Lessons for the health services from the Cork air crash

Our ability to care for patients in an emergency will never be better than our ability to care for them on a normal day, writes Peter Daly, Chief Emergency Management Officer, HSE South.

The Manx2 airline flight from Belfast to Cork crashed on approach to Runway 17 at Cork Airport at about 9.45am on February 10, 2011. The ‘plane was making its third attempt to land in low visibility conditions when it crashed, flipped over and burst into flames on a grass verge. Six people died in the crash, including the Spanish pilot and his British co-pilot. Two of the injured were able to walk from the wreckage of the plane, while four were taken out on stretchers. All six were taken to Cork University Hospital, which activated its major emergency plan.

Peter Daly
Peter Daly

The health services in Cork moved into action and did a wonderful job (and you would expect nothing less) and in looking at lessons to be learned from this crash we have to be careful that we don’t take the gloss off what was a phenomenal effort.  There is a very delicate balance to be struck between criticism and analysis.

But viewed from the position of, “if something like it were to occur again what would be done in a different way?” we can come up with a number of learning outcomes.

  1. When is a major incident not a major incident? At first glance it would seem that six injuries would not be the basis for activation of a major emergency plan but that supposes that a major incident is only defined by the number of casualties.  The initial information supplied was that a twenty seater plan had crashed. The receiving hospital, in this case Cork University Hospital, was already under stress even before the aircraft crashed. In some situations authorised officers may hesitate to declare a major emergency, even though such a declaration might well be justified by the circumstances. In this case a declaration was made at 10.20. If it becomes clear that the situation is easing and being brought under control the major emergency can be stood down without significant consequences.  Activation of the emergency plan for CUH was the correct action.
  2. It’s not how many, it’s how bad.  A major emergency is usually notified using the mnemonic METHANE where N stands for the number of casualties.  If you look closely at the textbook you will see that it stands for the number and type of casualty.  It was only when the medical team arrived at the incident that the exact type of injuries were relayed back to the receiving hospital.  The health professional at the receiving end of a METHANE message needs to ask the question: How bad are the casualties?
  3. Displacement of non-incident casualties must always be managed. There is a difference between a patient and a casualty. A patient is someone who is already in the hospital and includes those sitting in the waiting room having been seen earlier by a triage nurse. It also includes those who are sitting in the waiting room and have not yet been seen by anyone. We have to be sure when we are sending patients away that they are not in fact in a more serious condition than those due in from the incident. Closing the emergency department to all other patients will displace them to other health care facilities and this must be managed at a strategic level.  In the main the other health care facilities coped well, but in the event Mercy University Hospital was under significant strain. At one stage in the afternoon, well after the accident, the impact on this hospital was demonstrably greater than on the main receiving hospital.
  4. Fatalities are not the business of an acute hospital.  Dealing with fatalities in a major emergency is the responsibility of the local authorities.  In many cases, the local authority morgue is co-located with a major hospital and that is fine for normal activity.  Multiple fatalities should not be brought onto the campus of an acute hospital without the specific agreement of the Hospital Emergency Control Team and each region needs an agreed process for dealing with multiple, simultaneous fatalities.
  5. The impact of the media firestorm needs to be managed and controlled.  The degree of media interest in an incident should not be underestimated.  The media will follow the casualties, trying to get interviews with patients. Consideration should be given to setting up access control zones around any location where survivors, patients and their friends and relatives, including the deceased, are located. We were treated to the very unedifying spectacle of some members of the media pretending to be concerned visitors within the hospital itself.
  6. A ‘virtual airline’ has no local staff.  The move towards these kind of arrangements means that the health service can easily find itself with more responsibilities than it had planned for in providing help and support to distressed and vulnerable relatives.
  7. Recovery is the forgotten step. The emergency management paradigm always includes recovery and sets it a strategic responsibility on the Crisis Management Team and the Hospital Emergency Control Team for the RECOVERY stage.  There is a clear need to identify a named member on these teams to take responsibility for the recovery phase before an event occurs. People with financial responsibility are a likely choice. They will know their own organisations intimately but are not likely to be caught up in the heat of immediate response. They are also likely to be senior management figures, whose viewpoint will carry weight.
  8. Practice makes perfect.  There is a strong tradition of interagency emergency planning in Cork going back many years. The benefits of training and exercise were underlined in the first hour of the response to the Manx2 Flight Crash at Cork. All the key participants knew each other, had trained together and knew the capabilities of each others agencies. They were not meeting for the first time.

    The final casualty was British pilot Oliver Lee (29). He used to fly for the Manx2 airline between Belfast and Cork. Just days before the fatal crash, Mr Lee left the airline to join British-based Jet2, but he blamed himself for the tragedy. He believed it would never have happened if he was at the controls, as he was familiar with foggy conditions in Cork. Mr Lee’s body was found by a Jet2 colleague in the stables of his family home in England on Friday, April 29, 2011.

    To his family and to all those who lost loved ones on that day we extend our heartfelt sympathy.

  9. The ninth lesson learned was that our ability to care for patients in an emergency will never be better than our ability to care for them on a normal day.