公众大型集会的应急备灾——上海外滩“12·31”踩踏事件的经验教训

董永鹤，赵中辛，刘　菲



公众大型集会的应急备灾——上海外滩“12·31”踩踏事件的经验教训

董永鹤1，赵中辛2，刘菲1

作者单位： 200120上海，同济大学附属东方医院：1.消化内科，2.中华灾难医学分会

Emergency preparedness for mass gatherings: lessons of Dec 31 stampede on the Bund of Shanghai

DONG Yonghe1, ZHAO Zhongxin2, and LIU Fei1. 1. Department of Gastroenterology, 2. Chinese Society of Disaster Medicine, East Hospital Affilited to Tongji University,Shanghai 200120, China

Correspoding author: ZHAO Zhongxin, E-mail: zhongxinzhao1999@163.com

According to WHO, a gathering of persons was usually defined as more than a specified number of persons at a specific location for a specific purpose （a social function, large public event or sports competition） for a defined period of time[1]. A critical risk of these mass gatherings is stamped. Dec 31, 2014 Shanghai stampede was known mostly for its particular time period （New Year’s Eve）, the large amount of casualties, and the various rumors after it.

世界卫生组织通常将一个在特定的时间和地点，为了特定的目的（如社交活动，大型公众事件或者运动竞赛等），超过特定人数的集会定义为公众集会[1]。而大型公众集会的一个重要危险因素便为踩踏事故。“12·31”上海外滩踩踏事件为众人所熟知是由于其发生的敏感时间段（新年前夜），造成的伤亡人数以及不胫而走的谣言。

1　What happened? |事件经过

Starting from 20:00 31st of December, 2014, around 120 000 citizens and tourists made their way towards the Bund. By 23:00, the number reached 310 000. Around 23:35, a stampede happened at stairs between Chenyi Square and the observation deck, where the best viewing place for New Year’s Eve light show. The stampede caused 36 killed and 49 injured, most of whom were young students and tourists from places outside Shanghai.

从2014年12月31日 20:00起，约有12万游客及市民陆续到达外滩。直至23:00，人数达到了31万。大约23：35，在跨年激光表演的最佳观景平台和陈毅广场之间的楼梯处发生了踩踏事故。此次踩踏事件造成了36人死亡，49人受伤，大部分都是年轻学生和外地游客。

Prior to the stampede, people were coming from different directions and converged at the Chenyi Square. At the stairs to observation deck, crowds at the top of the stairs pushed downward amidst the congestion, and caused individual people to tumble, immediately leading to the stampede. Just right after the stampede, policemen at the scene and surrounding bystanders made an effort to rescue the people who had fallen. However, after multiple attempts, they didn’t succeed due to the density of people. The Shanghai Medical Emergency Center was informed at 23:41 and 19 ambulances arrived on the scene at 23:49. The victims were sent to the nearest hospitals and escorted to operation rooms through the Green Channels （channel to assist ease of access）.

事故发生前，人们从各个不同的方向聚集到陈毅广场。在通向观景台的阶梯处，上层的人们向下走，形成了压力，导致个别人摔倒，从而引起连锁反应，导致踩踏事故。事故发生后，现场的警察和周围的路人立刻尝试救助倒下的人。但由于人群密集，数次尝试未果。上海市医疗急救中心于23：41陆续接到报警电话，19辆救护车于23：49抵达现场。伤员被立刻送往最近的医院，并通过绿色通道被护送入手术室。

Generally speaking, the public was eager to obtain information about the process after big event. The media responded more quickly to news stories than the press conference of government, amd this brought time to breed all sorts of rumors. The one with largest impact being that the stampede was caused by a distribution of cash coupons.

通常情况下，重大事件发生后，公众急切想要知道事件经过，而媒体又比政府报道相对迅速，这便为孳生各种谣言提供了时间。其中影响最大的是关于某酒吧撒代金券导致踩踏事件的言论。

2　Why it happened? |事件原因

2.1Crowd factors |人群因素

2.1.1High density |人群密度Starting from 20:00, around 120 000 citizens and tourists made their way towards the Bund. By 23:00, the crowd number reached 310 000[2-5], a number at which people usually fail to respond rapidly enough if they stumble.

从20:00起，约有12万市民及游客陆续到达外滩。直至23:00，人数达到了31万[2-5]。在如此高的人群密度下，一旦发生踩踏，人们通常来不及反应。

2.1.2Flow direction |人群方向At the stairs, a large amount of attendees were moving towards the platform,while another crowd of people were walking down the stairs, which formed the “arch phenomenon”[4,5], an unstable situation among the people that is more likely to result in a stampede.

在事故发生的阶梯处，从观景台向下的人与仍在向上走的人群发生了挤压，从而产生“成拱现象”[4,5]，在这样一个不稳定的人流对冲情况下更易导致踩踏事故。

2.1.3Lack of self protection knowledge |人群自我保护意识缺乏In planning a mass gathering, promotion of emergency actions and availability of public information should be provided to minimizing the public health risks. Not only there should be clear leadership and governance arrangements, but also appropriate funding[6]. There were hardly any promotions prior to or during the event that targeted on self-protection and emergency procedures in a high density crowd. In addition, an early warning system wasn’t put in place. Thus, the general public wasn’t aware of the risks and hazards in their environment.

在筹备大型公众集会的时候，应该提升公众应急行动力和提供公众获取应急信息的途径，从而降低公众健康风险。另外，对于应急事件处置政府部门间的领导权和管理安排也应分工明确，并且有合适的资金来支持[6]。此次事件之前、之中，并无任何关于密集人群中如何自救和应急的知识普及。另外，预警系统也未启用。因此，公众对其中的危险因素以及可能的灾害并不了解。

2.2Environmental Factors |环境因素“Management of environmental threats for mass gatherings require clear, effective, and early inter-sectoral engagement and collaboration”[6]. Due to the convenience of the public transportation, and the attraction of the Bund, Chenyi Square was a public area with the highest crowd density, making the staircase in between the two attractions a very dangerous place. It had a total of 17 steps, parted by a 14 m2platform, where the members of the crowd could be easily tripped.

对公众集会环境中存在威胁的管理，需要明确、有效的和早期的部门间协商与合作[6]。由于公共交通的便利性，及外滩对游客的吸引力，陈毅广场成为人群密度最高的公共区域。这便导致两处景观之间的台阶成为了一个十分危险的区域。而由于这个17级阶梯台阶中间有个14 m2的平台，人群很容易在上面摔倒。

2.3Management Factors |管理因素

2.3.1Risk assessment |风险评估“Using risk assessment and risk management to guide preparedness planning can facilitate a successful mass gathering”[6]. While planning the New Year’s Eve light show, the organizer relocated the event from the Bund to Waitanyuan and had undertaken risk assessment for the new location. However, untial 30thof December, the location change was notified to the general public. Due to the lack of communication between the organizer and the attendees, most of the tourists and citizens failed to acknowledge this location change and many showed up at the Bund. The core of the risk assessment is to ask what could happen and how likely would it happen. When changing the location, the organizer should have considered the shortage of time and risk of incomplete communication.

运用风险评估和管理方法指导备灾计划有助于大型公众集会的成功举办[6]。此次新年灯光表演筹备时，举办方将地点改为了外滩源，并且完成了风险评估。但该改变在30日才向公众宣布。由于举办方与参与者之间的沟通不足，导致大部分游客和市民并不清楚修改后的地点，仍然出现在了外滩。风险评估的核心便是预想可能发生的事件，及该事件发生的可能性。在改变地点时，举办方应该考虑到如此短的时间可能造成信息交流不全。

3　Surveillance and Communications|监控和沟通

3.1Surveillance |监控During the event, surveillance can facilitate early warning of injuries. Enhanced surveillance is needed in order to rapidly identify public health concern that occur during the mass gathering, to communicate the information about them, and to respond to them[1]. During the event, there were approximately 350 policemen in which only 7 （later 13）were placed at Chenyi Square[2,3]. This was because of the change of event venue and miscalculation of the public’s actions. The lack of manpower and overwhelming amount of people meant it was difficult to even reach where the incident happened, not to mention offered assistance to those in need. There wasn’t enough surveillance to react appropriately. What’s more, Huangpu District Public Security Bureau didn’t enforce any traffic control even though they were instructed that it was essential.

要学好《测量基础》课程，不仅要求学生勤于思考、认真学习，也要求任课教师做好教学设计，不断创新，为后续专业课的学习打下扎实的基础。

监控可以在大型事件中对伤亡起到预警作用。大型公众集会中需要有效的监控，以此快速识别公众集会期间的公共卫生问题，交流这些信息，并响应这些信息[1]。此次事件中，现场约有350名民警，其中7名（后为13名）被安排在陈毅广场[2,3]。这是因为举办地点的改变以及举办方对人群反应的预测错误。不足的人力及密集的人群导致民警根本无法进入事发地点，更不用提实施救援。现场监控不足也使应对无力。另外，尽管被要求过，但黄浦公安分局并未进行交通管制。

3.2Communication |沟通Communication is the rapid and coordinated dissemination of information related to the awareness of and response to public health issues. Nearly all reports of actual events or exercises of events note shortcomings in communication, which further emphasizes its importance. After 8 pm on the 31st, the crowd was increasing rapidly. However, Huangpu District Public Security Bureau failed to measure the crowd-flow rate and didn’t manage to inform the duty office, which caused insufficient police presence during the event. In addition, Huangpu District Public Security Bureau failed to adopt effective measures in time, nor did they issue warnings to Huangpu District Government to react.

沟通在这里指的是快速协调地发布关于公共卫生问题的消息。几乎所有对事件或演练的报道都表明了其在沟通中的缺陷，这更强调沟通的重要性。在31日晚8点之后，外滩人流量急剧增加，但黄浦公安分局并未进行人流量测定，也并未向值班办公室上报，从而导致事件中民警安排不足。另外，黄浦公安分局未及时采取有效措施，也未报请黄浦区政府发布预警。

4　How is Hong Kong preventing a similar situation?|香港的做法

As a big city, Hong Kong also has plenty of public events, which can be defined as mass gatherings, including its own New Year’s Eve fireworks. However, a stampede has never happened since the Lan Kwai Fong incident in 1993. What are the reasons? Firstly, the event organizer releases the plan long before the actual event. For instance, this year the plan for the New Year’s Eve fireworks has already released by Hong Kong Tourism Board, including the time, venue, and even the ideal places to watch.

作为一个大城市，香港同样有许多大型公众集会，包括新年烟花表演。但自从1993年的兰桂坊事件以来，香港再未发生过踩踏事件。原因是什么呢？首先，举办方会在合适的时间提前公布事件的安排。比如今年的新年烟花表演，香港旅游局将安排在很早之前就已公布，包括时间、场地，甚至还有合适的观看地点。

Furthermore, in terms of contingency plans, the Hong Kong Government is committed to providing an effective and efficient response to all emergency situations which threaten life, property and public security. Hong Kong Police Force will be informed before an event is hosted and will undertake comprehensive risk assessment to guide and advise the organizer according to the law. In addition, a preparedness plan will be made regarding the methods, strategies and equipment required in case of emergency. What’s more, Hong Kong policemen are trained to be very professional, with significant training on responding to mass gatherings[7].

此外，就应急预案来说，香港政府致力于应对所有对人身安全、财产安全及公共安全造成威胁的紧急事件。事件举办前需要通知香港警务处，而后警务处会进行全面的风险评估并依法对举办方进行指导。警方也会针对应急情况下的战略、方法和所需装备制订预案。此外，通过针对大型公众集会快速反应的重点培训，香港警方在应对该类事件时做得很专业[7]。

Moreover, regarding information dissemination, Hong Kong has established the Information Services Department which is responsible for coordinating the Government’s information dissemination to the media. It will promptly issue advisory warnings, special announcements, regular situation reports and related information to the public through the media and also pass on such information to other Government Departments[8].

5　What can we do in the future? |事件的经验

5.1Legacy |宝贵经验After the stampede tragedy on Dec. 31st, many events, not only in Shanghai but in other major cities all over the country, were canceled. However, it is not beneficial to forbidden all the mass gatherings due to their spontaneity and uncontrollability. On the contrary, the government should evaluate the event, summarize the mistakes and learne lessons. The tragedy can be turned into a legacy that can guide the planning of future mass gatherings and improve the host community.

12月31日的踩踏事件发生后，不仅在上海，全国各地其他大型城市的很多大型活动都被取消了。但是因为公众大型集会的随机性和不可控性，就禁止所有群体聚集事件是无益的。相反，政府部门应评估该次事件，总结经验教训。这样一来，悲剧事件也可成为宝贵经验，被用来指导将来公众大型集会活动的筹备，也可改善举办活动的社区。

5.2Comprehensive risk assessment |全面的风险评估As mentioned before, risk assessment is essential to the planning of mass gatherings. During the 2010 Expo, a series of risk assessments were performed in order to identify and prioritize potential disaster hazards, and in order to assist with the prioritization of preparedness activities. The approach was based on the AS/NZ 4360:2004 Standard for Risk Assessment, and was modified according to amethodology provided by the US Centers for Disease Control[9]. It demonstrates that the government is capable of conducting a comprehensive risk assessment for an event as large-scale and international as the Expo, and should similarly undertake one for all other mass gatherings.

正如前文所提到的，风险评估对公众大型集会活动的筹备至关重要。在2010年世博会中，为了发现并区分潜在的灾难危险，以及优化活动的应急准备工作，相关部门提前进行了一系列的风险评估。评估方法是基于风险评估澳/新4360：2004标准，并且对美国灾难控制中心提供的方法学进行了改善[9]。这表明政府具备在世博会这样大型的、国际化的事件中全面风险评估的能力，那么在今后的大型公众集会活动中也应该并有能力进行类似的风险评估。

5.3Clear responsibility of stakeholders |利益相关者们之间明确责任One of the recognized complexities of mass gatherings is that there are often very different players involved. Those stakeholders may not understand the risks, roles and responsibilities associated with the mass gatherings or the need for preparedness and effective responses to any incidents. The importance of and principles in stakeholder engagement for mass gatherings has been identified and recognized for over 10 years and remains appropriate today[6]. Different stakeholders should establish a communication system which allows the information collected before, during and after the event to be evaluated and disseminated rapidly.

大型公众集会众所周知的一个复杂性因素，就是事件经常会有许多不同的参与者。这些利益相关者们可能不太理解大型公众集会的风险、自己的角色和责任、应急备灾和有效响应对任何突发事件的必要性。在大型公众集会中，利益相关者们参与的重要性和原则化已被发现和证实超过10年，而且现今仍然适用[6]。不同的利益相关者们之间应建立系统的沟通渠道，这样才能够将事件前、中、后的消息快速收集并评估。

5.4Surveillance and early warning system |监控和早期预警系统Like Hong Kong, the Shanghai government should establish specific departments to have better surveillance during mass gatherings. Different departments, like stakeholders, should set up a communication system which allows the government to respond more rapidly during big events. Particularly an Information Services Department is needed to inform the general public of advisory warnings, special announcements, and regular situation reports through different channels of media. It is also essential to follow and implement the national 4-level early warning system, which would inform the public about the possible emergencies, their effects, and actions to take[10].

像香港一样，上海政府应成立一个专门的部门，来保证大型公众集会期间有更有效的监控措施。而政府各个部门之间，也应像不同利益相关者们之间一样，建立一个系统的交流渠道，这样才能让政府部门在大型事件中更快地作出反应。尤其应该设立一个政府新闻处，通过不同媒体渠道向市民发出警告讯息、特别报告、定时情况汇报和有关消息。另外，执行和落实全国4级预警系统也十分重要，这样能够及时告知公众关于可能发生的紧急情况及其影响并应该采取的措施[10]。

5.5Sustainability |可持续性Engaging the community and making a program sustainable is always a difficulty in mass gatherings and emergency preparedness. Regarding the Dec 31st stampede, first-aid knowledge and basic life support training would have been very helpful for reducing casualties. Therefore, firstaid financing and organizations should be funded. At the national level, legislation for on-site mutual aid is essential to encourage the general public to perform basic life support[11]. Meanwhile, Emergency Medical Services are responsible for maintaining equipment and providing easy access when required in order to perform rapid rescue.

如何让社区参与以及如何使相关项目具有可持续性，一直是大型公众集会以及应急备灾的难点。就12月31日的踩踏事件来说，急救以及基础生命支持知识在减少伤亡方面，本可提供巨大帮助。因此，提供相关知识培训的急救基金会及组织应得到资助。就国家层面，现场互救的立法也十分必要，这便能鼓励大众在现场实施基础生命支持[11]。同时，应急医疗服务部门应负责设备保养并为紧急救援提供绿色通道。

【参考文献】

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[10]中华人民共和国中央人民政府网. 上海市突发公共事件总体应急预案（全文）[EB/OL].（ 2006-01-27）[2015-12-23]. http:// www.gov.cn/yjgl/2006-01/27/content_173385.htm.

[11]顾 璇，解 炯，张文超，等. 上海12·31踩踏事件应急救援的反思[J].中国急救复苏与灾害医学杂志, 2015, 10（7）: 671-672.

（2016-01-10收稿2016-01-29修回）

（责任编辑郭晓）

通讯作者：赵中辛，E-mail: zhongxinzhao1999@163.com

作者简介：董永鹤，硕士研究生在读，E-mail: danieldong92@qq.com

DOI：10.13919/j.issn.2095-6274.2016.02.016