Airport Emergencies Overview
Since 2000, ANSV reported a total of 51 commercial aviation accidents in Italy, causing 167 deaths. The deadliest accident, a collision during take-off, occurred in 2001 at Milano Linate airport, and involved a BOEING-87 airliner and a CESSNA 525-A business jet, killing all passengers and 4 ground personnel, a total of 118 victims. This event led to the introduction of a series of safety recommendations to prevent accidents and incidents.
According to ICAO’s ‘Standard and Recommended Practices for Aircraft Accident Inquiries’ the current definitions of accidents and incidents are 1 :
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1) Accidents: occurrences associated with the operation of an aircraft where a person is fatally injured, the aircraft sustains damage or structural failure, or the aircraft is missing or completely inaccessible.
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2) Incidents: occurrences associated with the operation of an aircraft affecting or potentially affecting safety.
These 2 events trigger the AEP and activate rescue resources, providing a structured response to any potentially dangerous event occurring on airport grounds. According to current regulations, airports are required to conduct periodic simulations, aimed at assessing preparedness, and coordination, as well as capabilities of the Airport Emergency service and the local response entities (firefighters, EMS, police, and others). Considering the low occurrence of real mass casualty events, drills, and other forms of simulation, such as table-tops, represent the main opportunity to acquire experience in managing this range of emergencies, highlighting critical elements, and testing the response capacity of emergency services. Reference Skryabina, Betts, Reedy, Riley and Amlôt2,Reference Idrose, Adnan, Villa and Abdullah3 This brief report describes the organization and the results of a full-scale disaster simulation held at Bologna airport in October 2022, involving local EMS personnel.
Description
Bologna “Guglielmo Marconi” airport
Bologna International (IATA code: BLQ) is the main airport of the Emilia-Romagna region in northern Italy, located 6 km from the city centre. Medical assistance within the airport area for ordinary emergencies involving passengers and workers is guaranteed 24 hours a day by a dedicated ILS ambulance crew (an EMT and an emergency nurse). Further support, such as emergency physician interventions for critical patients or transport to the hospital, is provided by the local EMS. The nearest hospital is Maggiore Hospital Carlo Alberto Pizzardi, a level 1 trauma centre located 4 km away. Six spoke hospitals are available within 30 km; the nearest burn unit is located at about 100 km away.
Airport emergency plan and emergency simulations
The level of protection required for an airport is expressed as “RFF aerodrome category” (rescue and firefighting services). It is calculated using the number of movements (landing or take-off) of airliners transporting passengers in the highest aeroplane category normally using the airport. Aeroplanes’ categories are related to their maximum number of passengers: for example, RFF aerodrome category 9 includes Boeing 777 or Airbus A330, which may transport 266 to 428 passengers, according to their different seat configurations.
The AEP is drafted by the airport authority, in cooperation with local emergency services, as defined in the National Civil Protection Department guidelines, issued in 1997. Following European Regulation 139/ 2014, AEPs include the organization of emergency drills regularly, including full-scale exercises at intervals not exceeding 2 years, and tabletop or partial simulations between them, to test some specific issues or gaps identified in full-scale exercises. Every simulation, according to its specific aims, could be dedicated to airport personnel or engage some or all the local emergency services to test their coordination and capabilities. Both types of exercises also evaluate participants’ non-technical skills. In the last years, BLQ airport in cooperation with the local EMS organized a series of airport emergency simulations (Table 1).
Simulation exercises (including tabletops) performed between 2017 and 2022 at Guglielmo Marconi (BLQ) Bologna international airport, Italy
Abbreviations: ALS, Advanced Life Support; BLS, Basic Life Support; ED, Emergency Department; EMS, Emergency Medical Service; EMT, Emergency Medical Technician; ETS®, Emergo Train System; FAST, First Assessment and Sequential Triage; HEMS, Helicopter Emergency Medical Service; ILS, Immediate Life Support; START, Simple Triage And Rapid Treatment.
Scenario
The drill takes place at BLQ Airport and replicates a real-life event that happened at San Jose International Airport (Costa Rica) in April 2022, when a cargo plane declared an emergency after take-off due to a hydraulic failure. During the emergency landing, the pilot loses control of the aircraft, ending off the runway (runway excursion).
The exercise was set up on the airport ground on a simulated aeroplane, to provide a high-fidelity scenario for all the agencies involved. Volunteer simulators interpreted 29 casualties acting as real patients, including the evolution of the clinical presentation depending on the actions performed by medical personnel. Patient conditions were communicated to EMS personnel only at their request; vitals parameters (i.e., systolic pressure or respiratory rate), decided by the organisers, were provided only if they tried to assess them. Triage colour codes have been established according to the START algorithm, adopted by the Emilia Romagna region as the Triage method for MCIs.
Before the simulation, all participants attended a briefing discussing basic concepts of disaster medicine (triage, command and control, casualty evacuation), the current AEP procedures, and the role of EMS resources (dispatch centre, airport ambulance, other rescue vehicles). Moreover, the briefing emphasized the principles of non-technical skills and general rules on how to behave with simulators, trying to make the drill as real as possible.
The organization simulated the number and type of EMS resources required in case of a real-life event (including availability, capabilities, and intervention times). All the resources dispatched during the simulation were additional, to avoid impact on ordinary emergencies. The simulation was considered concluded when all patients were declared “transported to the hospital” by the MEDEVAC officer.
Response
The simulation started at 01:29 AM, following a communication of an emergency from the control tower. One minute later (01:30 AM), the airport ambulance crew reported the emergency status to the local EMS dispatch centre. According to standard procedures, immediately following the communication of the emergency status, the EMS dispatch centre sent an ILS ambulance and a medical car to a predefined area, close to the airport entrance. At 01:37 AM, following a first assessment based on the METHANE scheme, the airport ambulance personnel confirmed the incident and started triage operations, while firefighters guaranteed the safety of the scene.
Subsequently, based on additional information collected by the rescue teams on the scene, other emergency vehicles were dispatched:
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1 ILS ambulance, 6 BLS ambulances, and 1 MCI van, directly near the airplane crash.
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1 medical car and 1 BLS ambulance in the area defined by the emergency plan, to set up the AMP, in cooperation with airport personnel.
Based on previous experiences, to avoid problems with ambulances taking the wrong road or missing the target, all emergency vehicles were dispatched to a single collection point near the entrance and constantly tracked via satellite by the EMS dispatch centre.
The first medical car arrived on the scene at 01:44 AM, while the first ambulance arrived at 01:53 AM. The local Trauma Centre was notified of an aeroplane accident with at least 20 injured passengers at 01:50 AM.
Emilia Est EMS Dispatch Centre employed 1 Call Taker, RN; 1 Dispatcher, RN; and 1 Nurse Coordinator as supplemental resources dedicated to the aeroplane crash. In case of a real event, these additional personnel are provided by a 24/ 7 on-call crew.
The ACP was established near the aeroplane crash, in cooperation with the Airport Fire Brigade. Specific roles of the EMS personnel were defined and identified with a specifically coloured vest (Figure 1):
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Medical-car physician, coordinator of the EMS teams (Incident Commander)
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Medical-car nurse, responsible for injured transport and evacuation (Medevac)
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ILS ambulance nurse, responsible for triage processes (Triage)
Specific roles of emergency medical service personnel. Legend: (a) medical-car physician, coordinator of the EMS teams (Incident Commander) and medical-car nurse, responsible for injured transport and evacuation (Medevac); (b) ambulance nurse, responsible for triage (Triage).
Injured passengers able to walk (green codes) were accompanied by airport shuttles in a dedicated area of the terminal. To increase the level of complexity, 1 pregnant passenger had a membrane rupture and, consequently, EMS personnel had to manage a premature birth which is an unusual emergency during a plane crash.
Casualties not capable of self-locomotion were transported, in cooperation with the Fire Brigade, to collect points in a safe area, and divided according to their severity.
According to the triage code and the type of lesion, EMS personnel opted for different strategies, transporting some patients to the AMP for first treatment or transporting patients from the crash site directly to the trauma centre.
Meanwhile, the EMS dispatch centre contacted the nearest hospitals to communicate the emergency and to assess their readiness and availability of beds. This information was forwarded to the MEDEVAC officer, to organize correct transport destinations for ambulances and to equally divide less severe patients within the hospitals. Even if no patient was effectively hospitalized, ambulances were considered unavailable for the estimated transport time, triage time, and return to the airport (approximately 25 minutes for the nearest hospital).
A total of 27 patients were assessed by EMS personnel (during the drill, 2 simulators suffered from hypothermia and therefore abandoned the area). Triage evaluation was correct for 22 patients (81.48%); 3 patients (11.11%) were over-triaged and 2 (7.41%) were under-triaged.
The simulation ended at 03.58 AM, 2 hours, and 28 minutes after the initial alarm. The simulation time does not include the initial briefing. A video of the simulation exercise is available on the Bologna EMS dispatch centre institutional website (https://www.118er.it/emiliaest/player/111).
Discussion
The specific aims of this full-scale simulation were to assess the organization of casualty collection points by EMS personnel and firefighters and the autonomous ability to enter the airport ground by emergency vehicles. The analysis of the event highlighted some aspects requiring attention, such as communication problems within the different agencies. Only the first emergency vehicles were escorted to the crash site and ambulance crews reported difficulties in moving within the airport runway without airport personnel guidance. Basic driving rules within the airport grounds will be added to the emergency procedures and explained during future briefings. Furthermore, a lack of clear leadership in the AMP affected the whole patient flow. This issue has been identified as a critical point and will be emphasized during the next training courses, as well as in a new full-scale simulation in 2024.
The response time proved an overall good response from all the agencies involved. The availability of a trauma centre within 4 kilometres allowed to transport patients directly from the field, without excessively affecting transportation times. Moreover, this strategy proved to be effective, providing definitive treatment for some lesions and delaying patient flow.
Triage accuracy was correct in more than 80% of simulated patients; the under-triage percentage was aligned with the lower rate reported in a recent meta-analysis. Reference Franc, Kirkland and Wisnesky4 Even considering the limits of the START algorithm, this tool has proven to be particularly advantageous for speed and ease of use, also by non-medical providers. However, dedicated training through full-scale exercises, table-tops, or distance learning is mandatory.
An emergency plan is a living document and should constantly be revised and regularly tested, sharing its content with all those involved. Reference Alexander5 The objective of these exercises is to test the entire rescue organization in case of airport emergencies, to modify and adapt procedures, emergency plans, and staff training. Reference Liu, Huang and Li6 As for other MCIs, airport emergencies are rare but potentially catastrophic and therefore, system, and personnel preparedness are crucial. Reference Biswas, Bahouth and Solomonov7 Simulation is an effective educational method and can be applied to train processes and both technical and non-technical skills. Reference Jorm, Roberts and Lim8 Literature underlines that simulating with the maximum realism possible improves its quality and efficacy. Reference Crimaldi, Zulliani and Porta9 Observing the different providers and their reactions in the first minutes allows the organizers to adapt the evolution of the scenario, creating a realistic situation instead of a movie, where the plot is already defined.
Notably, it is necessary to recognize some limitations: testing an AEP with a full-scale simulation requires a considerable commitment of time and dedicated staff, and its organization lasts several months before the event. In addition, the organization of a full-scale simulation involving the number of passengers transported by a modern large airliner would be extremely difficult to realize. Considering the ED overcrowding, it would be impossible to test the real in-hospital capacity with many patients, if not through a table-top exercise (as done in 2019).
To summarize, each simulation brings out certain criticalities based not only on what was initially planned to test; in this simulation, problems in the organization of the AMP inside the airport were noticed, probably related to a lack of leadership by the healthcare professionals who should lead, and manage, as well as supervise all the crews involved the event. The training for mass casualty incidents is not based on a single simulation but on a continuous path, allowing EMS providers to become confident and acquire adequate experience, communication skills, and adaptability to situations that may vary without warning. Despite the positive or negative results, full-scale simulations represent unique opportunities to test leadership, decision-making, situational awareness, and other non-technical capabilities under stressful situations and in unfamiliar environments.
Acknowledgements
The authors express sincere thanks to all personnel, technicians, nurses, and emergency physicians of Bologna EMS, volunteer rescuers, firefighters, and BLQ airport personnel who participated during the simulations. A special thanks to Italian Red Cross personnel who provided make-up injuries to the simulated victims and Roberto Iacenda (RN), for recording and editing the video.
Author contribution
All authors made significant contribution to the conception, study design, data collection, and analysis as well as interpretation, or in all these areas; took part in drafting, revising, or critically reviewing the article; gave final approval of the version to be published, and agreed to be accountable for all aspects of the work.
Alfonso Flauto: Conceptualization, Investigation, Resources, Data curation, Writing- Original draft preparation, Writing - Review & Editing; Lucia Marcis: Conceptualization, Resources, Writing- Original draft preparation; Paolo Pallavicini: Conceptualization, Resources, Writing- Original draft preparation; Federico Calzolari, Tommaso Nanetti, Antonino Giovanni Scopelliti, Martina Fabbri, Stefano Cremonini: Conceptualization, Resources; Writing- Original draft preparation; Guglielmo Imbriaco: Conceptualization, Investigation, Supervision, Writing Original draft preparation, Writing - Review and Editing.
Funding
This work has not received any financial support.
Conflicts of interest
The authors have none to declare.
Ethics approval
This is not required for this type of study. All participants in the simulation (EMS providers and simulators) signed an agreement form to share data and pictures for educational and scientific purposes.
