The Executive Yuan White Book on Public Safety Management

1. The Executive Yuan White Book on Public Safety Management Railroad Tunnel and Underground Station Yard Safety ManagementStandard Operation Procedure Host: Taiwan Railway Administration Co-host: National Fire Agency Ministry of Interior Department of Rapid Transit Systems, TCG Taipei Rapid Transit Corporation Presented by Ray-in Chen January 14, 2004

2. Chapter 1 Background • Chapter 2 Execution Situation • Chapter 3 Problem Analysis • Chapter 4 Policy Constitution and recommendation • Chapter 5 Standard Operation Procedure • Chapter 6 Establish the Monitoring and Examining Mechanism • Chapter 7 Expected Goads and Prospects

3. Chapter 1 Background • Underground railway is a unique space designed to gratify the requirements of communication and transportation in the city. Due to the unique characteristics of closeness and underground, the rescue procedures are different from the rescue procedures of common buildings. The underground railways are in an enclosed space, thus, when accident happens, communication will be a problem, rescue availability will be low, and the scenario will be hard to control. Once the fire does occur, neither the evacuation of people inside nor the rescuers from outside will be easy to access. Therefore, the fire control safety facilities should be carefully planned at the early phase of the tunnel design and construction. In addition, rescue plans should be setup for the management and use in the future and prepare to face the future disasters.

4. To ensure passenger safety and to begin the rescue operation and bring it under control as soon as possible, a definitive contingency plan and a rescue standard operation procedure in how to integrate and utilize the existing facilities (e.g. tunnel emergency stops, emergency exists, ventilation facilities, fire and disaster control facilities, rescue vehicles, rescue personnel, fire fighters and policemen, and hospitals), disaster relief strategies (e.g. disaster contingency mechanism, relief command system, and support from relative units), and emergency drill plans should be established for accidents happen in underground railways. The plans and procedures are expected to be followed step by step based on the disaster area conditions during the early phase of the disasters; in order to control the situation in a timely manner, reduce casualties, and minimize damage to facilities.

5. Chapter 2 Execution Situation • Unlike other transportation system, vehicles such as fire trucks and ambulances can not enter underground railways. Once an accident or emergency situation occurs, the fire brigades, wounded, and other passengers all need to exit through the nearest station, emergency stop, or emergency exit to reach the road aboveground. Therefore, the locations of underground railway stations and distances between rescue units affect the efficiency of rescue energy delivering to the disaster scene.

6. 2.1 Taipei area underground railways sectional relief resources layout ﹕ • Please refer to the handout. • The average distance between each emergency exit is 350 meters (857 m the longest; 30 m the shortest); it takes about 10 minutes for the relief team and fire fighters to reach the emergency exit; 3 minutes to carry equipments down stairs (3 to 8 floors), and another 3 minutes to walk to the center point (the average distance is 175 meters). It takes about 16 minutes total, which is longer and more difficult than the rescue actions aboveground. Therefore, the notification during the early phase of the disaster is very important, as well as the rescue teams’ familiarity with the environment. The emergency drill should be emphasized more.

7. 1. The review of underground railway accidents around the world and the analysis of probable cause. (Please refer to the handout.) • This table shows the underground railway accidents around the world from 1968 to present. 90% were caused by fire of the electronics on the train. Among the accidents, the following two cases have the greatest fatalities. On October 28th, 1995 at the capital of Azerbaijan, Baku, the accident caused 337 fatalities, and injured 227. It was due to mechanical failure of the train which caused the electricity supporting rail, the 3rd rail, on fire. On February 18th, 2003, an arson attack in the underground railway of Taegu, South Korea, caused 198 fatalities, and injured 146. The number of arson cases in Taiwan is increasing, thus the Taegu case is discussed as follows.

8. 2. The analysis of the Taegu, South Korea case • (1) Prelude • 9:55 a.m., February 18th, 2003, Taegu, the third largest city in South Korea, experienced an arson attack in the subway station. The fire was put out 3 hours after it started. The fire started in the Electric Multiple Unit (EMU) inside Chungangno Station. The EMU, which arrived shortly afterwards, also caught on fire. Through March 3rd, there have been 198 confirmed fatalities. The Taegu underground railway system was paralyzed, and there was chaos in the downtown area. It was the all-time worst catastrophe of railway fire.

9. (2) Conjectural details • According to witnesses and reported by the media, at 9:55 a.m., when the 1079 train of Taegu was coming into the Chungangno Station, the busiest station in the downtown area, a man in his 50s set fire to a green plastic milk carton containing a flammable liquid and threw it inside the subway train when the door was open. The flame quickly spread. When the incident occurred, the control center in the station stopped providing electricity, turning the platform into a pitch dark inferno. The doors of the train were unable to open due to electricity cut off. There was no automatic fire fighting system installed on the train. The 1085 train arrived at Chungangno Station when the 1079 train was on fire, and caught on fire immediately. There were about 800 passengers on board franticly trying to escape. Toxic gases were released into the trains and platform. Many passengers were able to escape in time and suffocated to death. 12 cars were completely destroyed by fire. The sequence of event is described in figure 1.

10.  One man has committed arson on Train No.1079 at 09:55am on Feb. 18th, 2003. 1 NO.1079列車

11.  While Train No.1080 was entering into the platform which caused both train were on fire nearly at the same time, the MRT underground station was in dark suddenly by lacking of its electricity. 2

12.  Total 12 vehicles of both trains were all on fire, and Train No.1080 was delaying to open its doors, at this moment, there are more than 800 passengers got into panic situation trying to escape from the station which caused lots of injury and death. 3

13. After the investigation, firefighters said there were a dozen bodies found in the 1080 train, which arrived after the 1079 train. The driver who survived said the command he received from the control center of the station was to pay attention to the fire. The surviving passengers also confirmed that there were already black smokes everywhere on the platform when the 1080 train approached the station. If the control center had ordered the 1080 train to stop outside of the station or pass through, more lives could have been saved. The worse part is, the control center shut off the electricity after the 1080 train arrived the station, which made the train unable to keep moving forward. The doors were all closed. 5 minutes had passed before the driver opened part of the doors manually, and some of the doors had been malfunctioned and could not be opened. Dozens of people were trapped and died in the train. (figure 2 and 3)

15. After the investigation, the emergency facilities in Chungangno Station were found to be far below the minimum requirement. After the fire started, the electricity was shut off automatically. However, there were no emergency lights leading people to the exits. Passengers had to escape in the dark. Although the policemen and fire fighters rushed to the scene, and more than 60 fire trucks came to rescue, the rescuers were not able to enter the station due to the toxic gases and the darkness. Besides, there were not enough vents and the ventilation was not good enough. It was still full of smokes more than one hour after the incident, and the smokes spread into the nearby underground stores through the ventilation ducts. It increased the complexities of the rescue operation. (figure 4 and 5)

17. The underground railway disaster has characteristics as follows: • Despite the fact that the fire was caused by arson attack, the fire spread to the train arrived later, and the train station was damaged as well. (The EMU did not use good fireproof materials.) • Most people died inside the car. (Need a better strategy and more fire extinguishers.) • The underground station and the nearby area suffered from great amount of smokes. (Bad ventilation system design.)

18. Chapter 3 Problem Analysis • The tunnel space characteristic: according to the researches on disasters at underground railways, the tunnel structure is limited by geological structure and technology, and it is a nearly closed structure design. The relationship between the tunnel space characteristic and disaster occurring characteristic affects the evacuation of people in the tunnel and contingency rescue plan. From the disaster point of view, the comparison between tunnel space and the space structure of aboveground buildings is as follows: 3.1 The enclosed structure design could cause insecure feelings, constriction, fears, and other negative feelings to people inside the tunnel. 3.2 Similar to the big scale underground enclosed space structure. Both have limitations on the quantity of emergency exits and the locations of exits to a safe open space outside the structure. 3.3 Due to the enclosed design, the ventilation is limited. Once it catches fire, it will like a huge nature oven.

19. 3.4 Most designs have no openings and prevent sunlight from coming in. Once the blackout occurs, during the time before the emergency lights turn on or the time when the emergency electricity could not be supplied efficiently, the tunnel will be in complete darkness. It will cause people’s lonely, restive and insecure feelings. • 3.5 The air can not be ventilated naturally. The exhaust gas from vehicles and smokes and toxic gases of the fire could spread all over the tunnel. Therefore, a large ventilator and smoke exhaust system should be installed. • 3.6 The communication between inside and outside of the tunnel is blocked by terrain, distance, and hardware equipments. It makes communication more difficult, and the situation is not easy to control. • 3.7 The narrow space does not have enough capacity for rescuers and rescue equipments, and limits the operational space of rescue equipments in the tunnel. • 3.8 The underground railway has 25 thousand volts power lines. It has to be grounded before using water extinguisher. The Railway Administration has a specific procedure to ground the cable, and it takes time for the station employers to arrive the scene, the rescue operation will be delayed.

20. Chapter 4 Policy Constitution • 4.1 Fireproof car policy： • 4.1.1Upholstery condition： • Taipei Railway Administration currently uses flame-retardant (or better flammability) materials for all non-metallic materials in the car to help prevent fire damage. The upholstery is also flame-retardant or better flammability. The flammability is the same as the materials in Japanese subway trains, as well as the upholstery inside the airplanes. The upholstery has the best flammability in the market. In addition to regular cleaning and maintenance, any upholstery older than two and half years is replaced to ensure the best quality service to customers. As regards to the upholstery in the vehicles under operation, it will be replaced when it is soiled to provide a more comfortable environment to customers.

21. 4.1.2Upholstery short-term improvement: • Taipei Railway Administration will follow the example of Rapid Transit Cooperation and purchase FRP upholstery for commuter trains. Tilting trains will have artificial leather that breathes for better quality. • 4.1.3Upholstery long-term improvement: • Taipei Railway Administration will try the newly developed fireproof or flame-retardant upholstery material when it first comes out.

22. 4.2The short, intermediate and long term plans of this type of disaster from Ministry of Transportation and Communications (MOTC): • Work to be done: • 4.2.1Short-term： • 1. Examine the fire extinguishers and escape facilities in the tunnels and underground railway stations regularly. • 2. Give employers education and training to be passengers’ guide on the platforms. • 3. The examination of escape signs and equipments. Training in ventilator operation in underground tunnels and stations. • 4. Cooperate with fire brigades in fire and escape drills. • 5. Recruit people to form a hazard mitigation center and hold contingency drills. Monitor and instruct the establishment and operation of the contingency center in each unit. • 6. Update the fire extinguish plan of the station along with other safety protection actions.

23. 7. Install the emergency button in each newly purchased car (to communicate with drivers and further more, report to train operators), and escape ladders for emergency stops outside of the train station. • 8. Study and establish an improvement plan for the current cars. • 9. Auto-protection system of ATP cars. (90.9-94.6) • 10. Radio dispatch system in the station. (92.3-96.9) • 4.2.2Intermediate-term: • 1. The integration and consolidation of safety units in each railway department. • 2. Business planning and standard consolidation of railway departments. • 4.2.3Long-term: • Consult the advanced facilities and rescue mechanisms of underground railways around the world to enhance the plan and management of the public safety hardware and software.

24. 4.3 Inquest and review • The basic principles of fire suppression and escape for underground railway systems are: avoid the occurrence of man-made calamity; prevent loss of lives and assets caused by nature disaster; when the disaster happens, evacuate passengers as fast as possible to prevent further casualties and to decrease the extent of damage in the underground railway system. Consult the experiences of fire in rapid transit systems in other countries. In detail designs, consider the integrated views. The following movements should be included: • 4.3.1 Possibly prevent the occurrence of disasters. (Use fireproof materials. Flammable and dangerous objects, as well as natural gas are prohibited in the station. ) • 4.3.2 4.3.2 The detection of the disaster in the early phase. (Photoelectric smoke detector, compensated thermometer, hot wire sensor, closed-circuit television.) • 4.3.3 4.3.3 Efficient evacuation. (Fire escape, emergency door, escape exit signs, and etc.) • 4.3.4 Prevent the spread of the disaster. (Fire compartment, smoke compartment, and etc.) • 4.3.4 Fire suppression equipments. (All kinds of fire suppression equipments, ventilation equipments, and etc.)

25. 4.4For the characteristics of the underground railway fire in Taegu, South Korea, items which are about the design of railway transportation system and are worth being re-discussed, are listed as follows: • 4.4.1Flammability of EMU interior materials review: • According to the disaster investigation of the South Korea subway fire, many car interior materials were found flammable. It led to fire spreading and toxic gas, which were the major causes of great casualties, shown in figure 6 and 7. • The materials of the EMU of TRTC meet the world’s highest standard of U.S. NFPA130. The car body is made by stainless steel which has high ignition temperature. Inside the body is the fireproof glass fiber heatproof cotton. The materials of interior facilities, such as chair and floor, are all fireproof, and passed the 45-minute fire withstand test. The materials only generate small amount of non-toxic smokes. • The weight of a car is getting lighter and lighter, and the interior materials are tend to be macromolecule materials (e.g. plastic, rubber). The functions of flammable car can not be easily substituted by inorganic materials. Therefore, the burning characteristics should be further examined. The test methods of fireproof materials in Japan and other countries are based on leakage fire, man-made mistake, and other small scale fire. It is not suitable for a large scale fire, e.g. arson attack and terrorist attack. The test methods and evaluation standard should be further analyzed.

26. 4.4.2 Fire suppression and escape system in underground stations review • Due to the fact that underground stations are in a special enclosed environment, to ensure the system operates normally and passengers are safe under emergency circumstances, the following should be considered when designing: • 1 Enough design capacity • The capacities of facilities in the station, e.g. stairs, escalators, aisles, auto toll collection equipment, emergency stairs, and platform width. They have to meet the traffic requirement during peak hours, as well as the NFPA130 standard about the escaping time. • 2 Facility safety design • E.g. the net distance between the two sides of an escalator, the minimum space between the side of an escalator and the nearby structure, the distance from the edge of the platform to the cordon, the minimum distance between EMU cars and platform, avoid the dead corner in public area, transparent elevator, locations of monitors, emergency use of ticket wicket, allocation of multiple communication access and fire suppression equipments, fireproof materials, clear sign systems, and etc.

27. 3Build a new security zone • Apply the positive and negative pressure mode in environment control system, as well as fire and smoke compartments, to build new security zone. An underground station is an enclosed space, and people are easy to lose the orientation when emergency happens. Researches on the group evacuation characteristics of a non-specifies group in an enclosed space were conducted. Although some results were found, it is difficult to have field evaluations of group evacuation characteristics. In the future, the hard/software design principles of the evacuation facilities need to be further evaluated.

28. 4.4.3 EMU fire disaster spreading prevention strategy review • The Taegu subway disaster happened to the EMU when it is during operation. Because the doors were unable to open, great casualties and injuries were caused. Therefore, it is necessary to review the fire spreading prevention strategy. The main purpose of the strategy is to ensure the flammability of upholsteries. If this can not be ensured, it is necessary to review the prevention of fire between cars and smoke spreading, as well as the operational method of EMU. • For the unpredictable circumstance, e.g. EMU fire spread to other cars in the station, the hard/software in the station could be focused. The emergency rescue evacuation from trains at nearby platform is also possible.

29. 4.4.4 Underground station ventilation review • Downcasts and ventilators are often installed in underground railway systems. With blasting on one end and vacuuming on the other, and at the right volumetric rate, it can be ensured that smokes move toward one direction, which allows the passengers to escape upwind. • The mechanical ventilators are often installed at platforms of underground railway stations. However, the underground station is not completely enclosed. It has a relatively open area in the upper level, the connection between tunnels, as well as the meandrous opening structures, e.g. stairs and escalators, which greatly increase the difficulties of smoke control modeling in detailed design. The three dimensional computational fluid dynamics analyses by STAR-CD program developed by a British company, Computational Dynamics, is broadly used in Taiwan to ensure the ventilation flowing and efficiency. However, when two cars generate smokes at the same time, it is difficult for the normal facilities to exhaust smokes efficiently. Therefore, smoke control is rather important on the early phase of the fire to control the burning scale.

30. According to “Taipei underground railway compartment security manual”, published by the Railway Rebuild Administration (RRA) and Taiwan Railway Administration (TRA), and “Taipei metropolitan public rapid transit system fire suppression design manual – underground station and rapid transit” (February, 2000), published by TCG, the underground railway compartments and the system concepts and design principles of fire suppression security at rapid transit stations are clearly defined. It includes structure evacuation plans, construction materials, fire and smoke compartments, evacuation signs, emergency lighting fixtures, smoke exhausting systems, fire suppression equipments, alarm equipments, emergency contingency plans, and etc. In viewing the characteristics of Taegu subway fire, if the same thing happened in Taiwan, the damages should not be as serious. However, to further ensure passengers’ safety, fire suppression and evacuation ideals should catch up with the society progress, and updated with the development of new ideals and new equipments. The fire suppression and evacuation ideals in Taiwan are hoping to have big progress in development by the inspiration of the large scale subway fire disaster. • 4.5 It is recommended to establish a national standard and assign the examine and monitor department for the train interior materials and fire suppression equipments used in the high speed rail, railway, and rapid transit rail.

31. Chapter 5 Standard Operation Procedure • 5.1 Disaster prevention • 5.1.1 Passive safety precaution • Passive safety precaution is to improve or adjust the construction process of hardware structure and landscape design based on the tunnel material and structure, by considering the possible consequence of accidents in advance. Besides decreasing the probability of disaster occurrence, with the increase of the ability in tunnel fire prevention, it can not only decrease the damage degree, but also ensure passengers’ life security. • The passive safety precaution of underground railways in Taipei area. (Please refer to the handout.) • 1. Ventilatory system 2. Evacuation system • 3. Light fixture4. Drainage system

32. 5.1.2Active safety precaution • The purpose of the active precaution is to improve the abilities of disaster detection, communication, automatic protection and disaster monitoring for the occurrence of common and severe accidents. It is hoped that the disaster can be aware of right after it happened, so that the damage can be decreased or eliminated. (Please refer to the handout.) • 1. Communication system • 2. Fire suppression equipment • 3. Closed circuit television • 4. Central monitoring system • 5. Operation and transportation • 6. Basic rules of disaster precaution • 7. Prevention of train fire and its deal principle

33. 5.1.3Miscellaneous • 1. The personnel change training mechanism in the management and executive department: organize fire prevention and tunnel emergency contingency drill each year by law, and emphasis on new employee’s training. • 2. The strategy of emphasizing the general populace’s education on prevention policy: TRA has posted clear instructions of tunnel emergency evacuation methods on LED signs at the stations and on the trains to enhance people’s knowledge of underground evacuation equipments and methods. • 3.Based on “The protection plan of Taipei Train Station, Rapid Transit, and Underground Shopping Mall”, the contingency plan and normal communication of the disaster protection center are reinforced.

34. 5.2 Emergency contingency plan • 5.2.1 Situation simulation • This Standard Operation Process (SOP) provides a proper contingency plan for all departments to follow when an accident occurs and rescuers from each department are needed. It is hoped that with the same rescue SOP, the rescue efficiency for all rescue brigades working together will reach its maximum.

35. 5.2.2Basic operation flowchart • The establishment of the emergency contingency SOP is based on the disaster time flowchart. It also lists the responsibilities of each corresponding department. The SOP is divided into 7 stages, as shown in the following table. Each stage is further divided into 3 steps, which are needed information, decision-making process, and action plan respectively. Each rescue unit can hold enough information before taking any rescue action. The SOP of fire accidents is listed as follows: • Please refer to the handout.

36. 5.3 Reporting record • All reporting units should record as it was. The radio base station in each train station should be equipped with voice recorder to provide evidence for investigation. 5.4Rescue accommodation mechanism: 5.4.1 The command authority transfer and accommodation procedure in TRA: driver → station master → head of local associated offices → transportation business department head → chieh engineer → director general 5.4.2Accommodation between departments: The “federal disaster contingency center” can contact TRA’s “station emergency response team”; the “local government disaster contingency center” can contact TRA’s “Taipei area emergency response team”. Whichever group arrive the scene first can accommodate the command authority with the above TRA units.

37. 5.5 Investigation and review after the accident 5.5.1Organization： To promote the driving safety, TRA has formed the “driving safety commission (DSC)”. Scholars and professionals are hired as full-time committees. The commission includes prevention, investigation, and examining departments. Its responsibilities are to monitor, examine, and advertise the automobile accident prevention plan, to collect information about automobile accident and investigate it, responsibility evaluation, and employee encouragement and punishment. 5.5.2 Procedure: • When major railway accident occurs, DSC and relative units arrive at the scene immediately to investigate. Organize a rescue command center. Transport wounded people to the hospital right away. Establish a name list and provide consolation. 2.The DSC investigation group will investigate the accident thoroughly, and collect accident relative information to evaluate the cause. When the responsibilities are clarified, DSC examining group will present the punishment list of breach of duty at the examining meeting. 3. The DSC prevention group will establish a prevention strategy and a reporting based on the causes of the accident. It will also notify each department to provide training and education regularly to ensure similar accident will not occur again. 4. Besides examining the cause of the accident and find the improvement modestly, DSC will also reinforce the monitoring system to be aware of employee’s breach of the rules which is harmful to the operation safety. The improvement is immediately required, and punishment will be given if the situation is serious.

38. Chapter 6 Establish the monitoring and examining Mechanism • Although the contingency rescue action will be provided as well as the detailed prevention plan and modern equipment installed in the tunnel, the rescue efficiency still depends on the overall performance of following the rescue plan. Therefore, simulation is recommended to help each rescue unit clarify the responsibilities of underground and station transportation disasters. The feasibility of the disaster contingency plan and rescue SOP will also be examined to reduce the unnecessary damage and to slow down the disaster spreading.

39. 6.1 Rescue SOP drill plan • The drill should be finished before the inauguration, so that each unit can actually control the rescue operation in the future. Besides drill before the inauguration, it should be held regularly after the operation of the train to ensure the rescuers can keep the familiarity of rescue operation. • 6.1.1 Drill source It is based on the Fire Code item 15. • 6.1.2 Drill plan Background and circumstance hypothesis 1 Apply the most serious situation which needs immediate rescue as the drill condition • 2 Two drills should be held each year by local fire stations. The drills should be monitored by the transportation management departments based on “underground railway fire SOP”.

40. 3. According to the “Railway Safety Drill Project”, Taiwan Railway Administration has well-drilled all members in our regional office annually wherein our 10 Regional Joint Mobilization Offices are basic units incorporating with their associated administration units; the model of drill includes the “High Commander Operation” and “Practical Examination”; therein items for the “High Commander Operation” are “Typhoon/Flood Protection”, “Train’s Fire Alarm”, “Natural Disasters (Earthquake)”, “Disaster of Gas Attack”, “Explosives”, “Malfunction on Bogies”, “Emergency Accident with broken Over Head Catenary System”, “Malfunction on Communication System”, and “Passengers’ Guidance and Evacuation” etc. and in addition, the “Arson on Trains” is the practical examination item which every unit must practice properly. 6.2Based on the organizational structure of Taiwan Railway Administration, there are sectional join departments particularly in charge of matters such as “Anti-Disasters Operation” (prevention, training, security contingency, post-implementation and investigation etc.) : This project has been incorporated into business schedule board of corporatization.

41. Chapter 7 Expected Goads and Prospects • Reviewing the major underground railway accidents happened around the world, they always caused great numbers of people’s life, and effected the economics of the society and government. Management and disaster relief departments did not have experiences on this type of rescue actions. Accidents happen in the future will challenge the management and operation bureaus’ reactions, as well as the local rescue units’ abilities. Therefore, we need to categorize the affections to underground railways of various disasters; assure contingency rescue strategy and policy; finish establishing the rescue SOP; present the underground railway accident contingency plan and drill procedure, and ensure the quality of drills. • The underground railways and rapid transit tunnels in Taipeiarea are at large quantity and long in length. It is very challenging to rescue in the fire. Life saving and rescue safety are the priorities when an accident occurs. Therefore, to increase the underground railway rescue experience, provide rescuers high quality equipments, and ensure a safe rescue environment is what we need to put out efforts on.

42. With the improvement of technology, new disaster rescue equipments are gradually developed by some countries. Although those equipments might not suit the environment in Taiwan, and the technology might not be mature enough, the improvement in rescuer protection and the enhancement of the ability of rescuing can be expected. If passengers’ lives are under consideration and the facilities in the tunnel are expected to be undamaged, the automatic fire suppression system is the only solution. The fire can be under control soon after it starts. Therefore, installing the water mist fire extinguishing system might be a considerable method. • It is hoped that after the underground railway construction is finished, the government and its relative management departments will put efforts on it continuously; such as conduct researches at national disaster protection center, university disaster protection center, and private engineering consultant companies. The railway management unit should send people to or hold international tunnel safety conference regularly to promote the ability of tunnel rescuing, and work together on promoting the operation safety in the tunnels.

43. Thank you very much.