Flight 427: lessons learned from a tragedy

“You don’t want to go up there. The whole world is in pieces up on that hill.”
The words are those of former Pennsylvania Lt. Gov. Mark Singel describing the scene the night of Sept. 8, 1994, when the tower at Pittsburgh International Airport lost contact with USAir flight 427 out of Chicago and en route to Miami by way of Pittsburgh. The plane vanished from radar less than eight miles from the airport. At 7:04 p.m., someone at the Green Garden Plaza shopping center near Aliquippa telephoned Hopewell Township police to report a plane crashed.

Alerted by the 911 system in Beaver County’s Emergency Operations Center, Hopewell and Aliquippa firemen arrived within minutes and hurried through the devastation, trying to find survivors. By that time, disaster response operations from Hopewell, supporting authorities in Beaver County and units from neighboring jurisdictions were already under way. The responders would face one of the worst massfatality accidents in U.S. aviation history — all 132 passengers and crew on the flight were killed.

A major disaster like the 427 crash quickly becomes a very large operation involving hundreds of people with a variety of skills representing virtually every level of government, volunteer organizations and professional associations. The 427 crash response was comprised of at least four federal agencies, more than a halfdozen state departments and agencies, several counties and local government elements and a number of other organizations, some from out of state. All brought differing requirements for leadership as well as logistics — and occasionally clashing agendas.

Under Pennsylvania law, Hopewell Township Manager Jim Eichenlaub would function as the unified command leader. Eichenlaub, along with Beaver County Emergency Management Coordinator Russ Chiodo and County Coroner Wayne Tatalovich, decided at a midnight organizational meeting that:

* Green Garden Plaza would be the staging area for initial response operations. Mall management and retail owners immediately gave permission to use the large parking lot and commercial facilities as meeting and briefing sites. The mall was closed that night and the day after the crash to provide space for response operations, which would later move to an adjacent Pennsylvania Department of Transportation facility.

* Access to the site had to be controlled. Eichenlaub received state police support for securing the area immediately around the impact site, the “inner” perimeter. County and township law enforcement agencies, aided by the Pennsylvania Air National Guard and U.S. Air Force Reserve, would secure the “outer” perimeter and control area traffic. All told, police arrested 12 people trying to gain access to the crash site.

* While Hopewell Township would retain leadership responsibility, the overall recovery effort would be a multijurisdictional effort involving personnel and equipment from Beaver County, the state, Allegheny County (Pittsburgh) and a variety of volunteer and professional organizations.

In the midst of the initial confusion, another problem appeared: within an hour of the crash, the first media satellite van (representing a Japanese news agency) pulled up. At dawn, about 30 large vans and dozens of smaller vehicles would be parked at the plaza, and 300 reporters were swarming the mall, looking for stories.

By early Friday morning, the National Transportation Safety Board (NTSB) and Federal Aviation Administration (FAA) “Go Teams” came in from Washington, D.C. The Federal Bureau of Investigation was also represented; at this stage criminal acts had not been ruled out as factors in the crash.

The crash site was a horror. The area was very small — perhaps 250 feet in diameter — but it contained all that remained of a Boeing 737 and 132 passengers. The largest fragment of the plane was a 10-foot section of the horizontal stabilizer. Only two of the passengers and crew were recognizable as human bodies.

Despite the difficult terrain and the stress of the work, by Sept. 18 the crash site had been cleared of human remains and aircraft parts, decontaminated, seeded and released. Additionally, while the response and recovery effort received high praise from the veteran federal agencies involved, there are some lessons to be learned.

Incident Command System (ICS)/Unified Command Post. People need to know from the very beginning there is one place to go to find either the incident commander or someone who can make decisions. If key responders cannot find the right decision maker, they may settle for a well-meaning official who seems to know the situation but does not. Establishing an ICS avoids this and provides for early, effective command and control.

“The decision to move the unified command post [later] to the Penn-DOT facility was probably one of the best decisions made,” says Carl Kuehn, Pennsylvania Emergency Management Agency (PEMA) deputy director. “There was easy access to the crash site, access to the command area could be controlled, and it kept operations out of the mall, where it was a reminder of the tragedy.”

Security. Once the determination was made that there were no survivors, the critical need was to secure the site from unauthorized access. This was done before the scattered fires at the site were put out. Township and county sheriff’s forces and state police recognized that unauthorized access included fire, rescue, medical and other uniformed personnel with no role to play in a mass-fatality site.

Controlling Site Access. Securing the inner and outer perimeters is one security problem, but controlling the site for the scores of people who must have daily access is another. The system put in place for the 427 site was ingenious and inexpensive.

Colored hospital wrist bands were issued daily to workers just before they suited up for the ride to the site. The bands, plus a login before entering the bus, provided effective control. There were problems with bleaching or covering the bands, but there are alternatives and overall the system worked well.

Photo IDs are now quick, cheap and made by portable machines. Site-produced, color-coded photo Ids, for example, would provide convenient access control. There are any number of good, copy-resistant solutions; what is important is they be thought out beforehand.

Media. The media can help — and overwhelm. The incident commander needs an experienced public information staff on hand 24 hours a day to meet the community’s and the media’s requirements. The timely arrival of the PEMA director and press representative, plus high-level political clout (Singel), helped get the media into one area and eventually provided a framework for meeting most of their needs. A schedule of daily briefings was established, and several responding agencies also conducted press briefings.

Relations with the media can sometimes be hostile. Media representatives used every ruse, from counterfeiting the wristbands to pretending to be window washers at the morgue site to try to gain access. But the media were also responsible for getting the word out to the public that there was no danger to the water supply from biohazards or other crash-related activities.

“We were running into problems early on when the media basically were pushing the edge of the envelope, trying to get into restricted areas,” Eichenlaub says. “It was infringing upon our ability to do our work. Most people did comply, but there were a few who tried to bend the rules.”

Incident commanders also should be prepared to receive at inconvenient times local, state and national political figures – none reluctant to respond to the red eye of a TV camera — who must be briefed so they can respond appropriately to the media.

Communications. After the crash, emergency radio nets were soon swamped. Most responders then relied on cellular telephones which, initially, were dependable. But, when an emergency lasts as long as this one, cellular nets also will become overloaded. Additional radio nets, including FM bands, and hardwire phones should be prearranged for emergency use and established before other communications collapse.

Police, fire and rescue authorities from neighboring jurisdictions often could not talk to each other on their radios during the 427 response. Although this soon was straightened out, it added an additional burden to the early response efforts. Most radios have unused channels that can be preset, and they should be tuned to the appropriate frequencies of adjacent jurisdictions.

911 Capabilities. A major disaster can flood a 911 system. Almost immediately after the crash, the Beaver County system could not reliably support response operations or its normal function as a community dispatch center. If possible, it would be better to handle disaster-related calls “off line,” which would free up the 911 system for its normal responsibilities. However accomplished, making sure the 911 system can function during a disaster is a necessary planning requirement.

Dealing With A Biomedical Hazard Site. The NTSB, after assessing the crash site, declared it to be a biomedical hazard site because of the potential presence of bloodborne pathogens, notably HIV and hepatitus B. NTSB personnel and other responders wore protective coveralls, boots and surgical and work gloves and were decontaminated each time they the inner perimeter.

Some coroners and medical personnel did not accept the necessity for this level of protection, nor believe it necessary for longer than 24 to 72 hours. It was not uncommon to see workers in full protective gear standing next to those wearing only boots and gloves. However, the NTSB maintains that such precautions will be routine for all sites with the characteristics of the 427 crash.

Parts Decontamination. Decontamination of aircraft parts became the responsibility of state-certified hazmat teams, which used long, narrow swimming pools, lined first with several layers of absorbent pads and two layers of impermeable plastic sheets, which caught the decontamination water. Wastewater was vacuumed from the pool by a sewer vacuum truck and disposed of in the county water treatment plant according to a coordinated plan. Parts decontamination and waste disposal is up to each manager’s ingenuity, but the process should not have to be invented on site.

Crisis Incident Stress Debriefing (CISD). Clearing the site of remains required days to accomplish and was a stressful activity. Responders discovered early that teams of about 20 each should not be “on the hill” for more than two hours at a stretch. Even so, about 40 percent of those who volunteered for this duty evertually asked for other assignments.

Chaplains and CISD personnel monitored the responders and met the buses bringing the workers back to the staging area. One of the mall merchants made his pizza parlor available and all responders and morgue personnel had the opportunity to benefit from peer debriefing. Disaster plans should ensure that all who may need stress management help not just responders, know it is available and how to obtain it.

Volunteers. Experienced responders know the problem is not too few volunteers but too many. Early in the response period a number of volunteers were on teams sent to remove remains and work in the morgue, but many were either emotionally or physically unable to take the stress and had to be replaced, adding both to the Work effort and to the requirement for CISD. Soon the majority of these responders were drawn from emergency medical service (EMS), security and other “professional” ranks, both military and civilian. Volunteers must be screened for the requirements of the tasks to which they are assigned.

Finally, a key element in the use of volunteers and donations is controlling their flow. Initially, everyone wants to be involved in the response and, unless this is coordinated, there may be too much of everything in the beginning and very little of anything at the end. The incident commander should plan to have someone coordinate both volunteers and donations.

Identifying the Victims. Just as the NTSB “owns” the crash site and the aircraft, under Pennsylvania law the coroner “owns” the remains and their possessions until they can be released. A number of agencies brought their special skills to bear in this highly technical area of identification.

“About 80 people were identified by dental records, about 70 by fingerprints,” Tatalovich says. “The Pennsylvania Dental ID team, FBI fingerprint team and Armed Forces Institute of Pathology team worked closely together.” These groups, along with anthropologists from the University of Pittsburgh identified all but seven of the victims.

To many it seemed that recovery from the accident came almost as suddenly as the crash itself. When specially trained dog teams could no longer find any trace of human remains and the NTSB was satisfied that no aircraft part of any significance remained on or under the site, it was time to phase out the response effort. While the morgue would remain in operation until all the identified remains and possessions could be released, the crash site itself was returned to its owners barely 1 1 days after the accident. PEMA is preparing its final incident report, which will detail every aspect of the response.