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 The emergency response was further delayed because the VOR access road--a partially paved, single-lane road that was the only ground access to the accident site--was blocked by a section of severed pipe when emergency responders arrived. Emergency responders had to walk to the crash site through steep, muddy terrain and dense vegetation until 0334, when a truck-mounted winch removed the pipe. Fire and rescue personnel stated that only small, isolated fires remained when they were finally able to reach the accident scene with firefighting equipment.

A U.S. Navy emergency medical technician assigned to the Naval Regional Medical Center reached the accident site on foot between 0245 and 0300. He stated that emergency responders established two triage areas to treat survivors. He added that transport of the survivors to hospitals was delayed because of the terrain and limited access to the crash site and the necessity to stabilize patients in triage. The first survivors were transported to hospitals between about 0300 and 0330. Rescue personnel testified at the Safety Board's public hearing that the pace of evacuations increased after the pipe blocking the access road was removed and a landing area for helicopters was set up near the VOR.

The Safety Board is concerned that the first emergency response equipment did not arrive at the accident scene until about 52 minutes after the accident. Although the harsh terrain and the broken pipeline could not have been controlled, the delay caused by air traffic controllers' initial unawareness of the accident, the need to recharge the brake system on the GFD Engine No. 7, and the lack of timely notification to the Federal Fire Department could have been avoided. Thus, the Safety Board concludes that a substantial portion of the delayed emergency response was caused by preventable factors.

The autopsy reports indicated that at least one seriously injured passenger was treated at the accident site. Although the autopsy report for this passenger did not identify a single cause of death (her remains showed evidence of multiple internal injuries but no burns or soot in the airways), the report indicated that she was alive when medical personnel arrived, was treated aggressively, and might have survived if earlier medical intervention and evacuation had occurred. Therefore, the Safety Board concludes that the delayed emergency response hampered the timely evacuation of injured persons, and at least one passenger who survived the initial impact and fire might not have died if emergency medical responders had reached the accident site sooner.

According to public hearing testimony by Guam's Civil Defense Director, at the time of the accident, Guam emergency response authorities had a memorandum of understanding (MOU) with the U.S. Air Force for emergency response but did not have agreements with the U.S. Navy or U.S. Coast Guard. The director further stated that, before the accident, a joint disaster drill had been conducted at the airport, but no drills had been conducted for off-airport crash emergencies. At the public hearing, the Guam Civil Defense Director and other Guam officials stated that a committee, including representatives from Guam, the U.S. Navy, the U.S. Coast Guard, and the U.S. Air Force,