| American Psychologist | © 1988 by the American Psychological Association, Inc. |
September 1988 Vol. 43, No. 9, 724-729 | For personal use only--not for distribution. |
Psychological services for air disaster victims have been neglected in past airport and airline crash response programs. This article explores the psychological impact of air disasters on passengers and airline employees, highlighting the victims' emotional needs following a crash. Organizational efforts that have been implemented to address human problems resulting from air crashes are surveyed. The paucity of specific governmental and corporate initiatives to provide psychological aid to human survivors of air crashes is cited. Issues related to the development of volunteer crisis intervention services for airports are discussed.
Few people like to dwell on thoughts of impending doom or to make plans for dealing with catastrophic events like airline crashes. Those who fly, a number that has grown substantially in recent years, much prefer to deny the possibility of crashes, but it is very difficult to ignore the reality of disaster for long. Consider these stark realities: Within the last few years, major air disasters have occurred at or near the airports of Boston, Chicago, Dallas, Denver, Detroit, Los Angeles, New Orleans, Reno, San Diego, and Washington. The National Transportation Safety Board (NTSB) reported that scheduled U.S. airlines had 31 accidents in 1987 alone, the highest since 1974 when there were 42 accidents ( United Press International, 1988 ). Airline crashes in the United States during 1987 claimed 289 lives. Despite measures taken to improve safety, aviation is not accident free; air crashes appear to be tragically inevitable.
At this point, there are no government-based national programs for providing psychological services for aircraft disaster victims and family members. Neither the Senate and House committees on aviation nor the national initiatives for disaster relief programs address the specific psychological needs of aircraft disaster victims. In fact, so neglected are these needs in Washington that we were unable to find a member of Congress interested in addressing the issue for this Public Forum.
Two organizations one might expect to provide needed services for air crash victims are airports and airlines; however, for numerous reasons, this important need has not been sufficiently addressed by these organizations in the past. Airports, especially those involved in carrier operations, are required by the Federal Aviation Administration (FAA) to have formal disaster plans describing rescue and medical evacuation procedures (see the article by Anderson, this issue , pp. 721—723). In the event of a crash at an airfield, established disaster units are mobilized to provide on-site fire, rescue, and first aid for victims. Medical evacuation units transport injured passengers and bystanders to the hospital. However, few airports have provisions for organizing and providing psychological support for survivors and family members of crash victims. The recent efforts to provide psychological aid, though probably effective, have been afterthoughts rather than preplanned operations ( Butcher & Dunn, in press ; Davidson, 1979 ).
For the most part, airlines, like airports, are unprepared for dealing with the psychological problems resulting from a crash. Many airlines have an emergency operations manual that designates individual employee responsibilities, organizational chains of command, and internal procedures to handle the effects of a crash while keeping the rest of the airline flying. However, significant variability exists between airlines in the selection and training of the personnel who will have contact with victim families. A few airlines recently have made efforts to provide psychological services for passengers' families and crew members ( Bales, 1987 ). Understandably, most airline employees are not well prepared to respond to a crash. Until a company experiences a major loss, it is easier to view a crash as a chapter in the operations manual or as a yearly exercise. Employees may fear a crash as a remote possibility, but most will complete their careers without ever participating in an aviation disaster response. After a first loss, procedural improvements tend to center on more sensitive distribution of information to the public, more effective investigation of the crash cause, and fewer interruptions in airline operations. As the memories for the event recede into history, new employees join the airline, and neither they nor senior employees care to dwell on the next potential crash. Although this process is understandable, the result is that airline employees must meet the families of crash victims with limited training and variable managerial support.
Psychologists and other mental health professionals can draw on a growing literature on disasters when developing services for air crash victims. In many respects, the emotional responses and demands of crash victims are similar to those of victims of other disasters such as hurricanes, floods, nuclear accidents, and volcanic eruptions ( Butcher & Dunn, in press ; Mangelsdorff, 1985 ; Williams, Solomon, & Bartone, this issue , pp. 730—739). However, there are a number of factors that can produce some clear differences:
Unlike some tragedies, airplane crashes are typically sudden and unexpected. There is usually no warning and no time to prepare. Many victims are in the most productive period of their lives and may have given no thought to their own demise. Consequently, they may leave their survivors with few resources and many loose ends.
Airplane crashes are seldom neat and tidy accidents. Individuals, even experienced disaster workers, may be psychologically stunned by the enormity of a disaster that may involve extensive destruction, fire, bits of personal possessions, and scattered human remains. It transforms the accident site into a scene of incredible carnage.
In an air disaster, victims are usually away from familiar settings and among strangers. Consequently, survivors are without the sense of community that characterizes many disasters, such as floods, tornados, and hurricanes, and that provides an immediate support network.
An airline disaster has a strong emotional irradiation effect , that is, it has an impact on individuals not immediately involved in the accident itself. For example, tornados or floods usually impact people living in the particular area. An airline crash in one city is often felt by victims' families in numerous communities because many flights are filled with passengers from different cities. In addition, an airline crash has an enormous effect on virtually everyone employed by the company. Major carriers, with bases in several cities, experience extreme morale problems following the loss of a plane. There is clearly a "dosage effect" operating in airline crashes; those closest to the trauma are most severely affected. However, an airplane crash disrupts many lives (cf. Williams et al., this issue , pp. 730—739, for a description of high risk groups).
Aviation accidents are different from natural disasters, for which human beings typically are not blamed. When a disaster is potentially attributable to human causes, however, the blame and anger characteristically felt by victims find a definite focus. Like other industrial accidents, airline accidents evoke a considerable amount of anger and "litigation motivation," which can serve to prolong the individual's readjustment for months or even years.
Although the impact of an air crash on survivors has been described ( Butcher & Dunn, in press ), the emotional effect on airline employees has not been well delineated. In recent major airline disasters, many airline personnel have mastered the multiple demands of their emergency roles and have helped victims and families significantly in these moments of shock and grief. Others were overwhelmed and could function only in a variable and ineffective manner. All of the airline crash response personnel we have interviewed, regardless of how they handled disaster roles, have wanted additional training and on-site psychological consultation. Although there is no completely comparable group in a natural disaster, the distinctive experiences of airline employees reveal emotional themes common to disaster victims in general.
During the postdisaster period, airline employees experience four common cognitive processes, all of which serve to recover a sense of mastery over the incident. The first process is fear driven and involves a search for information about their own family members or friends who were possibly on board the lost aircraft. Worried employees may place numerous phone calls to others believed to have been on the aircraft. These employees routinely return home to answer hours of messages from families and friends. Although they may understand the positive intent of these messages, they may not find such messages supportive but may perceive them as additional pressures and reminders of their own mortality.
The second cognitive process is a problem-solving orientation and involves a search for causation, alternating among mechanical failure, pilot error, and criminal act. Rumor or evidence that points to mechanical failure contributes to increases in already high levels of anxiety, as employees must continue to fly the same type of aircraft until sufficient evidence appears to warrant grounding and checks of a particular mechanism. Rumor or evidence that suggests pilot error, a question raised early in the postaccident investigation of most accidents, may provide a sense of relief and lessening of anxiety, by temporarily exonerating the aircraft, followed by a hastening of depression. Survivor guilt is augmented by guilt over relief that they are not at risk from an unidentified mechanical fault in the aircraft type. Criminal behavior as a cause of aircraft crash and massive loss of life is less frequent. Bombings account for most incidents. Only two crashes of scheduled U.S. airlines have been due to homicide of the pilot by a passenger. Rumor or evidence that points to criminal cause contributes to an increase in frustration and anger. Employees' previous fatalistic attitudes about the statistical risks of their profession do not encompass death by criminal act. In such cases, much thought and discussion turns on the sense of lost innocence and security.
The third cognitive process consists of conscious, repetitive fantasy replays of the events leading to the impact or disintegration of the aircraft. In the initial fantasy replay, known facts about the crash (e.g., the type of aircraft, aircraft mechanical or performance weaknesses, typical duty positions of flight personnel, pilot-to-ground communications prior to the crash, weather conditions, point of impact, and pattern of wreckage dispersal) are combined with known or rumored personality characteristics of the employees aboard the lost aircraft. Variations of overt survival behaviors thought to be typical of these individuals are inserted into the replay, together with hypothesized last thoughts of family and friends and unfinished life tasks. In the secondary fantasy replay, the airline employee inserts himself or herself into the crash scenario in a position typical of normal duty assignments. This time, the person attempts to predict his or her own survival behaviors and last thoughts. These replays do not characteristically lead to either optimum survival behavior or to a preferred pattern of last thoughts. Rather, their frequency diminishes as time progresses, accompanied by a return to a fatalistic view of such incidents and a reduction of anxiety to manageable levels. If the postcrash investigation produces new information from the recovered "black box" flight recorder, survivor interviews, or eyewitness statements, the replay process is prolonged as new items are incorporated into the fantasy.
Finally, the fourth cognitive process centers around the decision to continue flying, to maintain aircraft, or to provide services that keep others flying. On one hand, the crash has heightened awareness of the importance and tenuousness of life, which usually makes family and friends oppose continued flying by the employee. On the other hand, the employee feels that it is he or she, not family members or friends, who must get on the aircraft every day or provide services to other flyers; thus, the employee feels that only he or she is in a position to judge what is personally important and decide whether to continue in the job.
For the researcher who has studied trauma or the practitioner who has assisted its victims, our description of the postcrash issues facing airline personnel contains familiar, general themes of adaptive coping common in all kinds of disasters. However, both the scientist and the practitioner will recognize, in our example, the distinctive manifestation of these general themes as well as the distinctive internal relations within the airline employment setting. In addition to understanding these general themes as they apply to the airline industry, psychologists interested in providing services to crash victims also must recognize the jurisdictional systems in operation after a crash and know of the other service providers.
As can be seen in Table 1 , there is an array of organizations with overlapping interests and jurisdictional responsibilities in air crash response. On the federal level, the FAA is charged with regulating air travel, including safety issues within the United States. The NTSB is charged with investigating public transportation failures like air crashes. If there is reason to believe that the crash was caused by criminal acts (e.g., hijacking or bombing), the Federal Bureau of Investigation (FBI) is responsible for studying human and aircraft remains and other evidence in order to identify a suspect and collect evidence for a possible trial. The Federal Emergency Management Agency (FEMA) coordinates and assesses states in their rescue response both for natural disasters and for those caused by humans and provides extensive training in such responses to state and local agencies. Unlike the other three federal agencies, FEMA is not assigned a responsibility in determining the cause of the crash, but rather in enhancing the adequacy of the postcrash response of U.S. carriers. Each of these agencies may seek to participate in the postcrash investigation. However, there is no functional international agreement on standards for postcrash study, and countries vary widely in their receptivity to requests for on-site investigation by these agencies. The National Aeronautics and Space Administration Safety Reporting System has no involvement in general aviation or air carrier accidents but is limited to space program affairs.
At the state level, there is the Office of Emergency Services (OES) or its equivalent. OES functions much like FEMA, coordinating mutual aid and assistance across counties within a state. Although provided with the statutory authority for such efforts, state agencies vary widely as to level of funding and degree of actual control over politically powerful counties and municipalities.
At the local level, air crash response involves the airport authority (often a separate governmental entity not directly responsible to either city or county government), the county OES unit (coordinating response aid within the county and from outside the county), local fire and rescue departments, and local police agencies. It is the latter two agencies that physically secure the crash scene area and perform the rescue tasks.
In addition to governmental agencies, an equally imposing number of private service providers may aid crash victims ( Table 2 ). Airline management teams perform on-site investigation of aircraft remains and interview surviving flight crew members and maintenance personnel. The airline also is concerned with the health and morale of its employees, both the crash survivors and others who must continue to keep the airline flying. In the last 15 years, airlines have devoted some attention to seeing that surviving passengers receive adequate on-site physical health care and have also assisted relatives with information and/or transportation to an airport near the crash site.
Employee unions and associations also are active in the aftermath of a crash. The Air Line Pilots Association (ALPA) advises pilots on postcrash behavior and maintains a national accident investigation board. ALPA advises pilots to contact its office immediately after an accident and issues behavior guidelines ( McIntyre, 1984 ). These guidelines are directed primarily toward protecting pilots' rights, providing legal consultation, and instructing against any discussion without an ALPA representative present. Because pilot performance is a consideration in almost every crash, such guidelines are viewed as essential. The early intensiveness of the investigation, however, often makes it difficult to achieve a balance between preservation of legal rights and a full access to posttrauma psychological care. Flight attendants unions provide information, legal counsel, referrals for psychological care, and crash investigation relevant to flight attendant safety. Airline management sometimes offers similar services and programs that may compete with union efforts.
Nonprofit public interest agencies also send trauma response teams to air crash sites, as well as to sites of other types of disasters. One such group is the National Organization for Victim Assistance (NOVA), organized 13 years ago to lobby Congress for crime victim support legislation. In 1986, NOVA became involved in its first trauma team response to a mass murder and subsequently sent a team to assist individuals responding to the August 1987 Detroit crash. NOVA's team members are volunteers from a range of counseling backgrounds who participate in a training program and agree to follow specified guidelines for team activities. They view their role as brief (2 to 3 days) and oriented toward educating local care-givers.
A different approach has been taken by a Washington, DC public interest group, Americans for Legal Reform, known as HALT. HALT has published a free information kit, available on request, to assist crash victims and their families with the confusing legal issues and with approaches both by attorneys seeking clients and by insurance companies seeking cost containment. This kit, in an impartial manner, educates victims about their rights and options when approached by representatives of any vested interests in the postcrash period. At this point, such public information kits remain little known.
For disasters involving military personnel, significant effort has gone into the planning, training, and deployment of trauma response teams (
McCaughey, 1985
;
Sokol, 1987
). They include the U.S. Navy's Special Psychiatric Rapid Intervention Team (
Each of these organizations with general interest in air crash response contributes in its own area of expertise, and methods of working together have evolved over the years. Regular, comprehensive crash response rehearsals and cooperative leadership within each organization can successfully overcome the inherent fragmentation of interests. However, inattention to training and absence of leadership can produce on-site confusion that seriously impairs the crisis response. Williams et al. (this issue , pp. 730—739) provide a further description of the detrimental effects of this on-site confusion, as well as a discussion of the types of psychological services implemented for crisis victims.
Given that most crashes (85%) occur at or near airports during takeoff or landing ( Dove, Del Guercio, Stahl, Star, & Abelson, 1982 ), an effective way of preparing for psychological interventions is to integrate them into the existing, required airport disaster program. A psychological response program for airplane disasters involves the following components: immediate crisis intervention services for passengers' families and surviving victims; psychological follow-up in the weeks after the crash; and debriefing sessions for all personnel, including disaster response workers, who are at risk for developing problems as a result of the accident.
In the aftermath of the 1978 crash in San Diego, where 137 passengers and 7 people on the ground were killed, a group of private practice psychologists undertook one of the first crisis intervention service efforts for police and fire department personnel who were mobilized to clean up debris and body parts from the accident. These crisis intervention services, sponsored by the fire and police departments, continued for weeks after the crash. A total of 30 police and fire department workers and 50 civilians were seen in crisis counseling over about six weeks ( Davidson, 1979 ).
Another example of a crisis intervention disaster response program was implemented at the Minneapolis/St. Paul Metropolitan Airport in 1978 as part of a broader medical intervention and evacuation component included in the airport disaster plan ( Butcher, 1980 ). This program was based on two assumptions: First, it was considered important to have crisis intervention services available for surviving passengers at or near the site of the accident and to provide counseling for family members in the terminal area. Second, it was also considered important to have extensive debriefing sessions for air crash victims and disaster workers in the hours and weeks following the accident. The Minneapolis/St. Paul psychological intervention program is staffed by local practitioners who volunteer to participate. A crisis intervention facility was designated at the airport in the medical triage center. From its beginning, annual disaster drills have been held for all components of the airport disaster plan (cf. Anderson, this issue , pp. 721—723).
Prompt psychological services near the site of an airline crash are important to reduce the impact of the disaster. Timely interventions in the immediate aftermath of a disaster have been suggested as a means of reducing the long-term consequence of mental health problems ( Williams et al., this issue , pp. 730—739). However, at present, there are no funded programs or funding initiatives in the federal or state governments to support the development and evaluation of air crash crisis intervention services. Although there is a clear need for such programs, it does not appear likely that financial support will be available until the level of congressional concern is increased.
What can psychologists interested in providing disaster response services do until there are funding initiatives to support formal programs? Obviously, the need for disaster response programs will continue, and equally obviously, psychologists will continue to become involved in these efforts. In the near future, many of these important programs are likely to rely on volunteer services. However, the organizational difficulties inherent in volunteer programs are sobering.
Many communities have coordinated air disaster response programs involving hospitals, police, fire departments, ambulance services, emergency chaplains, and other rescue personnel. Before psychologist groups can introduce effective disaster planning, they must carefully study the local political structure of disaster response organizations. Negotiating an acceptable and workable relationship with the airport director, medical coordinator, and other rescue leaders may require some persuasive effort. A number of published and unpublished materials available provide a rationale and procedures for establishing a psychological response program. 1
Identifying a sufficient cadre of qualified crisis intervention psychologists to staff a volunteer program can be challenging. Willingness and an open schedule are not sufficient qualifications. Disaster response efforts can produce extremely trying and emotionally painful circumstances for the mental health professional ( Williams et al., this issue , pp. 730—739); the use of unseasoned or ineffective individuals can hamper crisis intervention efforts, in addition to creating "stress" among the volunteer professionals. Only therapists with experience and a temperament for crisis intervention work, that is, an ability to function under intense conditions for long hours with emotionally distraught individuals, should be recruited for an airport crisis intervention program.
Maintaining a roster of willing volunteers also can be problematic. Many practitioners voice a social concern and willingness to volunteer some time to disaster response programs, but other issues need to be considered. It may be difficult to find practitioners whose schedules are flexible enough to scrap their committed appointments on a moment's notice to go to the rescue headquarters. Psychologists who become involved in a disaster response effort will attest that it is a time-consuming and emotionally draining experience. Disaster response efforts seldom have a predictable beginning and ending. Individuals who volunteer are, in a sense, placing themselves in a position to be called on at inopportune times and possibly for prolonged periods. To those committed to a program, the work can seem unending. It is important to recruit psychologists who can report to the scene of the accident or to a designated area where victims or family members are gathered–usually at the airport terminal building, airline office facility, or adjacent hotel designated as a family area. Although the practitioner's office may be suitable for extended aftercare visits, it is impossible to organize a disaster response program using office-bound personnel. In most disaster programs, temporary treatment areas usually are set up in quarters such as a gate area, an airline crew lounge, or a hallway. Because of these logistic problems and time demands, it is difficult to sustain the interest of volunteer participants in air disaster response programs. Following the organization phase, there is an inevitable decline of volunteer interest and commitment as months and years go by before the air crash incident. Such a loss of volunteer interest can be utilized as a screening device for commitment or, unattended, can produce an illusory, paper-based response capacity.
Disaster response drills, although time-consuming intrusions on busy schedules, are an important component of a disaster program. It is impossible to simulate all of the conditions likely in an actual disaster. However, periodic drills are necessary to test call-up procedures, marshaling areas, communications links, roles, and responsibilities that are important in coordinating disaster response efforts. Drills can help maintain the interest of volunteers and remind them of the importance of the program, as well as provide important information on procedures.
The role of psychologists in an airport disaster program might be initially undervalued. An important aspect of a psychological disaster response program is educating other personnel about the role of psychologists in an airline disaster. This involves providing information on crisis intervention procedures to community agencies and other disaster response organizations. Once they are known, we have found that crisis intervention programs affiliated with metropolitan airports are called on to serve in nonairline crash emergencies as well (e.g., providing counseling for hostages and for disturbed airline passengers).
Although the organizational demands of developing and maintaining a volunteer airport disaster program can be great, the effort, as far as making an important contribution to the community, can be extremely rewarding. If called on to serve, the psychologist responding to a disaster will find a welcome and immediate acceptance from many emotionally needy people.