massive programmes of disinfection and
vaccination.

Impact on the historic and cultural assets. This refers in particular to those related to the
Municipal Library of Prague, the Institute of Archaeology and the Charles Bridge.
Social sector was directly affected. Flooding of underground public transport (the
Prague Metro). The failure of protection systems and emergency co-ordination has been
the subject of both studies and legal procedures.
It must be noted that similarly to Hurricane Sandy (see Chapter 9) all the sectors considered in
the morphological analysis were indirectly affected by the event. Even in this case, all the
aspects of social system are involved, from transportation to environment and reflect the
massive impact of the event. The flood directly the sector of emergency services, national
security and government sector requiring a mass mobilization to evacuate, minimize damages,
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provide emergency relief and support recovery. Clearly, healthcare was directly affected to
both in terms of increased pressure and of physical impact of the event. The spreading of
secondary disasters, such as the Spolana toxic release and water contamination, further
increased those dynamics. The public communication sector spread warnings before and
maintained the sharing of information among relief workers, but physical damage also involved
the telecommunications infrastructure. Ground transportation was interrupted in many areas
(bridges are particularly vulnerable to floods), while in this case air transportation was not
directly affected. Indeed, Prague airport was outside the flooded area but it was indirectly
affected in terms of the increased pressure of tourism repatriations and the delivery of
international aid. Energy production and distribution was heavily affected and supply was
interrupted. Production sites were outside Prague but must be considered in the present
analysis. Economic and financial services were suspended during the event and were under
high pressure after it (e.g. in terms of funding for recovery), while the residential housing sector
was affected by serious damage to buildings. The social sector was directly involved in the risk
of destruction of heritage sites and the suspension of education and community activities.
Damage to critical infrastructure generated secondary disasters, which originated in the water
supply and waste and biochemical sectors. The natural environment was directly affected by
water contamination and the long term effect of the Spolana emission. Thus, indirect effects
involved all sectors in the joint effect of the main hazard (flood), the amplification provided by
secondary hazards and secondary disasters such as the Spolana incident, and the disruption of
the main critical infrastructure that led to cascading disruption.
The state of emergency ended on 31st August, while a further alarm was declared from 1st
September to 31st October 2002 for the broader effects of the flood. For example, a further call
for mass vaccination was made on 5th September (Czech News Agency 2002). The estimated
damage in the Czech Republic exceeded US$2.92 billion, while there were 19 deaths, and 3.2
million citizens were directly affected. At the time this was reckoned to be the largest flood
damage in the history of the Czech Republic (Hladny et al. 2004).
Figure 24 provides a simple representation of the complexity of the event, by presenting
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Figure 24 Problem space overview of the 2002 Prague floods
The Figure below presents an overview of the unfolding of events in the Prague area. It starts
from the first meteorological event that struck the Czech Republic between 6th and 7th August.
Due to the complexity of the events and the conflicting nature of information sources, this
overview required a certain level of approximation. Measures such as warnings and evacuation
were identified in their starting date (12 August) but subsequently took place more gradually
in different areas. Similarly, the evolutionary timescale of the full impact of the floods induced
us to join together time periods such as the one between 12 and 16 August, because overlapping
measures were adopted, actions developed in non-linear ways and it was not possible to identify
clear cut-offs for all events. This approach is reflected in the decision not to indicate a defined
number of houses or buildings damaged or destroyed. The structural failures in the total amount
of damages have often not been immediate but may be related to the prolonged residence of
water on the site. In line with the last report by the Euro-Atlantic Disaster Response
Coordination Centre, the period considered in the time lapse concludes on 26th August 2002,
but the state of danger and the evolution of secondary disasters continued further. The four
secondary disasters identified earlier are indicated in the red boxes for simplification, as they
generated collateral vertical cascades that were too complex to be synthesized in a single
scheme.
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108
109
Figure 25 Visual overview of the 2002 floods in Prague
110
The interconnections that contributed to the cascade are presented in the first column of
Figure 25 and analysed below. In order to concentrate on the main patterns, co-ordination
problems at lower levels are not investigated, and neither are small-scale information
failures.
8.2.1 Box A: Pre-Crisis Political Relational Condition
Relational conditions are root causes of the 2002 floods in the Prague area. Political
decisions were made to use dams intensively on the upstream sections of rivers
surrounding Prague to produce electricity. These decisions were followed by the
urbanization of surrounding areas, but without the necessary development of land-use
planning strategies. The provision of adequate flood defences in Prague city along the
Vlatava (Moldava) River was a late decision and most of the work post-dated the 2002
floods.
The flood revealed different problems in the maintenance and security of underground
systems, sewers, and critical infrastructure at large that contribute to exacerbate the
effects of physical impact reported in Box C. In other words, pre-crisis political relational
conditions can be considered concurring triggers of in the failures of critical
infrastructure.
The damage to the Prague Metro was derived from the incursion of water in the soil but
also from poorly sealed electrical cables and poor connections (Chamra 2006). Many
residential areas were flooded or damaged because wastewater was spread by the
sewerage systems, which lacked backflow valves in the old tunnels beneath the city.
Basements were flooded and building foundation were damaged. Finally, as illustrated
in Box C, co-ordination and administrative centres were not located in safe places.
8.2.2 Box B: Pre-crisis Cultural-Relational Condition
The cultural relational condition is reciprocally influenced by the political-relational
condition. People started to build in areas subject to potential inundation, probably for
the high trust in structural barriers and flood models. Citizens ceased to carry out practices
to enhance their protection to floods. For example they stopped using buffering strategies
in the construction of buildings. This led to the destruction of homes, goods and
commercial properties.
8.2.3 Box C: Disturbance Relation (Geospatial and Physical)
Disturbance relations are critical in Prague case study. On the one hand, physical
relations are referred to the two episodes of extreme weather that determined the failure
of critical infrastructures (together with pre-crisis conditions). On the other hand,
geospatial relations are referred to the spread of secondary disasters due to the proximity
of critical infrastructures (CI). The failures of dams and river basins affects many CI
located in the nearby. The meteorological events of 6 and 7 August placed early duress
on river basins and crisis management programmes. In this first period of heavy rainfall,
some localized floods were observed in Prague, were mitigated by the use of reservoirs
and water basins such as the Vltava (Moldava) River cascade. According to the
International Federation of the Red Cross and Red Crescent Societies (IFRCRCS), on 9th
August the rivers had returned to their courses and evacuees were returning home
(IFRCRCS 2002). However, this first impact saturated river basins, which were then
unable to absorb water during the major rainfall that affected the region from 11th August
onwards. In other words, the need to contain the damages during the meteorological
events of the first week required the full use of the reservoirs that were not available for
the second event. Thus, river basins were saturated and lacked capacity to reduce water
flows during the event of 10th-13th August, generating the first physical impact of the
event: the Prague flood. In Prague and Karlin (downstream of Prague’s Jewish Quarter),
water heavily damaged the critical infrastructures, which generated both short-term and
long-term chain effects on all sectors. Indeed, the interdependencies of critical
infrastructures reported in deliverable D1.1 acted as amplificatory of cascading. Ground
transportation infrastructure, public communications, water provision and energy
transmission were heavily disrupted. Energy production was affected also in the Czech
Republic. Gas service was restored in October, electricity in mid-September and
telephone services in November. Road cracking and pavement buckling were common,
and two bridges on the Vltava River could be re-opened only on 25th September
(Deutsche Presse Agentur 2002). Flooding of petrol stations in Karlin contaminated
drinking water (Risk Management Solutions 2003).
The Spolana chemical spills required a constant monitoring and the intervention of
special hazardous material units including specialized personnel from Canada, affecting
than emergency services and national security. It created long-term contamination and
pollution effects in natural environment sectors, and determined the adoption of new
legislation immediately after the floods affecting government (NATO 2002c). Some 124
wastewater treatment plants were damaged, and inundated industrial sites released
contaminants into the water supply, while groundwater aquifers experienced increases in
levels of organic pollution (Haldney et al. 2004). In other words, it affected waste and
biochemical production, water provision and healthcare. This was reflected in shifted
efforts of international relief, which started providing portable dryers, floating pumps and
submersible electric pumps. It influenced assistance on an emerging cascade related to
water contamination, by providing vaccines against hepatitis, gamma globulin and
chlorine-based disinfectants (NATO 2002d).
Many co-ordination and public administration centres related to emergency services
sector and government sector were in area at risk and were evacuated or flooded,
generating chain effects both on emergency management (short-term) and long-term
management of the country. For example, in the City Court of Prague, 4.5 km of files
were under water but it was reported that some were not destroyed and were transported
to safety (Transitions Online 2002). The role of social sector was a final determinant in
increasing the chain-effect of damages, requiring personnel to protect key assets such as
the Charles Bridge. Indeed, chain effects in this case are related to the involvement of the
so called “icon sites” (please refer to ID 1.1) A large number of personnel and volunteers
were mobilized to save icon sites and evacuate precious books, while in some case
damages could not be avoided. The adoption and development of new restoration systems
was required are to be intended both in term of tangible and intangible damages. On the
one hand, the physical damages to cultural heritage were reflected in increased pressure
of international aid and emergency services. National emergency services had to mobilize
more personnel, coordinate with high number of volunteers. At the international level
Italy offered support for the restoration of cultural assets resulting from damage to the
historical sites in Prague (NATO 2002e), and more at large an international call for
founding the restoration of cultural hazards was made. On the other hand, the
involvement of icon sites implies indirect effects on mental health and community that
implied the massive mobilization of the community to protect the sites but also required
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to the government to adopt new practices to assure the security of the sites once the flood
was ended.
8.2.4 Box D: Pre-Crisis Condition: Failures of Structural Defence
A pre -crisis condition refers to human mistakes in the development of flood mitigation
measures that are the root of the crisis and one of its triggers. They cannot be referred to
the political or cultural setting of the event but to the specific failure of a category of
critical infrastructures. Dams were built according to inappropriate flood models (Radio
Free Europe 2002) and had insufficient size, lacked spillways or had uneven elevations
in their parapets (Haldney et al. 2004). In other words, it can be said that the root cause
of dam failure was not the water flow but their design before the crisis. This resulted in
water overtopping and determined the flood in Prague (physical trigger of cascading
effects to all sectors).
8.2.5 Box E: Negligence in pre-Crisis regulatory relation and organisational relation
Joint failures in pre-crisis regulatory dependencies and organisational relations are
reflected in sub-disasters that amplified the cascading and the overall impact of the event.
The relation reported in Box G has a similar nature to the one reported in Box E: it is a
concurring element that exacerbated the effects of the impact of flood on critical
infrastructures (Box C). In particular, the problems in Spolana chemical site (waste and
biochemical production) were drawn to attention by the international organization
Greenpeace the year before the floods, while lack of transparency by the owner company,
Unipetrol, was a determinant of the high damages. In the case of the Prague metro
(ground transportation), there was a lack of co-ordination of the activation plan of the
Metro's protection system with the flood control plan of the city, a problem that was
probably related to regulatory issues. Finally, many legal aspects had not been properly
implemented after the 1997 floods. In the Prague Municipal Library, a disaster plan was
drafted in 1999-2000 and formalized in 2001, but, at the time of the 2002 floods, many
responsibilities were still not assigned and contracts had not been developed (Ray 2006).
8.3 LESSONS LEARNED
The 2002 floods represented an important threshold at both the national and supranational
levels. As a direct consequence of the Central European floods, the European
Commission implemented the European Union Solidarity Fund and started to develop the
European Flood Alert System. In 2007 the European flood directive included also lessons
learned from this case study. In the Czech Republic the legislation was improved in all
sectors and included new criteria and regulations for chemical industries, as well as for
urban planning. Improved monitoring and alert systems were adopted in river basins. The
T. G. Masaryk Water Research Institute created an atlas of flood maps, a digital relief
model and recordings of post-flood conditions. Flood barriers were raised to the level of
the 2002 floods (+30 cm) and new measures were adopted in Prague for the Metro
system. Finally, during the floods in May 2013, one could note effective improvements
in the protection and management of critical infrastructure and facilities. In the following
paragraph, we will summarise what went well and what did not. As often happens in
disasters, some particular elements, such as the implementation of the post-1997 flood
legislation, acted both as a negative and a positive factor.
The main failures involved preparedness, co-ordination and mitigation measures. The
main failures in human subsystems determined the seriousness of the cascade. This is
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reflected in the three police investigations instituted after the flood on the management
of the Vltava Cascade, the flooding of the Prague Metro, on the chloride leakage from
the Spolana Chemical Company. All the problems related to the management of dams,
dikes and barriers, as reported in the first box of interdependencies, were determining
factors in the disaster, as well as the impact of two interrelated episodes of extreme
weather. Similarly, maintaining the emergency co-ordination of critical infrastructures,
such as the Prague Metro, was shown to be insufficient, and so were protection measures
for chemical industries. Some authors highlight co-ordination problems among local
NGOs that apparently were not able to harmonize different operational standards (Kumar
2005), but it is not clear how those patterns can be considered a physiological factor
present in mass emergencies and in overall matters of international aid. In some cases,
legislation developed after 1997 had been adopted at the political level but not effectively
implemented in all local institutions (Ray 2006).
The relatively low loss of life contrasted with the seriousness of the event and highlighted
the effectiveness of warnings and evacuation strategies. Warnings used a combination of
public media (radio and television) and mobile warnings, and involved all levels of the
administration and crisis staff. In some areas, it was possible to observe spontaneous
evacuation that took place without particular problems (Brazova and Matczak 2013). A
range of organizational and legislation measures adopted after the 1997 floods were
crucial to the limitation of damages, such as the development of the National System of
Crisis Management (Kumar 2005), or the metal barriers that protected the Old Town
(Transitions Online 2002b).
Similarly, what emerges from the documentation is a mass-mobilisation of society that
helped to compensate for some of the critical vulnerabilities present in the system.
Despite the limited economic resources available in the Czech Republic, all levels of
society and all emergency forces were activated and mobilized as local NGOs that
distributed aid and supported operations. For example, the propagation of inundation
following the failure of flood protection was prevented in some critical cases by the
massive efforts of emergency teams supported by a large number of volunteers (Haldney
et al. 2004). Even the damage to works of art and important cultural assets was contained
due to the massive efforts of personnel and volunteers that were repeated in the clean-up
operations (Ray 2006).
From a cascading perspective, international relief showed a fast response and mobilized
a large number of physical and economic resources that were able to answer all requests
by the Czech Republic in real time. Official communications dated 23rd August 2002
highlighted that most of the request were met (NATO 2002g). Further escalation, such as
that related to the contamination of water, was contained by the joint efforts of the
national and international authorities.
8.4 CONCLUSION
This case study of the 2002 floods in Prague defines some major patterns in cascading
effects and the escalation of disaster. In particular, we have demonstrated how the human
component is a critical factor in exacerbating the effects of extreme natural events.
Geographical and physical interdependencies represented by the development of two
extreme weather patterns (in particular, intense and prolonged rainfall) interacted with
human vulnerabilities such as failures in preparedness and mitigation. These were
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amplified by other geographical, physical and logistical interdependencies represented
by critical facilities and infrastructure. In other words, Prague floods are distinguished by
how diffused pre-crisis conditions were determinant to cause, exacerbate and amplify the
cascading effects of the event. However, we can also see that the mobilization of
community and the timing of actions by the international relief forces are elements of
resilience, as they can stop cascades from escalating.
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9
HURRICANE SANDY IN THE UNITED STATES, 2012
Sandy developed as tropical depression in the Southwest Caribbean Sea on
22 October 2012. It increased in strength and became a hurricane two days later, making
landfall as a category 1 hurricane in Jamaica on 24th October and a category 3 hurricane
in eastern Cuba on 25th October. On the latter day, Haiti and the Dominican Republic
were affected with significant damages and loss of life. On 26 October, the hurricane
moved north though the Bahamas and on 27 October it weakened to tropical storm force
and then acquired new strength. On 29 October, Hurricane Sandy made landfall in the
United States (Figure 26). It caused a catastrophic storm surge on the New Jersey and
New York coastlines. In New Jersey, hurricane-force winds exceeded 280 km/hr, and
over a diameter of 1,610 km, winds exceeded 65 km/hr (AON Benfield 2013). The US
Federal Emergency Management Agency (FEMA 2013) defined Sandy as the second
largest Atlantic storm on record. Its impact was intensified because extreme weather
concentrated in the most populated region of the USA, where much critical infrastructure
vital to the Nation’s economy is concentrated (FEMA 2013, 4).
As its magnitude overwhelmed the resources available for response and required both
extraordinary co-ordination and very large quantities of Federal assistance for response
and recovery, Sandy was categorized as an incident that required the highest level of
response. A report by Blake et al. (2013) provided a detailed overview of Sandy’s effects.
The hurricane directly caused an estimated 147 deaths in the countries affected. Of this
total, 72 fatalities occurred in the USA, and 41 of these were linked to the storm surge.
The authors of the report highlighted at least 87 other deaths indirectly attributable to the
event in the United States, 50 of which were apparently related to extended power outages
during cold weather. At least 650,000 houses were damaged or destroyed, about 8.5
million customers lost power and damages were estimates at more than 50 billion dollars.
Figure 26: 1: Virginia National Guard Soldiers support of Hurricane Sandy operations in
Norfolk on 3 Oct. (photo by A. J. Coyne). 2: residents of a blackout zone in Clifton wait to fill
their fuel cans on Nov. 3. 3: the impact of Hurricane Sandy on the US Coast (Dod/Alamy,
Heritage Foundation).
116
Hurricane Sandy is a clear example of a cascading disaster. It can be defined as a disaster
originating from a natural hazard, but its effects were dependent on the interaction of
natural hazards and technological hazards. Because monitoring activities and preparation
started nearly one week before the impact on US Coast, it can be defined as a disaster of
relatively slow onset. The US Federal Emergency Management Agency (FEMA 2013)
point out that the whole community made extensive preparations for the storm before the
hurricane made landfall and acted during relief and recovery phases. In other words, all
the national actors of Crisis Management were mobilized. Figure 27 shows the path of
the Hurricane after formation. The National Oceanographic and Atmospheric
Administration (NOAA) and its National Weather Service (NWS) started to issue public
advisories on 22 October affecting both directly and indirectly public communication,
On 24 October, FEMA started direct monitoring, and from 25 October it was possible to
notice a constant intensification of warnings.
On 26 October the President of the United States was briefed and the direct involvement
of US Federal Government began. The US Coastguard activated warnings and
preparation measures along the coast, while the US National Guard effectively deployed
12,000 Guard personnel (Bucci et al. 2013). A day later, New Jersey, Connecticut, and
Massachusetts declared states of emergency ordered evacuation along the coast of the
state from Sandy Hook South to Cape May. A declaration of emergency was signed on
28 October by President Obama for counties in Connecticut, Columbia, Maryland
Massachusetts, New Jersey and New York. On the same day, the DHS Office of
Infrastructure and Protection started preparation, co-ordination and inspection activities
in chemical facilities. Air transportation was suspended. Over 1,500 FEMA personnel
were placed in a state of readiness at the time of landfall (FEMA 2014).
Figure 27 Storm path from formation to landfall (FEMA 2013).
117
On 29 October 2013, President Obama signed a pre-disaster emergency declaration for
Delaware, Rhode Island and Pennsylvania states. The US Army Corps of Engineers
mobilised temporary emergency power resources while public transportation was subject
to a virtual state-wide shutdown (AON Benfield 2013, 18). The New York Stock
Exchange suspended transactions, and public offices closed. However, Some 7.9 million
businesses and households in 15 states were without electrical power. President Obama
signed a major disaster declaration, followed the next day by a declaration of public
health emergency for New York, which was released by the Department of Public Health
and Human Services. Funds for support the recovery of businesses and households were
released. On 2. November 2 President Obama declared that Sandy had created a severe
energy-supply interruption, and all the instruments available would be used to address it,
including ad hoc emergency purchases, oil reserves, Federal financial support, and
temporary blanket use of the Jones Act. The situation improved with the gradual
restoration of refineries and pipelines but it was not solved easily. Emergency loans of
gasoline from oil reserves were made, and recovery continued slowly into the long term
involving insurance companies.
At least five other secondary disasters originated from Sandy and contributed to the
escalation of the emergency:





Storm surge. The storm surge can be considered as a secondary disaster generated
by the hurricane, after the direct effects of wind damage.
Critical energy infrastructure compromised. The combined effects of the
hurricane and the storm surge generated major damages to at least nine sites
(AON Benfield 2013), which turned into a secondary disaster. For simplicity, they
will be considered as a single episode.
Urban fire. In the New York City Metro region (especially in Queens) a large fire
destroyed 126 homes and damaged 22 others.
Leak at Shell Oil and Saudi refining storage facility in Sewaren. The hurricane
caused a major tank to rupture, that represented a clear amplification factor with
major pressure for emergency services.
Leak at Passaic Valley wastewater treatment plant, Newark, NJ. Hurricane Sandy
caused various sewage overflows, which were all contained but represented
amplifications.
A specific point has to be made for the FORTRESS morphological analysis: all the
sectors considered were both directly and indirectly affected by the event. In other words,
all the aspects of social system were involved, from transportation to environment, as
effectively happened during the 2002 floods in Prague. This seems to be a joint effect of
the natural event, the amplification provided by secondary hazards, and the disruption of
the main critical infrastructure where most interconnections lie. As commonly happens,
the results of a major emergency affected the emergency services, national security and
government sectors, requiring mass mobilization in preparation for the impact, to provide
emergency relief and to support recovery. Clearly, healthcare was affected, both in terms
of increased pressure and the physical impact of the event (a hospital was flooded). The
spreading of cascades related to secondary events further exacerbated these problems.
The public communication sector was affected, as the early development of the hurricane
required warnings, and then it was significantly affected by physical damage to the
telecommunications infrastructure. The hurricane affected transportation ground, air and
water by the suspension of activities before the impact and the damages to infrastructures
118
after the impact. Energy production and distribution was so affected to escalate into a
secondary disaster. Damage to water infrastructures affected water provision, while
economic services were suspended during the event and under high pressure after it (e.g.
insurance). As houses were destroyed, the residential housing sector was affected. The
waste and biochem sectors were subject to damages and spills that generated secondary
disasters. The natural environment was directly affected by different levels of spill and
increased pollution. Thus, the indirect effects are derived from the interdependencies
spread by each sectors to the others according to what explained in D1.1.
Figure 28 provides a representation of the complexity of the event, by presenting
119
Case
Types of hazard
impact
Scope of impact
Onset of crisis
Scope of CM
Cross border?
Principal involved
actors in CM
Directly affected
sectors
Indirectly affected
sectors
cascade
Tsunami-Fukushima,
Japan, 2011
Natural
Physical
Global
Sudden
Global
Yes
Police
Transportation
GROUND
Transportation
GROUND
Firework factory
Social
border
Rapid (Hours/days)
International
No
Fire
Supply relation
Technological
Economic
National
Slow (Weeks)
National
Health
Energy production
Energy production
Heat wave 2003
(France)
Antagonistic
Political
Regional
Creeping
(months/years)
Regional
govt.
and distribution
Energy transmission
and distribution
Organisational relation
Local
National/central
government
Water provision
Water provision
Galtür, AT (1999)
National security
Central European
floods (focus on
Prague) (2002)
Insurance companies
Public communication Public communication Pre crisis condition:
(telecom)
failure of structural
defences
Waste & biochem
Waste & biochem
(2012)
Civil protection
authorities
Healthcare
(hospitals&clinics)
Healthcare
(hospitals&clinics)
Eruption of
Eyjafjallajokull in
Iceland (2010)
MACC, CMC, etc.
Emergency services
Emergency services
Civil society
organisation
Economic services
Economic services
Community based
organisations
Government sector
Government sector
Intergovernmental
organisations
Social
sector(Education,
aggregation, icon)
Residential housing
sector
Social
sector(Education,
aggregation, icon)
Residential housing
sector
Natural environment
Natural environment
Malaysia MH17 plane
crash (2014)
Local
Companies/ industry
Figure 28 Problem space overview of hurricane Sandy
In the following paragraphs the interconnections that contributed to the cascade are
analysed and reported in the first column of Figure 29. The wide involvement of
interdependencies in critical infrastructures determined that the directly affected sectors
for some dynamics were also indirectly affected by the disruption of the system.
123
124
125
Figure 29 Visual overview of Hurricane Sandy (2013)
126
9.2.1 Box A: Pre-Crisis Political-Relational Condition
Box A addresses a pre-crisis political relational condition in the use of land and
development. Indeed, it can be argued that the political choices to rely on a distributed
energy infrastructure and long-distance energy supply, and dependence on oil,
determined the overall vulnerability of the system to fluctuations in supply. What has
been considered a secondary disaster related to the “critical energy infrastructure” was
likely to have a lower impact if long range supplies were integrated with local renewable
energy sources. Similarly, the concentration of vital infrastructures for national economy
such as oil refineries and distribution hub in the geographical area has to be considered
as an effect of land use and increased the sensibility of the energy grind as a whole.
9.2.2 Box B: Disturbance Relation (Geospatial and Physical)
Similarly to Prague case study, disturbance relations are determinant in Sandy. On the
one hand, physical relations are referred to extreme weather that determines the failures
of multiple critical infrastructures, which generates secondary disasters (together with
pre-crisis conditions). On the other hand, geospatial relations are referred to the spread
of secondary disasters due proximity of in the same geographical area. Extreme weather
conditions compromised critical infrastructures and in some cases the delivery of aid. In
many cases, the physical effects of the storm surge interacted with those produced by
high winds, and this escalated the disaster. In other words, what happened is similar to
the dynamics of the 2011 Great East Japan Earthquake, in which a tsunami followed an
initial seismic event in the Pacific Ocean. On the one hand, according to the EIA (2012b)
winds and flooding damaged much of the energy infrastructure in the northeast, including
substations, refineries and petroleum product supply such as terminals. Energy
distribution and production were affected. The storm surge flooded a large number of
electrical substations and affected a major distribution hub for petroleum delivery in New
England, New York, and New Jersey. Winds caused a tank to rupture in Sewaren, which
allowed 12,700 hectolitres of fuel to leak into the Arthur Kill waterway affecting heavily
environment. The area affected encompasses approximately 8 per cent of total refining
capacity of the United States (AON Benfield 2013). On the other hand, extreme weather
conditions limited the work of relief squads in emergencies or emerging sub-disasters,
such as in the fires in New York as limited all forms of transportation (ground, water,
air). Various sewage overflows were generated, involving the management of waste and
biochem sector and affecting environment. The most critical wastewater leak happened
in Newark, where between 29 October 29 and 3 November 37 million hectolitres of
untreated sewage flooded in Newark Bay. Before the repair of the treatment plant, which
happened on 16 November, it is estimated that 132,000,000 hectolitres of partially-treated
sewage had contaminated the bay (Kenward et al. 2013). The gravity of this disturbance
relation affected directly all sectors used in our analysis, and consequently for their
interconnections was reflected in indirect relations.
9.2.3 Box C: Disruption of a supply Relation (Physical Media)
Immediately following the storm, the disruption of a supply relation becomes evident
because the lack of energy supply (Physical Media) stopped most activity in the area
Indeed, as energy can see a main driver of human activities and the most interconnected
element it generated cascading effects on all social sectors both directly and indirectly.
Indeed the blockage of energy transmission and distribution that had very severe effects
(AON Benfield 2013). It limited the supply of goods to the region, access to water supply
and as a consequence social sector and economic services were affected. On 31 October
the energy supply situation remained critical, even though the hurricane emergency had
started to decrease. Nevertheless, 4.8 million citizens were still without power in 15
states, and vast areas experienced shortages of gas. From this point, energy supply
became the most critical issue. On 3 November, gas was rationed in 12 counties. On 7
November, more than 600,000 people were still without electricity, and on 9 November
gas rationing started in New York City, Nassau and Suffolk (CNN 2014). Comes and
Van der Walle (2014) explain that infrastructure, such as pipelines, oil terminals, storage
tanks and filling stations, could hardly function without a safe and constant energy
supply. Moreover, Kuntz at al. (2013) showed that the industrial sector was overwhelmed
and damaged by its dependency on electricity and IT systems. Hospitals had to relay
completely on emergency generators, while emergency services where subjects to higher
pressure due to increased need of citizens and public institutions.
9.2.4 Box D: Disruption of a supply Relation (Delivery Relation)
A second supply relation is referred to the damages to ground and water transportation
that contributed to the disruption of refineries and terminals (delivery relation).
Together, they determined a loss of supply, but also the length of time that it took to
repair power and ICT infrastructure (Comes and Van Der Walle 2014). Kuntz et al.
(2013) highlighted the significance of the dependency of the industrial sector upon
transportation. The Energy Information Agency (EIA 2012) explained that terminals
located in the affected areas had a combined storage capacity of about 70 million barrels,
received via pipeline from refineries on the US Gulf Coast, the Philadelphia area, and
New Jersey. Furthermore, via tanker and barge they receive products from outside the
USA. Terminals in the region also supplied gasoline, heating oil, and diesel fuel for retail
and local distributors. The damage to the dock facilities was reflected in a reduction in
shipments of gasoline and distillate, which in the post-storm period were respectively 54
per cent and 46 per cent below ordinary levels (AON Benfield 2013).
9.2.5 Box E: Disturbance Relation (Geo-spatial relation)
Elements near in spaces but not correlated arrived in contact for the joint physical effect
of the event determining a second disturbance relation (geo-spatial) complementary to
the one reported in Box B. Strong winds toppled many trees and about 271,000 US
residents lost electrical power. In New Jersey Public Service Electric and Gas Company
pointed out that around 48,000 trees had to be removed or trimmed (Blake et al. 2013).In
many areas such, as New York, electrical grids were disrupted by high winds and fires
were generated by live wires disrupted by the storm surge. The fire was located in a
flooded area of Ocean Drive, Queens, and was generated by contact between water and
electrical wiring. For ten hours, the high winds and storm surge blocked emergency
workers, and the event was allowed to escalate. In New York City, at least 21 fires
developed, and they destroyed more than 200 homes and businesses (AON Benfield
2013). This affected housing sectors but also economic services (insurances) and
emergency services.
9.2.6 Box F: Disruption of an information Relation (Telecommunication Relation)
Sandy caused the disruption of information relation in the form of telecommunication
relation and data relation because the infrastructure of the Internet underwent serious
damages, generating cascading effects due to block of communication. The hurricane
caused service interruptions for specific networks over an extended period, in line with
reports about flooding and damage to equipment. As a direct effect of the impact in New
York and New Jersey, network outages doubled in the USA when Sandy made landfall
(Heidemann et al 2012). The report by AON Benfield (2013) pointed out that
128
communication disruptions generated scale effects on electronic trading and consequent
global scale effects of the crisis as a whole. The global economy was affected, particularly
in terms of the shutting down of NASDAQ and the New York Stock Exchange.
9.3 LESSONS LEARNED
Hurricane Sandy represents an interesting case study because it shows one of the
unsolved contradictions of disaster risk reduction and crisis management. On the one
hand, potentially devastating cascades were contained with the use of effective
preparedness strategies and with the deployment of broad, effective emergency relief.
Many lessons from Hurricane Katrina were effectively learned and applied in coordination and timing. On the other hand, Sandy highlighted that human space is filled
with sensitive critical infrastructure that can generate serious chain effects on society. In
this case, the vulnerability that enhanced cascading is not related in itself to preconditions, such as corruption, but to a wider conception of land-use planning and
development that should be discussed in regard to the long term. In most cases it is
possible to assist to overlapping dynamics that directly and indirectly affected sectors
such as economic
9.3.1 What Went Wrong?
FEMA (2013) provided an interesting summary of areas for improvement to ensure the
unity of Federal efforts. However, it concentrated on elements that are recurring problems
in major disasters, such as the need to increase co-ordination and the integration of
community actors. In our analysis, these elements were only marginally related to the
magnitude of cascading, which instead relies principally on the model development and
its interdependencies with the use of land and resources. Fuel and energy distribution
revealed a total dependence on long-range supply, which are sensitive to fast changes in
the balance of systems and can determine cascading effects that are strong or rapid.
Furthermore, economies of scale concentrate the functions on key infrastructure, and
consequently the sensitivity of the system to disruption generates faster chain effects and
makes the process of recovery harder. An interesting point of view is provided by Bucci
et al. (2013), which reveals that all the three parts of the power system (generation,
transmission and local distribution) were critically affected by Sandy. Even if the authors
wished to create a hurricane-proof system, they decided that this option was prohibitively
expensive. Instead, they suggested that it is necessary to promote contingency planning
and training, while increasing tests of power systems in order to reduce potential power
outages, speed up restoration and increase the resilience of critical energy infrastructure
as a whole.
9.3.2 What Went Well?
According to all sources quoted, the genesis of Sandy was properly forecast and it was
possible to deploy preparedness measures adequately, as well as to create a massive and
effective emergency response. This reduced and contained the possible cascades. In that
the affected geographical area is full critical infrastructure, these could have been much
higher. FEMA (2013) noted that the President of the United States expedited the disaster
declarations by the Governors of New York, New Jersey and Connecticut, and thus
facilitated deployment. An on-line crisis management system was employed effectively
to increase co-ordination among agents of the Federal response. Any failures by FEMA
in preparedness and response were effectively compensated for by the action of the
National Guard and the US Coast Guard (Bucci et al. 2013). Similarly, effective, timing
inspections and controls helped avoid the occurrence of secondary disasters such as
129
nuclear meltdowns or major chemical spills. We can argue that, in the case of Sandy,
some escalation in cascading was avoided by the adoption of appropriate risk-reduction
and security strategies. The concentration of critical infrastructures in the area had the
potential to create much more cascading, which highlights the interdependencies of
systems, especially in the energy sector. Bucci et al. (2013) reported that nuclear facilities
were fully monitored and made secure as routine preparation the week before Sandy made
landfall and no critical failures occurred in the nuclear power plants, even though the one
at Oyster Creek is the oldest functioning nuclear plant in the United States. The Nuclear
Regulatory Commission placed inspectors in all nuclear power plants on high alert. To
prevent any problem, three reactors were shut down. The nuclear power plant at Oyster
Creek, New Jersey, was closely monitored for risk due to high water and an 'unusual
event declaration'. Moreover, chemical spills were limited.
9.4 CONCLUSION
The impact of Hurricane Sandy upon the United Stated suggests different perspectives to
be integrated into FORTRESS. In conclusion to this study, the first observation is that
the effective deployment of disaster risk reduction measures, such as inspections of
critical infrastructure elements, helped limit the escalation of any problems with nuclear
power plants and chemical facilities. This is a key element that distinguishes Sandy from
the 2002 Floods in the Czech Republic and the 2011 Great Eastern Japan Earthquake. In
these cases, the Spolana chemical facility and the Fukushima Daiichi nuclear plant,
respectively, revealed existing vulnerabilities that acted as incremental factors in the
event. The different character of the onset of these two disasters meant that preparedness
and response had to be arranged in a manner that was different to how it was in Sandy,
but we could argue that intensifying routines controls and drills could help to contain
cascades that follow sudden-impact events. Other feasible steps to be implemented relate
to those reported by Bucci et al. (2013) about increased contingency planning and
training. FEMA (2013) identified strengths and areas of improvement to ensure unity of
effort in the response, in increasing survivor-centric intervention and developing a
professional emergency workforce. However, these are typical buffering strategies and
are part of good practices developed by the United States to enhance the country's
emergency management strategy. Less relevance has been attributed to the steps needed
to reduce the vulnerability of critical infrastructure in the long term. Hurricane Sandy
case shows that the main triggers of amplification were supply relations, determined by
pre-crisis political choices. As this case shows, given the high sensitivity of long-range
energy supply, increased redundancy could be achieved by localizing energy sources and
remodelling the energy grid. This would require a broader judgement by politicians on
which model of development is appropriate to reduce the risk of crisis and disasters.
130
10 2010 EYJAFJALLAJÖKUL
AVIATION CRISIS
VOLCANIC
ERUPTION
AND
CIVIL
There has long been concern in the civil aviation industry about the effect of volcanic
eruptions upon flights. A major emergency occurred during the eruption of Mount
Galunggung in Indonesia in 1982, when a British Airways Boeing 747 briefly lost power
to all engines as it flew through the ash cloud. A similar contingency occurred in 1989
when a KLM 747 flew through the ash cloud of Redoubt Volcano in Alaska.
Concentrations of ash in the atmosphere can determine different risks for flights as
represented in table 1. Since the 1980s alerts, forecasts and monitoring have enabled ash
plumes to be avoided, at least in terms of the worst consequences. However, the 2010
Eyjafjallajökull eruption took the international authorities totally unprepared and without
any emergency plan. In volcanological terms, this was a relatively modest eruption: it
reached VEI=4, with the emission of about 1 km3 of magma-equivalent (Newhall and
Self 1982). In comparison, the 1883 eruption of Krakatau in Indonesia emitted 17 km 3,
and prehistoric eruptions have occurred in the range 100-3,000 km3. The style was
Vulcanian, which signifies moderately explosive, and the ash plume reached an altitude
of 13,000 metres. As is normal for explosive activity, it had a rich content of silica,
amounting to 58 per cent, which is dangerous to jet-powered aero-engines. It should be
noted that Eyjafjallajökull is not one of the largest of the Icelandic volcanoes: Krafla,
Hekla, Bardabunga-Veidivotn and nearby Katla all appear to have a greater eruptive
potential. Moreover, Katla is part of a linked system of magma emissions that involves
Eyjafjallajökull, and in the past it has been known to erupt in sequence after the latter.
At various times over the week 14th-21st April 2010 313 airports were closed for effects
of the eruption, representing three quarters of the total. During this period, 108,000 flights
were cancelled, which amounted to 48 per cent of the number scheduled. Over four days,
the number of commercial flights in Europe decreased from 28,000 a day to 5,300 (on
Sunday 17th April). It is estimated that 8.5 million people were stranded by the shutdown, some as far afield as South Asia and South America. Pressure on alternative forms
of transport mounted and, for those who were stranded far from their home country, it
sometimes took considerable ingenuity to achieve repatriation. Until now, very little has
been written on the emergency management implications of the crisis (Alexander 2013).
Table 4 Volcanic Ash and Aviation Severity of Encounter Scale (USGS)
Class
0
acrid odour, electrostatic discharge
1
light cabin dust, exhaust gas temperature fluctuations
2
heavy cabin dust, external and internal abrasion damage, window
frosting
3
engine vibration, erroneous instrument readings, hydraulic-fluid
contamination, damage to engine and electrical system
4
engine failure requiring in-flight restart
5
engine failure or other damage leading to crash.
Source: Miller and Casadevall (2000).
131
The 2010 volcanic eruption in Iceland be defined a natural and technological disaster as
a main natural hazard impacted on unsolved vulnerabilities in the social and technological
domain. We can argue that the physical impact of the Natural event itself was of lower
intensity than the ones generated by the interruption of the activity of the European Civil
Aviation, which can be considered under all aspects a full secondary disaster. The onset
of crisis was creeping, with a sudden passage from ordinary routines to emergency status.
The scope of Crisis Management was mainly international and cross border as it involved
the European Civil Aviation and required a global effort of coordination.
Eyjafjallajökull is a relatively small volcanic edifice located in southern Iceland, 150 km
east of Reykjavik. It is a stratovolcano, and hence is composed of layers of ash and lava
built up over millennia by explosive and effusive activity. In 1821-3 it underwent a
sustained but moderate explosive eruption with the emission of 4 million cubic metres of
tephra over a 13-month period. This included 25 days of continuous ash emission. No
further activity occurred until the event we are reporting. In December 2009 harmonic
tremor began under Eyjafjallajökull. This is a sustained form of seismicity that can
presage an eruption, and was monitored by Icelandic Civil Protection while activity
increased. At 07:00 AM on 13 April 2010 Central European Time explosive
phreatomagmatic activity (i.e., composed of steam and tephra) began. The ash emitted by
Eyjafjallajökull concentrated at altitudes of 6,000-9,000 metres (see Figure 28). Although
this is below the cruising altitude of a typical jetliner, the problem was that of ascent and
descent through high concentrations of ash. The global circulation gradually drove it
southwards so that it covered most of Europe as far south as Florence in Italy and
Barcelona in Spain.
Figure 30 Eyjafjallajökull in eruption on 17th April 2010.
Source: Wikimedia Commons
At 10:13 of 14 April, the EUROCONTROL Central Flow Management Unit (NMOC)
received an email alert by the London Volcanic Ash Advisory Centre (VAAC) which
also quickly informed National Air Traffic Service (NATS) responsible of air traffic in
132
the UK. Norway and UK (Scotland) start to limit air traffic. Thursday 15th April the
Service banned all non-emergency air traffic from UK air space. Within 24 hours,
Scotland, Norway, Sweden and Finland had begun to restrict air space. The following
day, flights in Europe were down 27 per cent and gradually commercial flights were
grounded throughout the United Kingdom. By 18th April the level of closures had
become very restricted and the traffic registered 5,204 flights compared to 24965 the
week before the last interdiction. On 19 April a limited “No-fly zone” was established
by the States concerned, based on forecasts from the LVAAC and systematic updates
(every 6 hours) by EUROCONTROL. The regional offices of The United Nations
International Civil Aviation Organization (ICAO) agreed a meeting to consider the
effects of the eruption on North Atlantic Region. On Wednesday 21 April, 21,916 flights
were back in European airspace and represented almost 80% of normal traffic level and
the next days the traffic was mostly back to normal (Eurocontrol 2014). From 22 April
that day full emergency is over. Local closure of airspaces continued until 17 May in
different areas subjected to critical ash levels, with lower impact on the overall traffic
level. On 23 May the Met Office declares eruption over (UK House of Commons 2011).
Figure 31 below provides a representation of the complexity of the event, by presenting
133
Case
Types of hazard
impact
Scope of impact
Onset of crisis
Scope of CM
Cross border?
Principal involved
actors in CM
Directly affected
sectors
Indirectly affected
sectors
cascade
Tsunami-Fukushima,
Japan, 2011
Natural
Physical
Global
Sudden
Global
Yes
Police
Transportation
GROUND
Transportation
GROUND
Firework factory
Social
border
Rapid (Hours/days)
International
No
Fire
Supply relation
Technological
Economic
National
Slow (Weeks)
National
Health
Energy production
Energy production
Heat wave 2003
(France)
Antagonistic
Political
Regional
Creeping
(months/years)
Regional
govt.
and distribution
Energy transmission
and distribution
Organisational relation
Local
National/central
government
Water provision
Water provision
Galtür, AT (1999)
National security
Public communication Public communication
(telecom)
Central European
floods (focus on
Prague) (2002)
(2012)
Insurance companies
Waste & biochem
Waste & biochem
Civil protection
authorities
Healthcare
(hospitals&clinics)
Healthcare
(hospitals&clinics)
Eruption of
Eyjafjallajokull in
Iceland (2010)
MACC, CMC, etc.
Emergency services
Emergency services
Civil society
organisation
Economic services
Economic services
Community based
organisations
Government sector
Government sector
Intergovernmental
organisations
Social
sector(Education,
aggregation, icon)
Residential housing
sector
Social
sector(Education,
aggregation, icon)
Residential housing
sector
Natural environment
Natural environment
Malaysia MH17 plane
crash (2014)
Local
Companies/ industry
Figure 31 Problem space overview of the crisis related to the 2010 Eyjafjallajökull volcanic eruption
According to the sector considered in the Figure above, it can be said that critical feature
of this case study is not in the physical impact of the volcanic eruption but the social,
economic, and political consequences determined by its direct effect on a particular sector
(Air Transportation). The phenomena generated limited effects on human health
(respiratory symptoms) and natural environment (volcanic ash and gas), while it
generated a major secondary disaster by forcing a stop of the European civil aviation.
Similarly, it had directly effects on emergency services and government that had to
cooperate to resolve the emergency and generate new legislation and practices. Instead,
the involvement of air transportation generated indirect effects on most sectors of society
as effectively transportation is the most important driver of cascading with energy sector.
On the one hand it increased the demand and pressure on the other form of transportation
(Ground and water). Than it required wide updates and messages for the public (public
communication), increased stress (healthcare) and social sector (disruption of cultural
activity and family reunions). Economic services and insurances (economic sector) were
heavily affected by the massive economic damages to air transportation, while emergency
services and government where indirectly affected as a feedback loop.
The Figure below presents a visual overview of the disaster related to the volcanic ash
cloud. As in the case studies presented above, the first column indicates the main triggers
that caused cascading effects to occur, and the remaining columns show what happened
at certain times and what effects are associated with this. The second column indicates
the timescale of the unfolding crisis (column 4) and the actions in crisis management
associated with it (column 3). Direct negative effects that occurred are described in
column 5 and sectors directly and indirectly affected in column 6 and 7. It must be noted
that the impact of the crisis described here is largely concentrated on those impacts
associated with cascading effects.
The subsections following Figure 32 analyse each of the numbered boxes listed in its first
(green) column. As these boxes address the exact triggers responsible for the cascading
effects and dependency relations, the sub-sections provide a detailed analysis of the
cascading effects during the 2010 volcanic ash cloud.
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Figure 32 Visual overview of the disaster caused by the 2010 Eyjafjallajökull volcanic ash cloud
138
10.2.1 Box A: Pre-Crisis Political Relational Condition
The risk represented by volcanic eruption on civil aviation was concrete but it was
ignored by politics. No emergency measure was available at the time of crisis and this
exacerbated all direct and indirect effect of the crisis. In particular, Alexander (2013)
pointed out that the passive approach taken by British Government was more likely to be
a result of improvisation than foresight and planning. However, the British Government's
Cabinet Office Briefing Room (COBRA) had a meeting to determine national strategy
only four days later than early event and EURCONTROL, the coordinating centre for
European civil aviation, also took a "wait and see" approach as the crisis unfolded and
influenced the relations reported in Box D and Box E.
10.2.2 Box B: Disturbance Relation (Physical)
The volcanic eruption produced ash that stopped civil aviation and generated both direct
and indirect effects human subsystems. Indeed, transportation is a central sector in
globalization and one the most interconnected. In this case, flights in Europe were almost
stopped. The volcanic ash emergency lasted one week, during which flight cancellations
increased for three days, remained at their lowest level for one day, and diminished for
the subsequent three days (Figure 31). Among the primary impacts, airlines lost a total of
US$1.7 billion in revenue (Budd et al. 2011) and 10.5 million passengers had their travel
plans disrupted. The secondary effects of the eruption can be divided into those involving
passengers and those affecting the movement of goods. Business and leisure travel were,
of course, severely, if temporarily, disrupted. This put a strain upon alternative forms of
transportation, particularly railways, car hire and ferries. For example, on April 19 the
UK Prime Minister Gordon Brown arrived to announce that a Royal Navy Task Force of
three warships would be sent to fetch some of the 150,000 British travellers stranded
overseas. It should be noted in passing that military flights were not covered by the ban,
but experiments elsewhere in Europe with fighter planes, convinced the military
command to impose a provisional ground-stop.
Figure 33 Flight cancellations in Europe over the period 14-22 April 2010 compared with
normal levels of air traffic (from Alexander 2014, after EUROCONTROL).
10.2.3 Box C: Disruption of a supply Relation (Delivery and Service)
The stop of air transport has to be considered a disruption of a Supply relation both in
terms of delivery (transportation infrastructure) and services (e.g. cultural and economic
services). It exacerbated long range dependencies on physical and human resources. The
temporary cessation of air transportation disrupted the tour schedules of performing
artists, a problem that was particularly acute for symphony orchestras, who thus
experienced significant cuts in their revenue. In Europe there is also a thriving industry
based on conferences and conventions, for which postponements and cancellations are
very expensive. Many forms of perishable goods are transported by air because their shelf
lives are brief. About 80 per cent of Europe's cut roses are grown in Kenya, one fifth of
whose economy depends on shipping flowers to European destinations. Economic
hardship resulted. Bone marrow shipments from North American donors were delayed,
with potentially fatal consequences for the European recipients.
The event triggered an organisational relation, which revealed again the total lack of
preparedness for the event in term. The event was characterized by the total absence of
international coordination, which exacerbated cascading effects produced by the physical
stop of civil aviation in all sectors. No “Plan B” were effective to manage the social
emergency caused by disruption in transportation. Any alternative to flights were
immediately subject to excessive demand, higher prices and shortage of tickets. At the
same time, the imbalance in movement with respect to its predicted levels meant that in
some places the hospitality industry was languishing while in others, notably Paris, it was
booming and full to capacity. No regulation of prices governed either hotels or
transportation and so there was profiteering, although its extent has never been assessed.
This lack of organization decreased trust of transport industries in government and was
reflected in increased pressure on emergency management sector, insurances and legal
systems. That day, a research flight took off from Cranfield University Airport in central
England and collected samples of ash from the atmosphere. Both British Airways and
Lufthansa defied the ban on flights and sent up one large aircraft each without passengers
aboard. They were concerned that the ban might unnecessarily be affecting their revenue.
All three flights produced encouraging results. On 19 April the Air Transport Association
expressed the complete dissatisfaction against the lack of coordination and emergency
management shown by governments, while the European Commission and
EUROCONTROL organized a meeting and decided to move towards a harmonized
European approach (set out below) that permitted flights where possible. On 22 April
Mr Michael Ryan, CEO of RyanAir, took the leadership against the European regulation
261/2004, which requires airlines to give passengers whose flights have been cancelled a
refund and pay for board and subsistence until they can be given new flights. The
regulation was intended to counter malpractice and inefficiency among the airlines, and
Mr Ryan argued that it was inappropriate to cases in which force majeure obliged them
to make the cancellations. The European Commission was unmoved by such arguments.
10.2.5 Box E: Disruption of an information Relation
Lack of accountable data on the ash cloud was a critical element in particular in the earlier
phases of the emergency, while the information was shared at the national more than
continental level, revealing the existence of an information relation in the event. This
contributed to exacerbate the lack of coordination reported in Box B. Furthermore, the
initial monitoring and modelling response used by the United Kingdom Met Office
revealed inadequate, and an effective one was confirmed only on 11 May. Initial
thresholds for and security were introduced, but revealed inappropriate influencing the
chain effects reported in Box D.
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10.3 LESSONS LEARNED
The eruption of Eyjafjallajökull was neither the worst example of volcanic ash in the
atmosphere to have occurred in the jet age nor the longest lasting eruption. However, it
was the only one to have occurred over an area of more than 500 million people with a
very highly developed civil aviation system and, of course, a high dependency on air
travel for certain kinds of commerce and social interaction.
In many, although not all, instances, there are alternatives to air travel, or trips can be
postponed, if necessary indefinitely. Besides ground and sea transportation, some
meetings can be held using electronic communication instead of face-to-face contact,
products can be sourced locally rather than from afar, vacations can be postponed and, as
a last resort, government subsidies can keep enterprises and industries solvent until their
activities able to resume. However, contingency planning is required, and in 2010 there
was relatively little sign that it had taken place or that existing plans were effective.
The United Kingdom was nominally the worst-affected country and was also the one that
took the lead in managing the crisis. However, volcanic emergencies were not in the
recently published National Risk Register, although they were added to the next version
to be published (UK Cabinet Office 2010; 2013, 8).
Initially, there were no reliable data on the concentrations of ash in the atmosphere, none
on the concentrations at which it was safe to operate commercial jetliners and none on
the levels at which airliners would suffer damage. Early opinions on these questions
differed between the engineers, atmospheric scientists, meteorologists, regulators,
administrators, airline executives and airport operators. Amidst this chaotic situation, and
the bitter surprise of passengers who found themselves abruptly and unexpectedly
stranded, there was an initial lack of visible leadership and timing response.
The initial monitoring and modelling response conducted by the UK Meteorological
Office used the Numerical Atmospheric-dispersion Modelling Environment (NAME III)
digital model (Jones et al. 2007), which, however, responded to the wet conditions of
major storms, not the dry ones of suspended volcanic particulates. Later in the crisis,
more sophisticated and appropriate remote sensing was brought to bear, but in the early
stages the behaviour and concentration of the plume were not well understood, although
its pattern of dispersion was made clear by the meteorological models.
Neither atmospheric science nor flight engineering adequately justified the thresholds
that were selected: 200 and 2000 μgm-3. The UK Government's penchant for risk aversion
had already been well demonstrated in 2000, when a fatal rail crash at Hatfield, southern
England, led to 1,200 30 km/hr speed restrictions that put paid to the national timetable
and led to nationwide chaos on the railway system. In 2010, the initial approach was to
assume that 200 μgm-3 was an appropriate threshold. However, six days after the start of
the crisis a distinction was introduced between the 'black' zone (>2000 μgm-3), in which
flights were banned, and the 'red' zone (200>μgm-3<2000) in which 'enhanced procedures'
were required. Most of these involved increased monitoring of the condition of aircraft
and accelerated maintenance. Frantic efforts were being made to ascertain the effects of
limited concentrations of suspended volcanic ash particulates on jet engines and other
equipment. Previous research had focussed on how to avoid highly concentrated ash
plumes and there was little expertise on what to do about relatively minor concentrations
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of highly dispersed ash. Finally, many commentators (e.g., Sammonds et al. 2010) have
suggested that the ash concentration thresholds, and measures taken in response to them,
were arbitrary and lacked a viable basis of science and engineering. The risks of levels 4
and 5 ash encounter events were regarded as overstated.
The Eyjafjallajökull crisis revealed a lack of planning to cope with the cessation of civil
aviation. Tentative contingency plans were made to collect long-haul passengers at hub
airports in the less affected areas, such as Madrid in Spain. However, the lack of
integration and elasticity in other forms of transport ruled out any concerted effort to
reorganise the way people in Europe travel. Some military personnel and a few civilians
reached the United Kingdom by landing at Madrid, catching buses to Bilbao and boarding
a British Navy ship bound for England, but no plan existed to increase such capacity.
European and British civil aviation authorities had the makings of a system of
collaboration, but what was really lacking was an international contingency plan to move
the stranded passengers and goods. Moreover, this needed to be followed by business
continuity plans for airlines, airports, the operators of other forms of transportation, the
hospitality industry, tourism and businesses that normally require employees to travel
internationally. There is a particularly acute problem of how to expand and adapt air, sea
and road transportation to cope with the needs generated by any sudden cessation of air
traffic. Moreover, this needs to be done in a coordinated way. During the Eyjafjallajökull
crisis it was tacitly assumed that the only contingency of this kind was to get people back
to their countries of origin. This was patently not so, and a more protracted crisis would
have revealed many other needs, such as how to keep certain forms of commerce going,
and how to save civil aviation from bankruptcy. It is estimated (Mazzocchi et al. 2010)
that a few more days with a general interdiction upon flights would have been enough to
start bankruptcies and redundancies in the airline industry.
The Single European Sky is a European Commission initiative to harmonise the work of
national air traffic control services and make safer and more efficient use of European
airspace. It was first proposed in 2000, but early progress was slowed by Britain's
objection to Spain's position about Gibraltar's airspace. The process, centred upon
Eurocontrol in Brussels, was greatly accelerated after the eruption of Eyjafjallajökull
(Dopagne 2011). Ground and sea transportation rose to the challenge, and civil protection
services looked after the needs of many people who were stranded. Businesses adapted
as best they could and people soldiered on in their attempts to get home or wait the crisis
out.
10.4 CONCLUSION
As it affected about 80 per cent of European territory, the eruption of Eyjafjallajökull was
a cross-border crisis par excellence. In this case, the cascade is not critical for the quantity
of sectors directly affected but for the gravity of a total disruption that affected a highly
interconnected one. In terms of co-ordinated action on behalf of aviation safety, it was
hampered by the fact that, although very many flights are international, they are managed
on a country-by-country basis. Eurocontrol began to assume a much greater profile in
dealing with the cross-border aspects, although there was no indication that it could
override national responsibilities. As the country most affected and home of vital
monitoring services, the United Kingdom took the lead and other countries followed, but
this process did not follow a plan. Moreover, there was no plan at all for many of the
cascading effects.
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The principal cascade involved the change of transportation mode from air to land or sea,
and associated effects within the hospitality industry. Ground and sea transportation
became seriously overcrowded or was unable to offer reservations within a reasonable
time frame. Tourism was disrupted, with expected presences either doubled or decimated.
Business activities that depended on face-to-face meetings were postponed, and the
delivery of perishable or time-limited goods was also put back. Hotel and restaurant
capacity became severely unbalanced between places of unusually low and high demand.
The courier industry and many other businesses that surround and depend on airports,
also suffered. People in transit through Europe and those who had journeys to or from
other continents had their plans disrupted and some were able to make only expensive
and unpalatable alternative arrangements.
Finally, it should be noted that the Eyjafjallajökull crisis was small and short-lived in
relation to what could happen. For example, the Laki fissure eruption of 1783 produced
starvation in its home country, Iceland, and elsewhere in Europe a massive ash fall-out
that lasted five months and a thick sulphur dioxide fog (Thordarson and Self 2003). It is
likely that a longer eruption, with more protracted and serious atmospheric effects, would
produce more cascading effects, for example, on public health and agricultural
production.
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11 CONCLUSION
Cascading effects in crisis situations can increase the negative impacts of disastrous
events far beyond their initial impacts. The analysis of how such cascading effects are
triggered, what sectors and infrastructures are commonly involved, and what frequently
generated impacts are, can contribute to providing a better understanding of these effects,
and can be beneficial for the development of tools and procedures in relation to this.
Within the FORTRESS project, such an understanding can be used as a basis for the work
carried out in this and other Work Packages.
The present report has involved the analysis of cascading effects and their triggers in nine
historical crises. The choice of the crises case studies was informed by an analysis of
crises most frequently occurring in Europe between 2003 and 2013, based on data
available in EMDAT. The frequency of certain types of crises was considered, as well as
the cross-border aspect of crises and the presence and severity of cascading effects.
Additionally, three non-European case studies were included as these are illustrative
examples of large cascading crises. The nine case studies selected include the Enschede
fireworks factory explosion (the Netherlands), the London attacks (UK), the Fukushima
nuclear disaster (Japan), the Galtür avalanche (Austria), the European Heatwave
(research carried out focused on France), the MH17 plane crash (Ukraine), the
Eyafjallajökull volcanic eruption (Iceland, but with a focus on the UK), Hurricane Sandy
(USA), and the Central European floods (with a focus on Prague).
As discussed in the introduction to this report, each of the case studies were completed
by means of a visual overview. These overviews consisted of seven columns which aided
the analysis of the crises. Six columns were used to identify and specify what happened,
on what time scale it happened, what actions in crisis management were carried out, what
the direct negative effects (i.e., casualties) were, which sectors were directly affected and
which sectors were indirectly effected. The visual presentation also provided an
indication of how different entries in the columns related to one another, for instance,
how actions in crisis management affected the unfolding of the disaster. A final column
in the visual overviews identified cascading effects. Also here it was also indicated how
they related to the other entries in the overview. Drawing on Becker et al. (2012), Rinaldi
(2001), and Voogd (2004), a categorisation for the identification and labelling of all case
studies’ triggers of cascading effects was created. This contained the following
categories: disruption of an information relation, disruption of a supply relation,
disruption of an organisational relation, malfunctioning of a legal and regulatory relation,
disturbance relation, and pre-disaster conditions (for a detailed description of the
categorisation see section 1.1). It must be noted that as the analyses of the nine cast studies
were limited to the identification and discussion of cascading effects, they do not present
comprehensive accounts of all aspects of the crises.
The analyses revealed that there were three overarching categories of triggers that were
most common: A. disruptions of relations that should have been functioning, B.
disturbance relations, and C. pre-disaster conditions. The following three sub-sections
will discuss each of these categories in greater detail.
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11.1 DISRUPTIONS OF RELATIONS
The disruption of relations that are commonly expected to function frequently triggered
cascading effects. As listed in Table 3 (Chapter 1), disruptions to three types of relations
were identified in this context: information relations (referring to a relation in which
system elements or actors are dependent on the communication of information),
organisational relations (relations of organising, making decisions, and making different
people or things work), and supply relations (relations in which system elements or actors
are dependent on supply activities by other system elements). In this respective order they
are discussed in the following paragraphs.
With the exception of the case studies on the Fukushima nuclear disaster and the floods
in Prague, disruptions of information relations as triggers of cascading effects were
addressed in all case study chapters, and were identified 12 times in total. The vast
majority of these triggers concerned the congestion of telecommunication networks
(radio, and landline and mobile phone networks), which complicated effective crisis
management as communication between first responders could not take place or could
not be relied upon. The Enschede explosion, London attacks, and Galtür avalanche case
studies present descriptive examples of this. They illustrate the importance of having
reliable communication systems that work across emergency services, and continue
working when other networks may fail. In London, for instance, such a communication
system was implemented in response to the difficulties in communication experienced
during the London attacks.
Disruptions of organisational relations were identified eleven times. These triggers of
cascading effects are often related to disruptions of information relations, but are more
than that. Rather, they refer to a relation of organising, making decisions, and making
different people or things function in emergency management. The chapters on the
Enschede explosion, Fukushima, London attacks, heatwave in France, the MH17 plane
crash, and the Eyafjallajökull volcanic eruption identified and analysed such disruptions
of organisational relations. These analyses highlighted some common sources of
disruptions. First, there are the decisions made based on incorrect information that
directly caused cascading effects related to the organisation of crisis management. For
example, Box E in the Enschede case study illustrates how the intentional withholding of
information by personnel of SE Fireworks led to the fire brigade taking actions which
were not optimal for preventing the situation from escalating. This illustrates that such
disruptions of organisational relations do not concern a breakdown in communication
systems, but simply relate to inaccurate, incomplete or wrong information. A second
source of disruptions of organisational relations are the decisions taken that caused
organisational problems. Contrary to the previous point these were not based on incorrect
information, but, in hindsight, proved to be the incorrect thing to do. Box D in the chapter
on the London attacks provides a clear example of this: the decision to change a meeting
location for members of the Gold Coordination Group impacted the coordination of
responding to the attacks, as congestion on the roads meant many officials experienced
severe delays in getting to the new, rather remote location. Whereas in this example it
was clear who was responsible for the decision that was made, there are also cases in
which it is not clear who should take decisions or at what point decisions should be made.
This relates to the third source: organisational responsibilities were not agreed upon, or
were at times not even outlined. The Eyafjallajökull eruption and the French heatwave
provide illustrative examples of how the absence of organisational plans for crisis
management lead to extensive cascading effects. The latter case study showed how the
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absence of a heatwave response plan presented challenges for classifying the event as an
emergency which negatively impacted on the heatwave’s death toll. This emphasises the
significance of a systematic organisation of not only people but also resources. It is
important to keep in mind that this concerns the organisation of people and resources both
within and between organisations.
In seven case studies disruptions of supply relations were identified - this trigger was
mentioned eight times in total. Remarkable was that the lack of supply of water as a
trigger of cascading effects was identified twice in this context: the Enschede case study
illustrated how the use of water for firefighting negatively impacted on the drinking water
provision, and the chapter on the French heatwave detailed the consequences of the lack
of water, as part of the nature of the crisis, needed for the cooling of power plants: nuclear
power stations were forced to shut down. More generally the identification of disruptions
in supply relations as a trigger for cascading effects also shows that besides focussing on
the role of humans (i.e., their actions and decisions) the fundamental importance of
resources should not be overlooked.
11.2 DISTURBANCE RELATIONS
Disturbance relations are the unintended relations of interference that only come into
being in a crisis – they did not exist before, and are therefore not disruptions to preexisting relations. They refer to those situations where the functioning of one system or
actor becomes dependent on or is influenced by another system or actor during the crisis,
whereas that was previously not the case, and subsequently cause cascading effects.
Disturbance relations as triggers of cascading effects were identified 12 times. They were
identified in seven out of nine case studies; only the Enschede and the MH17 plane crash
case studies did not identify this trigger.
Frequently identified in the case studies were disturbance relations related to weather
conditions - the Galtür avalanche, the French heatwave, the floods in Prague and
hurricane Sandy all address such triggers. For example, the Galtür avalanche case study
showed that because of the extreme weather conditions rescue teams could not reach the
affected area. Rescue operations therefore solely depended on the emergency personnel
already present. This particular example illustrates that disturbance relations are not only
those in which the functioning of one system or actor becomes dependent on another
system or actor; they also include situations in which there is a shift in the degree of
responsibility for the functioning of disaster management between actors.
The case of Fukushima illustrated the nature of a clear disturbance relation that was not
weather-related. Due to the failure of pumps, seawater could not be accessed and used
for cooling the nuclear reactors. All of the sudden firefighters became responsible for this
process, whereas this was not a relation of dependency present in an everyday situation.
It was a given fact that the power plant was dependent on water for cooling the reactors.
It was also known that the area is seismically active and that earthquakes and tsunamis
could potentially cause damage to the water provision. Yet, no adequate preparedness
measures were taken for the fire department to deliver alternative water injections, and
they faced great difficulties in doing so. The lack of preparedness measures draws
attention to the role such measures could play in limiting cascading effects in commonly
occurring crises. Knowledge on one’s environment and the hazards that are expected to
occur in that is a valuable resource, and it should not be overlooked that this can be used
as a basis for preparedness actions.
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11.3 PRE-DISASTER CONDITIONS
Pre-disaster conditions leading to cascading effects were identified 12 times, in six case
studies in total. Interesting is that the triggers identified were rooted in conditions which,
at times, were very different in nature. For example, the case of Fukushima illustrates
how wider economic trends (i.e., nuclear power becoming less profitable in Japan)
instigated specific behaviours (i.e., the investment in cost-reduction measures rather than
safety measures) that subsequently caused cascading effects. The case of the floods in
Prague illustrates the opposite: how specific behaviours (political decisions) gradually
caused changes of a broader nature (i.e., changes in settlement patterns which increased
the susceptibility to cascading effects occurring if there would be a flood). Despite their
differences, these pre-disaster conditions as triggers are of a different nature than the
triggers in the above sub-sections (disruptions of relations, and disturbance relations) as
they did not generate cascading effects because of something that happened during the
crisis situation, but because of conditions prior to the crisis. Hence, although these are
triggers of cascading effects, it is harder, if not impossible, to address such triggers during
crisis management. Nevertheless, in many cases there was plenty of time to mitigate risks
associated with such conditions prior to the crisis.
11.4 LESS FREQUENT TRIGGERS
Related to the previous section are several triggers that were mentioned less-frequently,
but also concern the pre-disaster phase more than the actual crisis situation. The
malfunctioning of pre-crisis legal and regulatory relations was mentioned three times: in
the Enschede, Fukushima, and Prague case studies. This category of triggers largely
concerns the lack of inspections or assessments that should have been carried out, or the
lack of sanctions with regard to not complying with orders from a higher authority. The
Enschede case study provides a clear example of how the malfunctioning of pre-crisis
legal and regulatory relations between local government, national government and
industry contributed to the cascading effects in a crisis: SE Fireworks did not meet its
legal obligations with regards to fire-safety but was able to get away with that as
inspections were not carried out sufficiently by the local government. Combined, this
contributed to the spread of fire and the subsequent explosions. Hence, the
malfunctioning of legal and regulatory relations can create vulnerabilities which may not
be alarming in pre-crisis situations, but which lead to a proneness to cascading effects
during a crisis.
An interesting case of a trigger also related to the pre-crisis situation was the
malfunctioning of a pre-existing backup supply relation of electricity in the Fukushima
disaster. The back-up system aimed at providing the nuclear power station with electricity
in case of emergency was not functioning. This presents a different angle to triggers
which have their roots in a pre-crisis phase: that of assuming that functioning
preparedness measures are in place and possibly placing trust in the functioning of such
systems, whereas in reality this was an expectation based on false presumptions.
Additionally, assuming that emergency back-up systems or any emergency preparedness
procedures work, can negatively impact on investing in other preparedness measures.
11.5 LESSONS LEARNED
The analysis of historical crisis cases studies in this report shows that triggers of
cascading effects can have their roots both in the turn of events during crises, as well as
in a pre-crisis context. The latter illustrates that crisis preparedness cannot be viewed in
147
isolation from the everyday conditions that take place in a given society, country, or area.
Particularly when planning for ‘known’ crises, those that take place with a certain
frequency and which are expected to occur again, such pre-disaster conditions should
play an important role in planning and preparing for crises. Regulations play a large role
in this. A key point to consider is that the effectiveness of regulations depends on their
implementation as well as the compliance by those subject to the regulations. Compliance
is not only the responsibility of those being regulated, but also of the regulator, as the
Fukushima case study illustrated. Inspections should be carried out, and possibly
followed by binding instructions, and sanctions if these instructions are not carried out.
More complicated to address are the pre-crisis conditions that caused cascading effects,
such as economic, cultural and political developments. As these are frequently linked to
gradual changes over long periods of time and have their roots in several developments,
changes, and events, these triggers of cascading effects can rarely be pinned down to one
single event or cause.
With regards to the triggers that originate during crises, either as a result of a disruption
of relations or disturbance relations, there are several opportunities for alternative
measures of disaster management that could aid in limiting their cascading effects. The
examination of triggers of cascading effects indicated that disruptions of information
relations and organisational relations commonly cause cascading effects to occur. These
are often, though not always, closely related as incorrect information or the absence of
information problematises decision-making, and accessing information and
communicating information is crucial for effective crisis management. In many cases
more extensive preparedness measures with regards to having separate communication
systems and back-up lines, as well as pre-established plans of approach and divisions of
responsibility could improve the organisational response to crises and limit cascading
effects arising from disruptions of the relations of dependency. Although such measures
could not address all cascading effects resulting from disruptions to information and
organisational relations, these are probably the most straightforward to prepare for and
address in the pre-crisis stage.
Regardless of whether triggers of cascading effects originated prior to or during crises,
this report made clear that cascading effects are not merely related to flaws in
interdependent infrastructure systems, but can be a result of various other factors. Human
errors, a lack of resources, the absence of a disaster management plan and outlined
responsibilities, or the absence of information are common causes of cascading effects
that have little to do with the failure of systems such as telecommunication. This is a key
point to consider when examining the ways cascading effects occur and unfold.
Planning for emergency with the aim of reducing cascading effects does not only depend
on physical or material solutions, strengthening human resources plays a considerable
role in this.
Although it is acknowledged that nine case studies may not offer sufficient data for
detailed and scientifically sound recommendations for research, the data gathered does
illustrate the areas that would benefit from future research. Research into critical
bottlenecks in access to and communication of information, and into the most common
flaws in the functioning of legal and regulatory relations would enhance the
understanding of triggers of cascading effects. As such, the approach utilised within this
study may be of use to others in extending this type of analysis of past-events. Such
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research could subsequently inform measures taken to prepare for crises and decisionmaking within crisis management.
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Crisis case studies of cascading and/or cross- border

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