Major Incidents, Mass Casualty Incidents

North Carolina Agencies Partner to Prepare for a Mass Casualty Incident at the Charlotte Douglas International Airport

Issue 9 and Volume 40.

It’s a clear, crisp October morning and a commercial Airbus with 130 passengers and a five-person crew has been cleared for takeoff. As the plane accelerates, a small general aviation aircraft mistakenly taxis onto the active runway directly into the path of the quickly approaching Airbus. Tower controllers order the Airbus to abort its takeoff roll, but it’s too late. The larger aircraft strikes the smaller plane, causing an explosion that engulfs the lesser apparatus and causes the Airbus to break open. Passengers, crew members, luggage and pieces of aircraft are scattered along the end of the runway as the Airbus comes to a violent halt.

Proper Preparation

This scene at the Charlotte Douglas International Airport (CDIA) in Charlotte, N.C., was part of a carefully designed and implemented functional exercise for emergency response. Known more formally as the Part 139 Full Scale Exercise, staged mass casualty incidents (MCIs) like this are a requirement of the Federal Aviation Administration (FAA) for all international airports in the U.S. Exercises involving local, state and federal agencies are required of the airport every three years, with tabletop exercises conducted in the years in between.

Maximizing these exercises is especially important for the CDIA because it’s the nation’s eighth busiest passenger airport, serving more than 44 million passengers annually.1 The FAA sets specific parameters and requirements for the Part 139 Full Scale Exercise so that the airport facility and partner responding agencies can demonstrate actual response capability to an aircraft accident. For airports the size of CDIA, one of those parameters is a response incident that involves a minimum of 80 casualties.

Every patient was prepared with a pre-set backstory, symptoms and injuries that had been studied beforehand.

The Crews

Among those organizations partnering with the CDIA for this exercise are Medic (Mecklenburg EMS Agency), the Charlotte Fire Department, the Charlotte Mecklenburg Police Department, the Transportation Security Administration, the FBI, the American Red Cross and MedCenter Air.

Medic’s participation in these types of MCI drills has spanned more than two decades. The service is the busiest EMS system in the state, covering a service area of 546 square miles in Mecklenburg County, N.C. In addition to the required FAA drills at the airport, Medic is also required by FEMA to participate in annual preparedness exercises for the two separate nuclear power facilities located in and adjacent to Mecklenburg County. Medic also participates in annual MCI drills required by the Federal Transit Authority every three years in support of Charlotte’s growing light rail system and in a full-scale casualty reception and transportation exercise every three years as part of its participation in the U.S. Veteran’s Administration’s National Disaster Medical System (NDMS).

While all MCI drills offer valuable opportunities to evaluate EMS performance related to incident/unified command and management; patient triage and treatment; as well as transportation to appropriate receiving facilities, this drill provided a platform to focus on Medic’s capability and readiness. This vantage point allowed for developing a scenario that was highly realistic, emphasized strong collaboration with Medic’s partner agencies, incorporated a number of Medic special operations capabilities, and evaluated MCI plans and capabilities.

Instead of simulating on a remote part of the airport property, CDIA operations closed an active runway and staged the planes as they would have been found by first responders.

Heightened Realism

Medic Deputy Director Kevin Staley, MPA, CEM, was designated as co-exercise director. According to him, MCI responses are the toughest to prepare for because they’re low-frequency, but high-consequence events. This makes practice crucial. Unfortunately, these types of drills are very resource intensive, very expensive, require a lot of people, and must be conducted while not compromising the active 9-1-1 system.

A focus for Staley was to include realism into the exercise scenario. Medic’s education and simulation center program has had a lot of success at making the scenarios and the environment as realistic as possible by paying attention to the small details. This sets the stage for performance and behavior to occur as close to the real thing as possible.

Table 1: Mecklenburg EMS agency (Medic) at a glance

Staley recruited more than 100 volunteer role players from the local Central Piedmont Community College and Charlotte Chapter of the American Red Cross, as well as some family members from Charlotte Airport Operations employees, to act as patients. Each was prepared with a backstory, symptoms and injuries that had been studied beforehand to flush out the patient as a person as well and to add to the real-life engagement first responders might encounter.

Although the “patients” were much better than the sometimes-used cardboard cutouts for MCI drills, Staley went even further toward his goal of patient realism by enlisting the help of nearly a dozen moulage artists from across North Carolina to create the sometimes shocking injuries an EMT, paramedic or other first responder might encounter on such a large-scale MCI response.

To complete the realism, Staley collaborated closely with Airport Operations Manager and exercise co-director Jimmy Mynatt to arrange for a commercial airliner from hub airline American Airlines and partner U.S. Airways to be used during the exercise. Instead of conducting the exercise on a remote part of the airport property, CDIA operations closed an active runway and staged the planes as they would have been found by first responders had this been an actual incident.

An airplane crash simulator, complete with gas burners to simulate a post-crash fire, was provided by nearby Cleveland Community College to serve as the general aviation aircraft that collided with the commercial airliner. Scattered between the American Airlines Airbus and the airplane crash simulator were aircraft parts, debris, old luggage, drink carts, seats and lots of moulaged patients.

Lester Oliva, EMT-P, a first-time Medic crew participant on the FAA Part 139 Exercise, found the heightened realism to be valuable for preparedness training. “The sounds of that many patients screaming, the visual effects of the moulage, hearing those big commercial airliners landing and taking off right near you, the debris field scattered with airplane seats, luggage and clothes—it definitely brought a level of realism I wasn’t expecting,” he said. “I went right into paramedic mode and increased my adrenaline and that feeling when you’re on scene.”


In addition to raising the level of realism for optimal effectiveness, Staley focused on scenarios and implementation that would challenge and evaluate areas specific to EMS MCI response and worked closely with Medic Special Operations Supervisor Michael Stanford to identify specific objectives.

“One of the challenges with an MCI is effective triaging and prioritizing patients,” Stanford, who brings 28 years of EMS experience to his position, said. “This drill allowed Medic to better assess our utilizing of the START (simple triage and rapid treatment) triage system and determine how we can better ascertain the number of patients by priority and, in turn, get the right amount of resources to the scene. It truly is about getting the right patients to the right place at the right time.

“Another critical objective for us was to evaluate our levels of effective collaboration with the stakeholders and partners. Increasing our ability to quickly determine the set of common, agreed-upon objectives in order to mitigate the situation as rapidly as possible is key for patient care, crew safety and resource deployment. These drills allow us a valuable opportunity to practice that and improve.”

Oliva cited some of those objectives as valuable exposure and training. “The training we get as paramedics and EMTs really teaches us to take care of our patients. Putting a black tag on someone and needing to move right on to the next patient is challenging, but probably the hardest thing to do in MCI triage is prioritizing patients. With an MCI, you can have 18 different red tags, where on a normal day the one red tag is my priority and most important patient. Here, having to prioritize between eighteen different critical patients can be really difficult.

“This drill really opened my eyes to the mindset and capabilities you’re going to need to effectively and efficiently triage patients and do so by priority. That was definitely something I took from the exercise and how I can better prepare as a paramedic for an MCI response.”

Staged MCIs like this are a requirement of the FAA for all international airports in the U.S.


Upon completion of the Part 139 Full Scale Exercise and several operational debriefs, there were many lessons to learn. First responders should be aware that the length of time it takes to process patients will be longer in real life. Despite all of the planning and engineering, it’s still a drill and, therefore, the actual operating system can’t be compromised—for Medic or for the airport. Logistical management of limited space will likely be more complicated than planned for or expected. With an MCI of this nature, remain flexible and expect the unexpected to some degree and be able to respond as such.


1. Charlotte Douglas International Airport. (2014.) Fast Facts. Retrieved March 17, 2015, from