Incident directory

1984 - Brightside Lane

14/12/1984

Country:

UK

  • Building Fires

Severity:

Description

Date of event

14th December 1984             

Time of event

12:57 HRS (INITIAL CALL)

Name of premises

National Freight Consortium Warehouse Building

Location

Brightside Lane, Sheffield.

Service area

South Yorkshire County Fire Service (SYCFS) then South Yorkshire Fire & Rescue Service (SYFRS), now South Yorkshire Fire and Rescue (SYFR).

Nature of incident

Fire

Property type

Warehouse and adjoining transit shed approximately 323m x 120m

Premises use

Warehouse and rail transit shed.

Construction type and materials

Transit shed of steel portal frame over a concrete base with steel sheeting roof and walls. The warehouse was of steel framed ‘Northlight’ construction with plastic coated steel sheeting on the roof, underdrawn with asbestos board suspended below and translucent glass reinforced polyester (GRP) with vertical wired glazing on the North Slope. Much of the buildings were clad internally with asbestos boards. Some steel structure was sprayed with asbestos for fire resistance. Some brick and steel, profiled sheet partitioning was also present within.

Occupancy

Staff.

Fire source and location of fire

Unknown ignition but suspected to be a heater within an unattended warehouseman’s cabin within. Poorly joined wiring was also present in the area and deliberate intent could not be ruled out.

Synopsis

Brief Synopsis

South Yorkshire County Fire Service (SYCFS) were called to a fire at the National Freight Consortium Warehouse Building on the 14th December 1984. The building was in use by a number of subsidiary companies at the time. A well-developed fire had been spotted by a visitor within unit 1 of The Transit Shed. SYCFS received 30 calls in total and initially sent 2 pumps, 2 hydraulic platforms (HP) and an emergency tender (ET). The first pump arrived at 13:01 and immediately made pumps 4 and commenced firefighting. Water supplies were limited. At 13:09 a make pumps (MP) 6 assistance message was sent with MP 10 sent at 13:22. Additional aerial appliances were also requested bringing the total to 3 HP’s and 1 turntable ladder (TL) (HSE, 1984).

A wide variety of materials including a variety of chemicals, polypropylene granules, house hold goods, cardboard, food items, was within the warehouse and transit shed most of which became involved in the fire (HSE, 1984).

By 14:00 the fire had spread from unit 1 into unit 2 and had vented itself via the roof. Attempts were made to stop fire spread and crews were forced to withdraw at times. At 14:12 a MP 16 assistance message was sent. At 14:38 a MP 17 message was sent. There was a rapid fire development (flashover) at approximately 15:00 with crews again withdrawing. By 15:40 all but unit 4 of the whole building was involved in fire. At 18:37 the Chief Fire Office sent a ‘fire surrounded’ message with a stop message sent at 04:40 (HSE, 1984).

Numerous firefighters were exposed to smoke during the fire and on the following days while damping down took place which ended on Tuesday 18th December. 41 firefighters were later examined due to ill health complaints/effects and were subsequently categorised;

Category A - symptoms and signs consistent with exposure to a complex mixture of smoke and chemical fume.

Category B - symptoms of irritation of eyes, upper respiratory tract or skin attributed to exposure to chemical mist and/or fume, but with no obvious chest symptoms.

Category C - no definite clinical evidence to link symptoms with exposure to smoke and fume.

The number of men seen in each category were as follows: Category A – 27, category B – 11, and category C – 3. (HSE, 1984).

Further information hoping to be identified and still to be located.

 Pic 02

Diagrams and pictures from HSE Report.

 Pic 03

Diagrams and pictures from HSE, 1985.

 Pic 04

Diagrams and pictures from HSE, 1985, amended by A. Course & W. Hayward (SYFR).

 Pic 05

Diagrams and pictures from HSE, 1985.

 Pic 06

Diagrams and pictures from HSE, 1985. Unknown time.

 Pic 07

 Diagrams and pictures from HSE, 1985. Unknown time.

 Pic 08

Diagrams and pictures from HSE, 1985. Unknown time.

 Pic 09

Photo 1 approximately 1 to 2 hours into the incident. Courtesy of South Yorkshire Fire & Rescue (SYFR).

 Pic 10

Photo 2 approximately 1 to 2 hours into the incident. Courtesy of South Yorkshire Fire & Rescue (SYFR).

 Pic 11

Photo 3 approximately 1 to 2 hours into the incident. Courtesy of South Yorkshire Fire & Rescue (SYFR).

 Pic 12

Photo 4 approximately 2 to 3 hours into the incident. Courtesy of South Yorkshire Fire & Rescue (SYFR).

 Pic 13

Photo 5 approximately 2 to 3 hours into the incident. Courtesy of South Yorkshire Fire & Rescue (SYFR).

 Pic 01 and 14

Photo 6 approximately 2 to 3 hours into the incident. Courtesy of South Yorkshire Fire & Rescue (SYFR).

 Pic 15

Photo 7 approximately 2 to 3 hours into the incident. Courtesy of South Yorkshire Fire & Rescue (SYFR).

 Pic 16

Photo 8 approximately 2 to 3 hours into the incident. Courtesy of South Yorkshire Fire & Rescue (SYFR).

 Pic 17

Photo 9 approximately 2 to 3 hours into the incident. Courtesy of South Yorkshire Fire & Rescue (SYFR).

 Pic 18

Photo 10 at approximately 17:00 to 19:00. Courtesy of South Yorkshire Fire & Rescue (SYFR).

Main findings, key lessons & areas for learning

Further information hoping to be identified and still to be located.

Fire & Rescue Service summary of main findings, conclusions, key lessons & recommendations

Further information hoping to be identified and still to be located.

FBU summary of main findings, conclusions, key lessons & recommendations

Further information hoping to be identified and still to be located.

Other report summary of main findings, conclusions, key lessons &recommendations

Further information hoping to be identified and still to be located.

IFE Commentary & lessons if applicable

None produced at this time.

HSE investigation & report findings, conclusions and recommendations

Taken from; Health and Safety Executive (HSE). (1985). The Brightside Lane warehouse fire; a report of the investigation by the Health and Safety Executive into the effects of the fire at the National Freight Consortium warehouse building, Brightside Lane, Sheffield on 14th December 1984. [pdf] Available at; https://www.icheme.org/~/media/Documents/Subject%20Groups/Safety_Loss_Prevention/HSE%20Accident%20Reports/The%20Brightside%20Lane%20Warehouse%20Fire.pdf [Accessed on 15th August 2016].

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Problems emerging from the fire

Problems relevant to the Fire Service

104 The Fire Service faced several immediate difficulties when they arrived at the fire ground. First, the fire had taken such a hold that the Pickfords furniture store in Unit 1 was already lost. Indeed, the fire was spreading into Unit 2 and soon would prove to be beyond control. Second, the water supplies on site were at once found to be inadequate for checking such a blaze. Third, the railway lines restricted access by appliances to two sides of the building. Fourth, there was uncertainty and therefore apprehension about the contents of the warehouse and the hazards that might be encountered.

105 Once the roof had collapsed and combustion gases could escape, inrushing air created furnace conditions in the building which no amount of water could hope to quench until the fire had exhausted its supply of fuel — the stored goods. Despite the rapid spread of the fire, however, there was no threat to the lives of any occupants, all of whom had been able to evacuate the building safely and even move their cars out of danger. No other property was seriously at risk.

106 Thus, by Fire Service standards, it was a relatively simple though very large fire: for a while it involved the attendance of nearly half the firefighting appliances in South Yorkshire in attempts to bring it under control. It is not part of HSE’s function to form judgments about how the Fire Service tackled the fire. Senior fire officers were clearly faced with a difficult situation and a perplexing choice between attempting, at some risk, to bring the fire under control and save part of the building or simply containing it until its fuel was exhausted, with least possible risk to firemen, bearing in mind that the lives of occupants and other property were not in jeopardy. Striking the balance between such choices is not easy. Better information about the water supplies, the physical problems likely to be met and the probable contents of the building might have been available, and might have assisted, had the Fire Service performed a more recent inspection of the complex under Section l(l)(d) of the Fire Services Act 1947 but, constrained by the resources available for this work, priority had been given to other premises where risk to life was judged to be greater.

107 The fire spread quickly into Unit 2 because the metal sheet partition reached only to the underside of the asbestos underdrawn insulating roof lining. The metal sheets themselves readily absorbed and radiated heat, setting fire to materials in Unit 2 simply by contact: they melted where they were exposed to high temperature from within the furniture store. Effective fire compartmenting might have contained the fire and enabled the Fire Service to control it at an earlier stage.

108 In certain multi-storey storage buildings, according to the height of the building, the Building Regulations set limits of either 1000 m2 floor area per storey, or 21 000 m3 volume on compartment size, but a single storey building may have unlimited floor area and cubic capacity without compartmentation. The Brightside Lane building was too extensive for the fire brigade to be able to span with their water jets.

109 The hot gases trapped in the underside of the roof span were able to travel along the space between the outer roof and the underdrawing, melting and burning the bitumen of the inner skin of the outer roofing sheets and weakening the lightweight framework on which the underdrawn asbestos sheeting was suspended. When this framework failed the asbestos boards fell down, enabling the burning bituminous asbestos felt to fall from the roof sheeting and set fire to the goods below. Until the suspending framework failed and the asbestos boards fell they masked the developing fire and the firemen were prevented from fighting it from below with their jets.

110 It was reported that the burning bituminous material easily ignited stored goods heated by radiant heat and so contributed to the spread of fire at ground level. The roof sheeting had been tested in accordance with the standards specified in BS 476, Fire Tests on Building Materials and Structures, and met the requirements of Section E of the Building Regulations. The latest revision of BS 476 takes into account any dripping from a test specimen but does not provide for any such phenomenon to be indicated in the classification category.

Operational

111 Accuracy and use by the Fire Service of prior information The Fire Services Act 1947 gives fire services power to enter premises to acquire information necessary for firefighting purposes in order to discharge the duty placed upon them by Section l(l)(d) of that Act. In the South Yorkshire County Fire Service this information is obtained by firemen working from operational fire stations and is transferred on to a card, designated FS1250, which is kept in a file on each pumping appliance expected to respond from the local fire stations to fire calls involving buildings within the operational area. A copy of the FS1250 should have been kept in the Control Unit, a mobile operation centre.

112 For the Brightside Lane warehouse the relevant fire station (No 23) was at Darnall Road. The date of the last visit to the warehouse for the purposes of Section l(l)(d) was 22 June 1978, at which time the premises were occupied by NCL. The predetermined attendance, the appliances which should respond to an initial call, was two pumping appliances (referred to as water ladders) having water carrying capacity of about 1730 litres, and a turntable ladder with a built-in pump. At the Darnall Road Station the turntable ladder had been replaced by a hydraulic platform with a maximum vertical reach of 25.5 m.

113 The size of the predetermined attendance varies according to the category of risk allocated to the area in which the premises are situated. For Category A — the high risk area — initial turnout should be three pumps, two of which should arrive at the fire ground within five minutes and the other within eight minutes. For Category B the turnout should be two pumps, one to arrive within five and one within eight minutes. The predetermined attendance shown on the FS1250 for NCL was therefore appropriate to a Category B risk area although it had at one time been Category A. At the last inspection the firemen recorded that the roof of the building was made of asbestos cement sheets like those on the western elevation next to the railway line, since they were similarly shaped.

114 The FS1250 referred to the four inch internal main on the site which was intended to be used for firefighting purposes and recorded the positions of hydrants. FS1250 indicated that firefighting operations would require ten jets (i.e. ten water nozzles), calling for 50 lengths of hose, each 22.75 m long, that the water required for those ten jets — at 680 litres a minute — was 6800 litres a minute and that it would take 50 men to operate them. This would call for the attendance of ten appliances, since pumping appliances in South Yorkshire carry five men as a general rule. The jets referred to are those on nominally 6.3 cm diameter hose as distinct from the smaller diameter nozzle (about 80 mm) on the fixed hose reels fitted on the appliances.

115 The FS1250 also indicated that breathing apparatus would be required at the Brightside Lane warehouse due to the storage of PVC materials as noted at the last visit. While the information about the goods stored was not up-to-date, it was nevertheless still appropriate to require the use of BA when dealing with a fire at these premises. Regardless of the nature and extent of any chemicals which might be stored, fire within the premises was likely to give off toxic products of combustion to which it would be undesirable for anyone to be exposed, particularly while the roof remained intact and the combustion products remained trapped within the building. In the event, during the short time it took for the first appliances to reach the site from their stations, crews were fully occupied with dressing in fire kit and communicating with the central Mobilising Control, and did not consult the FS1250.

116 The performance of the internal water main had not been checked by the Fire Service since the mid-1970s. Apprehension about their liability for any damage when carrying out full-scale tests contributed to the length of time since the last test but a major influence was their need to reassess priorities following fires involving multiple fatalities. Naturally this caused operational staff to concentrate more on premises posing a risk to life than those such as Brightside Lane where the greater risk was to property. Furthermore the industrial area in which the warehouse was situated had been in decline for several years with a corresponding diminution of anticipated risk, hence the change of risk category for the area.

117 A South Yorkshire County Fire Service Order (No 11), revised in September 1980, set out the procedure for dealing with all aspects of firefighting water supplies as part of their duty under the Fire Services Act. A coordinating (civilian) Water Officer was appointed at the South Yorkshire County Fire Service headquarters to liaise with the Water Authorities where necessary'. Order No 11 intended the Fire Service to inspect private hydrants twice a year and make a written report if a defect was discovered; the positions of all relevant hydrants, whether public or private, were to be identified to avoid delay in locating them in an emergency. One of the hydrants on the private main which was identified on the FS1250 could not be located, despite a thorough search after the fire.

118 The Order also set out the general policy of the South Yorkshire County Fire Service to inspect bypass valves on private mains annually by agreement with the owners. No relevant records of inspections were produced in respect of the private main or its associated meter bypass valve. The property owners — NFC Property Group — had not been approached by the South Yorkshire County Fire Service nor had they appreciated the need to monitor the performance of their private internal main.

119 Liaison between visiting Fire Prevention Officers and operational staff The Fire Prevention Department of the South Yorkshire County Fire Service, from their Divisional Headquarters at Handsworth in Sheffield, had been involved with the development of Unit 6 into a vehicle workshop and the preparation of a certificate covering means of escape in case of fire. Officers had visited the premises in connection with the fire protection of the offices and workshop, in the course of which visits they had become familiar with both the staff and the nature of the premises. Arrangements existed (by use of their Form FS925) for the exchange of information between the Fire Prevention Department and the Operational Section to update the details on the FS1250, but no exchange had taken place.

120 Control and communications at the fire ground Overall control of the operations on the fire ground was the responsibility of the Officer-in- Charge, normally the most senior officer on site. He would operate initially from an appliance or car identified by a flashing blue light. The central Mobilising Control would normally dispatch a Control Unit to the fire ground when the number of appliances reached five or when requested to do so by the Officer in Charge. A Headquarters Duty Officer would be responsible to the Officer-in-Charge for the function of the Control Unit. His responsibilities would include maintaining records of movements of personnel and appliances on and to the site, communications on the fire ground and to the Control Centre and keeping records of them, ensuring that officers wore clear identification of their allocated duties, and arranging for the supply and servicing of BA. The Duty Officer should also appoint an officer to be BA Main Control to operate if Stage II BA procedures were introduced (see paragraph 142) and an officer to be in charge of BA servicing.

121 The investigation revealed several instances where designated tasks had not been carried out in accordance with Fire Service orders and established procedures. The departures from expected performance by both firemen and officers at senior level contributed to shortcomings in fire ground control, coordination and discipline and gave rise to a number of the issues considered in this report. The Chief Fire Officer has been informed of all inadequacies which came to light during the investigation.

122 The local method of communicating on a large fire ground is by means of hand-held battery-powered Storno radio sets. On first attendance officers speak to each other using one specific channel on the radio sets. Once the Control Unit has been established on a fire ground it issues an instruction to switch all sets to a second channel. Officers can then speak only to the Control Unit, which itself is in communication with the central Mobilising Control. For protracted fire ground activity the Control Unit would also be connected to the public telephone system.

123 The Storno radio batteries are subject to a weekly recharge, which requires the complete discharge of the battery first. Before the Brightside Lane incident it was the custom throughout the South Yorkshire County Fire Service to recharge the batteries at the end of the week. Therefore, on the day of the fire (Friday) the radios were brought into use with only partially charged batteries which soon expired. Communications between fire ground officers and the Control Unit became impossible after very few messages had been sent, when an aerial on the Control Unit became waterlogged. Staff in the Control Unit were still able to speak to the Mobilising Control by radio, however. Action was taken immediately after the Brightside Lane fire to stagger the days on which stations within the South Yorkshire County Fire Service recharged their Storno radio batteries.

124 In the absence of effective radio communication on the fire ground the Duty Officer should designate firemen to act as runners and provide them with distinctive tabards so that they are not diverted to other duties. Similarly, officers with designated fire ground roles should also wear colour-coded tabards. No runners were so designated and some officers did not wear relevant tabards.

125 Environmental — Information about Building Contents The Chief Fire Officer expressed concern after the fire that inadequate information was available about the nature and extent of the goods present in the building. During the fire, warehouse employees were interviewed in the Control Unit to assist in drawing up a plan of the building showing the nature and location of the stored goods. The information was supplied from the employees’ memories since they were isolated from the offices in which their records and manifests were kept. The office in which the longer-term warehouse records were kept survived the fire intact; the office in which the transit shed manifests were kept, although eventually destroyed by the fire, was accessible until approximately 1530 hrs. The understandably shocked employees, being interviewed in the Control Unit at the site entrance some 45 m away from the nearest point of the burning building (Unit 1), could not be aware of the conditions in the transit shed (Unit 5), where both offices were located. They were not asked where the records were. Laporte Chemicals Limited were not contacted for advice.

126 The chemicals to which firemen were potentially exposed during the firefighting operations on the Friday were limited mainly to those owned by Laporte, which were stored near the north eastern entrance to the transit shed. Other recognisable chemicals in various parts of the building, such as small tins of weak formaldehyde solution, water treatment chemicals and household bleach, were all in areas so heavily involved in the fire that firemen were unlikely to get close enough to be contaminated by any spillage from ruptured containers. The Laporte chemicals, which were all stored in sacks or drums on pallets, were involved in the fire for a short time following a ‘flash- over’ towards Unit 6. Damage to the sacks and drums seemed more likely to have resulted from the impact of water jets and firemen’s urgency in removing labels for the purposes of identifying the contents to the Control Unit. The torn sacks and ruptured drums spilled some of their contents, which contaminated water from the fire hoses as it built up nearby. On the advice of the EHOs the area was bunded, by using first a charged hose and later sand.

127 The presence of the Laporte chemicals, and the difficulty in quantifying any risk associated with the drums of anthraquinone disulphonic acid salts, increased apprehension — later shown to be unfounded — about the possibility of firemen being exposed to further unknown risks. There were adequate supplies of chemical protection suits at the fire ground, but these were not used, despite apprehension about the presence of chemicals and information supplied to the Control Unit at 1746 hrs that complete protective suits were needed in connection with “disulphate salt”.

128 The known cases of immediate contact with stored chemicals are confined to one or two firemen who removed labels from packages, so it may be supposed that subsequently reported ill health among firemen arose from exposure to atmospheric contamination resulting from the products of combustion, rather than from physical contact with chemicals in the warehouse. While the full scientific appraisal of the likely contents of the gases and their inter-reaction in the heat of the fire could take many months, the gases likely to be produced from the combustion of individual materials at varying rates and temperatures can be forecast: smoke and fumes evolved in various parts of the building could contain cyanides, isocyanates and carbon monoxide (from polyurethane foam-filled furniture), hydrochloric acid (from PVC materials), sulphur dioxide (from, among others, the bituminous content of the roof sheet coating) and nitrous fumes resulting from the general fire. It reinforces the view offered by EHOs on site that there was likely to be a “cocktail” of toxic gases given off; this would be the case in almost any serious fire, irrespective of whether chemicals were involved. The cocktail on this occasion was probably little different from the contents of smoke plumes given off from other serious fires.

129 Experience of warehouse fires in recent years has indicated the need for information about potentially hazardous contents and their disposition to be available to the emergency services. The recent CPL Regulations now enable warehouse operators to assess the hazards from materials they store and to manage their undertakings accordingly. The Health and Safety Commission has now made proposals for regulations to require sites to be marked indicating the presence or possible presence of dangerous substances and to ensure that relevant information is passed on to fire services. However, it will still be for fire services to ensure that any site hazard warning or information provided by HSE is supplemented by information obtained during their own inspections and kept readily available for use.

130 Decontamination Procedures In fire service parlance decontamination means a full-scale hosing down (usually with the fireman being treated continuing to wear the BA in which he has been working when he became contaminated), followed by a complete change of clothing. This standard decontamination may be carried out in a tent-like structure and lagoon constructed on the fire ground or in a special-purpose mobile unit, brought to the site. Full-scale decontamination can take between 15 and 20 minutes per man.

131 Uncertainty arose on the fire ground about risks from contaminants to which firemen might be exposed. While the presence of the Laporte Chemicals was known very soon after the first appliances arrived at the site, the major concern centred on the asbestos material contained in the bituminised felt particles which were falling away. It had also been recognised that the structural steelwork in the warehouse section of the building was protected by Limpet sprayed asbestos, parts of which were being disturbed, with the risk of fibre release. After consultations had taken place on site between the Chief Fire Officer and the EHOs because of possible contamination with asbestos, instructions were issued that firemen leaving the site should remove fire jackets, turn them Inside out and bag them for “special” cleaning: “wet-legs” (waterproof over-trousers) and boots should be hosed down before the firemen left the site. Since some crews had already returned to their stations, the Chief Fire Officer sent a message from the Control Unit at 1734 hrs to inform Stations 13, 23 and 24 that all personnel who had been at the incident should have their uniforms cleaned before further use. Normally, uniforms would simply be hung up to dry and only sent for cleaning when soiled: routine arrangements for this cleaning, which was different from the special cleaning required for asbestos-contaminated garments, had been made with commercial cleaners.

132 A further message was sent by the Chief Fire Officer at 1736 hrs ordering the despatch to the fire ground of one pump and the Decontamination Unit. Although this Unit arrived at 1805 hrs and remained at the site entrance for a period, it was not taken into use since full-scale decontamination was not considered to be necessary.

133 Most, but not all, of the firemen had their wetlegs and boots hosed down before they left the site. It appears that individual crews made their own arrangements for this to be done until about 1930 hrs when a decontamination area, including arrangements for collecting jackets, was set up near the main gate.

134 The instruction that jackets should be sent for special cleaning was not satisfactorily communicated: the message intending to repeat the site instruction did not make it clear that special rather than normal cleaning was required nor was it sent to all stations to which firemen may have returned without having been given the instruction on the fire ground.

Breathing apparatus

135 In the weeks following the Brightside Lane fire considerable publicity was given to the FBU’s allegations that the ill health of firemen who had attended the fire ground was directly attributable to the failure of the South Yorkshire County Fire Service either to provide and maintain adequate BA or to allow its members to use it when necessary. In investigating the firefighting operation, therefore, HSE inspectors paid particular attention to this aspect of the employer’s responsibility for the health and safety of employees.

136 Provision The South Yorkshire County Fire Service sets one of the highest standards in the country in the provision of BA. With a total of some 1200 employees, of whom about a quarter are on duty at any one time, it carries 284 sets of BA with 263 spare cylinders. Each pumping appliance (water ladder) whether based at a station manned by a full-time crew or by retained (i.e. part-time) firemen, is equipped with five sets of BA. Of the three emergency tenders provided in the county, two carry six sets of BA and the other seven. In Divisional staff cars there are 14 further sets with a reserve of three sets at each of the five Divisional Stations. The Fire Service Training Centre at Rotherham has 16 sets which can be brought into use if necessary. Although the specialist appliances - the hydraulic platforms, turntable ladders and rescue tenders - do not carry BA, the scale of provision on appliances which are already in attendance at incidents to which the specialist appliances are called normally ensures that BA is available for all those firemen who need to use it.

137 Spare cylinders for the sets are distributed throughout the county and recharging compressors have been installed at all of the fire stations manned by whole-time crews as well as at the Training Centre. The desirability of acquiring a portable compressor to recharge cylinders on site has been given further consideration by the South Yorkshire County Fire Service since the Brightside Lane fire,

138 Use Firemen’s lives may depend on the use of BA to provide an adequate supply of clean air totally independent of the atmospheric conditions in which the firemen might have to work. Such vital equipment must be meticulously prepared and its use subject to rigorous control. The Home Office (Fire Department) has therefore provided very specific guidance to fire authorities on this subject, through the procedures described in the Manual of Firemanship (‘The Fireman’s Bible’) and by Technical Bulletins which describe in precise detail the equipment and systems to be adopted nationally. The Manual of Firemanship emphasises the importance attached to the prescribed discipline when working with BA.

“It is important that every man who is required to wear BA is not only adequately trained and thoroughly understands the ‘Procedure’ in all its aspects, but also that he faithfully and meticulously carries out the ‘Procedure’ at a fire or other incident, for on each member of the team or crew will depend the success of the operation in hand. It is not only a question of the man’s own safety, but also that of his colleagues with whom he may be working at the time or subsequently. The success of BA operations does not rest alone with those men working inside the building. It is not sufficient for men to be completely confident of their ability to work with BA in hazardous conditions; they must also have full confidence that the control and support arrangements outside the building are beyond reproach. The whole success of any BA job is teamwork, and it is incumbent on all those engaged in the operation to ensure that they are competent and fully conversant with their BA and with the ‘Procedure’ for its use.

“BA is worn at a fire or other incident only on the instructions of the officer-in-charge who may, in fact, be a leading fireman or even a fireman in charge of the first appliance to arrive. The general principle should be that BA is worn whenever its use will facilitate the location and extinction of a fire, or at any other incident when, by wearing BA, discomfort and possible injury to a fireman’s respiratory organs can be avoided.

“The decision to order BA to be worn will depend on a number of factors, such as the volume and type of smoke; whether the atmosphere is deficient of oxygen, is toxic or has a high temperature; the length of time men are likely to be exposed, or whether there is a hazard from radioactive substances. “As soon as instructions have been given for BA to be worn, the officer-in-charge must nominate a BA. Control Officer so that Stage 1 of the ‘Procedure’ can be put into operation. This is a simple act which need cause no delay as the control officer could be the pump operator who accepts the tallies from the wearers before they go in, having first made sure that the information required on the tallies, including the cylinder pressure, has been checked by the wearer when he dons his set, and is recorded on the tallies....

“If the incident is seen to be large or is likely to be protracted, Stage II of the ‘Procedure’ may be necessary before action is started. In such cases the officer-in-charge may decide to await reinforcements before committing men to work if his availability is inadequate at the time; for example, the officer-in charge may decide that communications equipment, which might not be available on the first attendance, is necessary before the men enter the premises.

“When plans of the building or hazard are available, they should be referred to as soon as possible, or if an occupant of the building who has a comprehensive knowledge of the layout of the building is present, he should be consulted. Any time devoted to consultation and study of the situation may result in a considerable saving of time and effort later.”

139 The Manual is quite explicit on the subject of evacuation of premises by firemen wearing BA: “If men wearing BA hear repeated short blasts from a whistle, they should immediately make their way out of the premises”.

140 The purpose of BA control procedures is to ensure that, once the Officer-in-Charge has decided to send a fireman wearing BA into a building, sufficient details are kept in a safe position outside the building to enable the safe use of the BA to be effectively monitored. Details of the fireman concerned, the volume and pressure of his air cylinder and the time at which the set was started have to be written on the tally, a coloured 125 mm x 38 mm plastic tag which is normally attached to the BA set when not in use. As soon as the set is taken into use the tally should be removed from the set and clipped into a Control Board on which the estimated “time of whistle” (the time at which a low pressure warning whistle is due to sound on the set) is recorded. The Control Board for Stage I entry is kept on the appliance, usually by the driver/pump operator. It is normally expected that firemen using BA will return to the BA Control before the low pressure warning whistle sounds. Should the whistle sound while the fireman is still in the building, as might happen if the work done has been particularly strenuous, he must break off and make his way back to the Control, since the air left in his cylinder will only last about a further ten minutes. If he fails to withdraw from the building at the proper time the BA Control Officer should initiate emergency measures.

141 The procedural rules require, among other things, that BA must be donned in fresh air; that men are to work in teams of at least two, with no man being left alone at work; that whenever a member of a team has to withdraw for any reason, i.e. if the withdrawal time of the team member with the shortest duration has been reached, or in the event of an accident, injury or illness affecting a team member, the whole team must withdraw; that men are not to enter a building without depositing their tallies with a BA Control Officer and on leaving they must report to the Control and collect their tallies, and that there should be a separate record for each re-entry.

142 Stage II procedure is normally initiated by the Officer-in-Charge if the situation demands more than one point of entry or where it seems likely that operations may be protracted; a Stage II Control Officer should be appointed for each entry point. All the control measures applicable to Stage I continue to apply to Stage II but with additional requirements, most significantly that at least two men should be standing by in BA for emergency all the time the Control is operating. The Stage II Control Board carries more comprehensive information, including the location of teams of BA wearers, but may be used for Stage I procedures.

143 A Main Control should also be set up when Stage II is introduced in order to coordinate arrangements for reliefs, emergency rescue and maintenance of cylinders and equipment.

144 The Manual of Firemanship also gives specific advice on the individual’s use of BA.

“Breathing apparatus must always be donned and started up in fresh air, and men standing by at a BA Control should make sure that they remain in fresh air until required. The practice of men rigging in fresh air but not putting on their face masks, or not putting in their mouth pieces, until they reach smokey atmospheres and then starting up their sets, is extremely dangerous and must not be permitted.

“Only in most exceptional circumstances should an officer or man who has already inhaled smoke, oxygen deficient or toxic fumes, subsequently rig in BA; the reason for this is that once smoke or toxic fumes are present in the lungs and respiratory passages, it takes an appreciable time for them to be completely cleared. If closed-circuit BA particularly is donned after smoke has been inhaled, the smoke will be continually circulated and will cause irritation to the respiratory system and discomfort to the wearer. If carbon monoxide or other toxic fumes have been inhaled the continual circulation could have serious consequences....

“The mouthpiece or face mask of a BA set is designed to prevent any external atmosphere from entering the respiratory system, and it is exceedingly dangerous for the mouthpiece or face mask to be removed when the wearer is in a smokey or toxic atmosphere. Once the mouthpiece or face mask is removed, smoke, carbon monoxide or other toxic gases can enter the respiratory system and the conditions described above will be created to a dangerous degree.”

145 The South Yorkshire County Fire Service in common with all other fire services has paid particular attention to training in the use of BA. It is a reasonable expectation, therefore, that all the professional firefighting employees should not only be familiar with the general principles described above but should be so schooled in the execution of the procedures that they adhere strictly to the rules as a matter of routine, regardless of the circumstances.

146 It was obvious almost from the outset that this was a fire where BA would be necessary, irrespective of chemical risks which had to be assumed, and that rapid establishment of command and allocation were essential, since in a large fire involving BA the procedures depend upon coordination of arrangements from a control point or centre in accordance with the developing needs of the fire. Communications from the control point to all parts of the fire ground are important not only for the control of fire, which is not HSE’s concern, but for ensuring that in the heat of the moment the fire fighters’ needs for protection are identified and met. Whether control and communications were adequate in this case for the effective fighting of the fire is not our business. But, as the following paragraphs show, they fell short of providing adequate protection, a matter with which we are concerned.

147 The use of BA at the fire ground can be seen as falling into three distinct phases, the first spanning the time from the attendance of the first crews at 1301 hrs to 1800 hrs on Friday 14 December when the shifts changed; the second from 1800 hrs on Friday 14 December to the shift change at 0900 hrs on Saturday 15 December, and the third period from 0900 hrs to 1800 hrs on Saturday 15 December.

148 Phase One In the initial stages of the attendance at the fire ground the use of BA was understandably ad hoc, each crew establishing their own Stage I arrangements according to their own needs. In the first 15 minutes there was little demand for BA, since conditions in Unit 1 soon made entry impossible and conditions in the other units did not require it. A Stage I Control Board was nevertheless established by the first crews on the site in the depot yard adjacent to Units 1 and 6; a Control Board was operated in this area until approximately 0630 hrs on Saturday 15 December. Similar Stage I Boards were set up by crews deployed along the Brightside Lane front of the bunding, but only for short periods, since the advance of the fire through Units 2 and 3 rapidly drove the men out of the building.

149 Once the fire was burning fiercely throughout Units 2 and 3 there was no alternative but to fight it from outside the building, through access points available within the confines of the loading bays from which jets could be directed. Video film shows clearly that, while some firemen directing jets from within one loading bay were wearing BA, the face pieces were hanging loosely in front of them. These firemen were eventually forced to withdraw from the loading bay by falling asbestos roof lining boards. Entry to the Brightside Lane side of the building was achieved later in the afternoon, without the use of BA.

150 Part-way through the afternoon a Stage I entry point was established for a short time at the south west end of Unit 5 and at least two entries were made by one crew at this point. BA was used intermittently during the course of the afternoon, but at the discretion of the officers in charge of the individual areas despite the arrival of the Control Unit, from which an officer should have been designated to take overall command of the use of BA as a Main Control.

151 The greatest demand for the use of BA was in the depot yard adjacent to Units 1 and 6 where conditions deteriorated very quickly as a vortex in the lee of the building forced smoke from the escaping plume downwards to ground level. Where operational procedures were followed they were restricted to Stage I level throughout the afternoon.

152 We note that there were extensive departures from the established procedures for ensuring the safety of those wearing BA. While some minor variations from procedures might have been understandable in the circumstances, the number and nature of the departures noted must be regarded as serious. These included failure to establish and maintain proper direction and control to ensure that BA was used whenever necessary, that firemen wearing BA actually used it, and that the relevant control system was operated, in such a way that the location of BA teams was known and could be controlled. Stage I procedures continued to be applied after the time when it would have been appropriate to initiate Stage II. The location of all BA control points had not been properly planned and at least one became smoke logged to the extent that the Control Officer himself had to wear BA. No proper arrangements were made for relief nor for emergency rescue; nor were the arrangements for BA maintenance and cylinder filling adequate - some depleted and used equipment was replaced on pumping appliances after use or even left inside the building.

153 Phase Two At 1830 hrs the Stage I Control Board in the depot yard was taken over by the new watch who continued to work from this point under Stage I entry conditions for most of the night.

154 At approximately 1900 hrs the Chief Fire Officer briefed newly-arrived officers about the plan of attack which included a progressive entry into the building using BA. However some officers who had arrived early missed this briefing. Stage II was introduced and BA Main Control established at approximately 2000 hrs on the Brightside Lane side of the building, in the charge of a Station Officer who was coordinating three Stage II control points - one at the Brightside Lane side of Unit 3, one at the south west (Sheffield) end of Unit 5 and one on the north west elevation (the railway side) of Unit 5. The Stage I Control Board in the depot yard at the north eastern end of the transit shed remained in use throughout this phase.

155 The BA Main Control exercised effective procedural control over the three Stage II entry points known to the Main Control Officer until the Main Control was closed down at 0100 hrs on Saturday 15 December. The Stage II entry point at the south western end of Unit 5 closed down at approximately 2245 hrs on Friday night. After the BA Main Control had closed down, BA entry was still being made to Unit 5 from the depot yard at the north eastern end and recommenced at the south west (Sheffield) end. Both entry points were being used under Stage I procedure. The south west entry point was in operation until approximately 0415 hrs and the north eastern entry point until approximately 0630 hrs.

156 We also note that serious departures from set procedures continued during this phase of the firefighting operations, the most important again relating to control of BA. The BA Main Control was unaware of a continuing Stage 1 entry. This entry point was in use and a further Stage I entry established after the Main Control under Stage II had been withdrawn. Senior staff appeared to be aware of this.

157 Phase Three Different operational considerations now applied. The Brigade watches had changed so that many of the crews arriving at around 0900 hrs on Saturday were seeing the site for the first time, having missed the drama in which their colleagues had participated a few' hours earlier. The fire, although not totally extinguished, had subsided, due partly to the efforts of the firefighting crews the previous night and partly to the exhaustion of its fuel. Deep-seated pockets of fire still had to be extinguished but the smouldering remains did not present any off-site problems. Firemen were able to gain access among the debris with their cooling jets and there was no longer the pressing urgency of the previous day.

158 A significant number of those who reported symptoms of ill health subsequently were among the firemen attending the site for their first time on the Saturday. There was no indication from the firemen interviewed by the HSE investigating team that BA was used during the morning. A BA Main Control with two Stage II entry points was established at approximately 1330 hrs that day.

159 Working conditions varied considerably across the site and officers in charge of individual crews had to judge whether BA should be used to avoid discomfort or possible injury. A crew in one area worked at damping down for more than one and a half hours without BA during which time they were periodically enveloped in thick smoke. The crew variously described the conditions as anything from “absolutely terrible” to uncomfortable, but we’ve been in a lot worse”. During periods of discomfort the firemen retreated to fresh air for a few minutes. All firemen involved in this incident reported symptoms of ill health in varying degrees of severity.

160 The officer in charge of this crew did not order complete withdrawal. Eventually he left the building to seek BA but failed to find any, including the two unused sets on his own appliance parked in Brightside Lane. The officer returned to his crew and continued working without BA. He did not seek help from the Control Unit.

161 All crews were withdrawn shortly after midday when a question was raised about possible storage of isocyanates. This was later disproved but during the break the Divisional Commander, the Officer-in-Charge at the time, took advantage of an offer from EHOs on site to test the atmosphere in the building. Although the tests revealed no significant hazard it was thought prudent to issue an instruction to avoid two areas in Unit 5 where drums of anthraquinone disulphonic acid salts and the fluorides were stored. It was also decided by the Divisional Commander that all further work was to be done in BA.

162 Circumstances during this period of fire ground activity illustrate the difficulty in making judgements about the need to use BA and how this may depend on the past experience and attitudes of those in charge. No urgency was attached to the work being undertaken at the time and officers could readily have withdrawn themselves and their crews if atmospheric conditions became unfavourable and BA was not available. Nothing emerged from HSE enquiries to suggest that any officer would have been criticised for withdrawing his men, a step which might have reduced the number of those eventually found to have been affected. The damping down operations continued for the remainder of Phase Three, entries being made under appropriate Stage II conditions, until BA was discontinued at 1800 hrs.

163 We further note that during the first half-day of this phase of the fire ground activity BA was not used in situations where it clearly would have been appropriate.

164 Maintenance Under normal circumstances servicing a BA set involves cleaning and sterilising the face piece and replacing the cylinder with one which is fully charged - a relatively simple and speedy operation. A supply of fully charged cylinders needs to be available. The demands on the air compressors described at paragraph 137 had never been as great as during the Brightside Lane fire. The presence of unidentified chemicals’ • on the site and the release of charred asbestos felt particles combined to give rise to a fear of contamination and this generated sufficient confusion to cause delay in servicing BA sets.

165 The Duty Officer in charge of the Control Unit should have designated an officer to be responsible for the servicing of the BA which had been widely used on the site from the outset. At about 1715 hrs, when the available sets and spare cylinders in the immediate area of the depot yard at the north east end of the building became exhausted, the Control Unit despatched a van to collect all the available BA sets on the fire ground into one place. Not until that time were arrangements put in hand to establish a servicing area in the adjacent yard. By 1830 hrs, 15 fully operational sets had been collected as well as numerous full spare cylinders and eight sets needing to be serviced. During the 1800 hrs shift change-over additional sets arrived for servicing, bringing the total to about 20. Although the servicing area was established before the shift change, the cleaning and servicing equipment was not delivered until about 1930 hrs.

166 Servicing was being carried out in the open air, although there was an underground car park nearby which would have provided protective cover against any smoke or fallout of asbestos.

167 No officer was specifically designated to coordinate and oversee the collection, servicing and distribution of the BA sets.

Medical

168 The assistance of EMAS was requested to determine whether the symptoms reported to have been experienced by firemen were due to exposure to smoke at Brightside Lane, and establish any evidence to suggest short or long-term damage to their health. The possible effect of exposure to smoke and fumes at firefighting operations after the Brightside Lane fire could not be discounted, but the duration of the major incident would certainly have predominated. EMAS was also asked to consider the medical treatment and health surveillance of firemen in the South Yorkshire County Fire Service.

169 Ill health of firemen Some delay was experienced in obtaining from the FBU a full list of affected firemen for submission to EMAS. Arrangements had immediately been put in hand by the local Employment Medical Adviser (EMA) to collect appropriate background information from consultants who had been involved in examining the 11 firemen whose names were available. In the absence of further information from the FBU, HSE requested from the Fire Service itself names of further firemen who had reported symptoms of ill-health. The responses to the resulting Fire Brigade Weekly Order produced a list of 40 names, including some of the original 11 supplied by the FBU, of men who had experienced symptoms with varying degrees of severity. Forty-one firemen were seen in the course of the EMAS investigation, which was aided by the cooperation of the Deputy Chief Medical Officer of the National Coal Board, whose local facilities and expertise were used for the clinical examinations.

170 Medical information was obtained from local consultant chest physicians who had seen firemen following referral by their general practitioners. Additional reports and records were obtained from local hospital accident and emergency departments concerning men who had attended for investigation. The Fire Service’s Medical Adviser (FSMA) had no medical records to contribute to the enquiry. A detailed occupational and medical history, including smoking habits, was obtained from each fireman, followed by a full clinical examination. An x-ray and respiratory function test were carried out on each man and his present state of health ascertained. These factors would have been influential in an individual response to exposure to smoke and fumes.

171 For the purposes of the investigation three categories were adopted to allow simplicity of reporting, although in several instances clinical details of the individual cases were more complex. The following classifications therefore give general guidance only.

Category A - symptoms and signs consistent with exposure to a complex mixture of smoke and chemical fume.

Category B - symptoms of irritation of eyes, upper respiratory tract or skin attributed to exposure to chemical mist and/or fume, but with no obvious chest symptoms.

Category C - no definite clinical evidence to link symptoms with exposure to smoke and fume.

172 The number of men seen in each category were as follows:

Category A - 27

Category B - 11

Category C - 3

173 In Category A there were symptoms and definite clinical evidence to indicate damage to the upper respiratory tract and bronchi in the majority of cases seen, although these varied in severity. Twenty four men were off sick at some stage following the fire and three had symptoms which lasted for more than four months. These three have been followed up as outpatients at the local hospital.

174 The main symptoms affecting men falling within Category B were sore throats and skin rashes which were consistent with exposure to an irritant contaminant in the atmosphere. One fireman seen had a rash on his neck some four months after the incident.

175 The medical history, clinical examination, x-rays and pulmonary function tests showed that although an immediate effect on health had been demonstrated for those in Categories A and B, there was no evidence to suggest the development of long-term chest disease. The findings were consistent with current medical literature relating to smoke inhalation and surveillance of firemen (see Bibliography).

176 Medical treatment and health surveillance of firemen. In 1970 the Home Departments issued guidance following recommendations, endorsed by the Secretary of State, made by a committee appointed to review the medical standards for fire services. No routine medical surveillance was recommended although it was proposed that each fire service should have the advice of a medical officer who understood its needs and who was known and accessible to the men. It was also recommended that all firemen currently joining the Fire Service have a pre-employment medical examination, no further medical assessment being required until they reached the age of 40 except in the case of those men applying for the heavy goods vehicle driving licence required for the Fire Service’s major firefighting appliances. From the age of 40 the firemen should be medically examined every three years.

177 Arrangements in South Yorkshire followed the Home Departments’ guidance on medical examinations. The EMA reported that basic pre-employment medical records were maintained by the FSMA but that nothing to indicate exposure to smoke or fume was shown routinely on the medical records. More significantly no radiology or spirometry was carried out on new entrants to establish base-line records.

178 While there were some severe short term effects, there were few lasting symptoms, and the South Yorkshire County Fire Service had generally followed the Home Departments’ guidance dealing with toxic hazards and the medical treatment of firemen, which recommends that firemen overcome by smoke at a fire ground should be taken as soon as possible to the nearest casualty unit; men who develop symptoms sometime after exposure to the smoke should report this to management who would consult the FSMA before issuing a card (Fire Service No FS134) to indicate the substances to which the firemen could have been exposed. The information on the card is for the guidance of general practitioners or hospital accident and emergency departments.

179 Some firemen interviewed were unaware of the procedure for issuing the information card.

180 Following the Brightside Lane incident many of the men reported to their general practitioners independently, in accordance with the normal procedure, which resulted in many men being referred to different specialists and consultants. Such a system dilutes the information available to the FSMA and can frustrate follow-up.

181 No routine periodic medical surveillance was carried out on firemen engaged in firefighting operations and no information was available in the medical records on current smoking habits or additional part-time occupations. Except for men over 40 and the HGV drivers, the FSMA only saw firemen at the specific request of management, usually following prolonged sickness absence or at the request of men seeking early retirement on health grounds. The FSMA was not available to the men except via management. There was no routine recall system for men known to have chest diseases or men known to have been exposed to high levels of smoke during firefighting operations.

182 These arrangements did not appear to satisfy the purpose of the Home Departments’ recommendation: there were no routine procedures whereby the FSMA could offer or the Fire Service request medical advice except in individual cases. The FSMA, a retired general practitioner, was currently employed on a part-time basis. In the Fire Service Headquarters he had one small room containing a filing cabinet of records, a couch and little else. He had no additional staff to help him. He was not a member of the Fire Service’s Health and Safety Committee, nor had he asked to be a member or attend any meetings to raise matters of medical concern.

183 In the course of his investigation the EMA compared the standard of medical surveillance of firemen in South Yorkshire with that advocated in the HSE Guidance Note Health Surveillance by Routine Procedures and reported that it did not accord with the recommendations in the Guidance Note in the following respects:

(a) Provision of adequate facilities, accommodation and equipment for the use of the FSMA;

(b) Frequency of medical assessments, despite periodic exposure to toxic substances;

(c) Adequacy of medical records including details of sickness absence and names of toxic substances encountered at work, and

(d) Additional use of medical tests (respiratory function tests and radiology).

184 Additionally it was suggested that consideration should be given to the recommendations below.

(a) Routinely notifying the FSMA of men exposed to significant levels of smoke and fume so that a recall system could be introduced.

(b) Introducing regular medical sessions to replace the present haphazard system.

(e) Making on call and locum arrangements to provide cover when the FSMA was unavailable.

(d) Having the FSMA attend meetings of the Health and Safety Committee when matters of medical interest were to be discussed.

(e) Arranging for firemen seen during the investigation to be followed up to identify any evidence to suggest a long term effect on health following the Brightside Lane incident. Responsibility for this follow-up and subsequent examinations should remain with the South Yorkshire County Fire Service.

185 Further guidance on these matters was available from EMAS and information on the establishment of an occupational health service and the role of an occupational physician was contained in the HSE publication, Guidelines for Occupational Health Services.

Environmental problems

Effects on members of the public

186 At about 1530 hrs the Police asked EHOs to make an assessment of the likely risk to the public and to decide whether evacuation of residents should be considered. The EHOs alerted the relevant departments within the local authority before attending a conference on the fire ground with the Police and the Chief Fire Officer at which the criteria for considering evacuation were discussed. Two EHOs then left the site to track the smoke plume and see whether it was descending. The plume was tracked as far as Parkgate and Rawmarsh in Rotherham. It was still maintaining height, and was beginning to disperse. Air monitoring was carried out, with negative results. No odour was noted. As darkness fell it became impossible to track the plume any further. The wind change forecast by the Meteorological Office did not develop until later in the night and the EHOs judged that evacuation was not necessary. As a precautionary measure air monitoring for toxic gases was carried out throughout the night to the north and east of the site, particularly in the Wincobank and Brightside areas. All results were negative. The EHOs reported that the smoke had abated considerably by 0200 hrs on Saturday 15 when mainly water vapour was coming from the site.

187 While their colleagues were tracking the smoke plume, the Sheffield EHOs remaining on site had been informed of the fallout of materials — the charred bitumen/asbestos felt from the roof sheets — downwind of the site. At about the same time their opposite numbers in Rotherham were carrying out tests on the fallout material at a school in Kimberworth, after the headmaster had reported that charred paper was falling on his school field. The Rotherham EHOs used their mobile laboratory to establish that the fallout material contained asbestos and justified immediate removal by a specialist firm. They then visited the fire ground and consulted with the Sheffield officers to coordinate their respective activities. Air sampling for asbestos was carried out off-site by the Rotherham officers while the Sheffield EHOs confined their asbestos sampling to the fire ground itself.

188 The Rotherham EHOs contacted two local radio stations to inform the public of the problem and to invite telephoned information from 0900 on the Saturday. As a result it was established that fallout had occurred over a mile wide corridor the length of the Borough of Rotherham, including the Kimberworth, Greasbrough, Rawmarsh, Swinton and Wath areas (see Figure 9).

189 Weather conditions overnight had been damp and it rained on Saturday morning. Inspection of the corridor revealed widespread contamination by material which looked like charred paper or card up to 25 cm by 15 cm in size. All the material on the ground was wet.

190 The Rotherham EHOs consulted their relevant departmental directors and a clean-up operation was initiated on the Saturday afternoon, using Local Authority employees. As a precautionary measure 37 schools in the area were closed until they had been cleared of the fallout material. It was concluded that, since the material was wet, asbestos fibres were unlikely to become airborne during the collection of the fragments and respiratory protection equipment was not necessary. In order to encourage people to treat the material with care, they were advised to wear rubber gloves when collecting the material: they were also advised to place it in plastic bags which should be sealed to await disposal.

191 The report of the Rotherham EHOs emphasises that at no time was there any danger to the public health from this incident. Their judgement was based on their Scientific Officer’s report of his analysis of the air samples and smear slides taken from several schools and on their conclusion that the fallout material, kept wet by the rain and snow falling over the weekend, could be handled safely without respiratory protection. This was supported by simple experiments carried out subsequently by HSE which recorded significant fibre release only from dry material.

192 The on-site monitoring for airborne asbestos fibres carried out by the Sheffield EHOs gave similarly reassuring results. All the samples submitted for analysis showed less than 0.01 fibres/ml, the lowest effective detection level. The Sheffield EHOs therefore concluded that residual asbestos-containing material on-site would not cause any significant off-site pollution hazard.

193 As part of a national survey of smoke and sulphur dioxide in the general atmosphere Sheffield Environmental Health Department run two sites for the Warren Spring Laboratory of the Department of Trade and Industry. Daily readings are recorded of concentrations at the two sampling points, one of which was situated just south of the path of the smoke plume. The second sampling point was a considerable distance to the north. Although some rise in sulphur dioxide concentrations was recorded at the nearer sampling point on 15 December, the result was reported to be within the normal range of variation. No rise in smoke concentrations was recorded.

194 As a precautionary measure the Sheffield EHOs alerted the Yorkshire Water Authority at the Blackburn Meadows Sewage Treatment Works and the sewerage section of the Sheffield Works Department of the possibility of toxic materials being carried to the works by the volume of water running off the Brightside Lane fire site.

195 Collection of the charred asbestos material was carried out immediately following the fire by employees of the two local authorities involved. The Sheffield EHOs estimated that some 500 kg of material was collected in their area; the Rotherham EHOs expressed their estimate as “at most a dustbin full”. It was not possible to calculate the total amount of asbestos material discharged from the site in the smoke plume since there were too many unknown factors. The research project in hand is expected to provide more detailed information about the behaviour of asbestos materials when subject to fires in buildings.

196 In view of the reports of symptoms of ill health experienced by Local Authority Officers and Police attending the site, in addition to reports of an increased level of ill health among members of the public living near the site, EMAS was asked to carry out a medical investigation, to determine whether there was any evidence of an immediate or long-term health risk to the community.

197 The EMA confirmed that current medical knowledge suggested that brief exposure to levels of asbestos fibre below 0.2 fibres/cm3 was insignificant.

198 In considering community health, the EMA took into account the wintry conditions prevailing during and after the fire. He interviewed three general practitioners practising in the Wincobank and Brightside areas of the city in an attempt to ascertain whether any patients attending surgery had been affected by the fire. In addition community medicine specialists for Sheffield and Rotherham were interviewed.

199 Two of the general practitioners stated that the numbers attending their surgeries were the same as in previous years and that there had been no noticeable increase in the number of chest complaints or skin rashes. One general practitioner, however, said that for several weeks after the fire he had seen approximately three patients additional to the normal numbers attending his surgery for several weeks after the Ere; in his opinion the symptoms of sore throats and chestiness could be attributed to exposure to smoke and fume. He also pointed out that the worst affected patients had acknowledged that they had stood and watched the firefighting operations. The community physicians stated that they had received no reports of increased numbers attending practices in the fallout area which would have suggested an adverse effect on the community’s health.

200 The EMA emphasised that the fire took place at the time of year when the number of chest complaints and sore throats was customarily high. Although it was recognised that those who already had chest diseases would be susceptible to smoke, there was nothing to suggest that this had occurred following the incident.

201 The EMA concluded that the long term health risks to the community were negligible.

202 Of the 153 police officers attending the fire over several days the EMA reported that 52 complained of symptoms — sore throat, dry skin, mouth ulcers, chesty cough, cold sores and headaches. Three were absent from duty following the fire, one for one day, one for three days and one for two weeks. It was not possible to indicate whether the men were off as a result of exposure to the smoke or whether there was an associated viral infection. All the police officers had recovered fully and were suffering no further ill effects after the fire.

203 The Local Authority Principal Building Surveyor who had attended the site had experienced an intermittent skin complaint after the incident, but the symptoms had ceased when he was seen by the EMA.

Conclusions and recommendations

Cause and origin of the fire

204 The fire started in an unattended warehouseman’s cabin inside Pickford’s furniture repository and probably arose from the use of an old fireclay panel heater. The electricity installation supplying the cabin did not satisfy the requirements of the Electricity Regulations. If Pickfords had notified HSE of their occupation of the premises an inspector would have visited before the fire. Periodic examination by management to ensure that appropriate safety standards were achieved would have identified long-standing hazards and enabled them to be dealt with.

205 We recommend NFC to ensure that its member companies are aware of current legislation applying to their occupation of its premises and make effective arrangements to monitor their performance in the light of such legislation.

Delay in detection

206 The initial outbreak of fire was undetected until it had such a hold that considerable damage and loss was inevitable. The provision of automatic fire or smoke detection equipment could have alerted staff earlier and, if linked to a fire station, could have enabled the fire fighters to deal more successfully with the fire in its initial stages.

207 We recommend those responsible for large buildings, particularly those which are unoccupied or only occupied in part or for short periods and in which a fire might remain undetected until it has a firm hold, to review the need for automatic fire detection equipment, possibly linked directly to a fire station. Advice should also be taken on the benefits of installing a sprinkler system to detect and control a fire at its origin.

Rapid spread of fire

208 This incident illustrated how easily fire, once having secured a hold, can spread in an open plan building. It demonstrated the ineffectiveness of dividing partitions which were not fire resisting and were not properly joined to or built through the external roof.

209 Clearly, the risk of fire spreading exists in other similar open plan structures. We recommend owners and occupiers of such buildings to make existing partitions effectively fire resisting and to consider constructing fire resisting divisions to reduce the risk.

210 The spread of fire was undoubtedly facilitated by the undivided air space between the fire resisting underdrawing and the roof sheeting. The key factor, however, was probably the build-up of hot gases in the roof, which would have contributed to the spread of fire by radiating heat and accelerating the combustion of material stored below. The burning rate of the roofing material, normally fairly slow at ambient temperatures, would have been similarly accelerated. Effective venting of the fire through the roof would have reduced the speed and extent of its spread through the space above the underdrawing. The provision of divisions in the roof space would also have reduced the ease with which fire spread under the roof.

211 We recommend that adequate fire vents be installed in such buildings and roof partitions be fitted where fire resisting compartmentation is not practicable. We also recommend that the test procedures in British Standard 476 for the performance of roofing and ceiling materials in fire be reviewed in the light of the evidence from the Brightside Lane fire.

212 We understand that the Building Regulations are framed to protect people rather than property, but note that some features such as speed of fire spread and access for fire services etc. must influence the risk to which firemen may be exposed when fighting fire. We have been informed that the Department of the Environment is currently carrying out a review of the Building Regulations and will soon be considering the technical content of the Regulations and supporting guidance. Accordingly, we recommend the Department of the Environment to consider in the course of their review whether further attention could be given to those matters which might affect the safety of firemen such as setting limits for the size of compartments in single storey buildings, requiring partitions to be made fire resisting or requiring the provision of fire vents in roofs, and whether guidance should be issued on these matters.

Information for fire services

213 The contents of the building contributed not only to the fire but also to the problems facing those fighting it. The hazardous materials could not be readily identified by the Fire Service. If the occupier had kept such materials suitably segregated, in a protected fire compartment, the Fire Service would have been spared the apprehension and uncertainty evident during the firefighting operation. Better information could have been available if locations of goods had been kept on a site plan. Moreover, the availability of the private water supplies for firefighting had not been regularly checked.

214 We recommend users of such buildings to ensure that they obtain appropriate information about the potential hazards associated with the materials they are storing; materials which are particularly toxic or corrosive, highly flammable or potentially explosive, should be suitably stored in a dedicated fire compartment. Arrangements should also be made for relevant information to be readily available to emergency services and for private firefighting water supplies to be regularly and competently checked by owners.

215 Information provided to the Fire Service by an occupier at the time of a fire needs to be supplemented wherever possible by information routinely collected by the periodic inspections made by the Fire Service. The information noted on the South Yorkshire County Fire Service records was nearly six years old and did not reveal the inadequacy of the water supply; this was also unknown to the occupier who had not made recent checks. The South Yorkshire County Fire Service might wish to consider whether higher priority should be given to inspection of premises for which information is substantially out of date, even if risk to life is small.

Safety of firemen

216 The investigation of the activities on the fire ground revealed features which might have affected the efficiency and effectiveness of the firefighting operations — these are not the concern of HSE; they have been brought to the notice of the Chief Fire Officer and will also be of interest to the Home Departments. However, there were features of the operations which resulted in firemen being exposed to unnecessary risk; the Manual of Firemanship is a clear statement of what is considered by the relevant authority to be reasonably practicable. The actual operation as described in paragraphs 48 to 70 fell short of the advice in the Manual, crucially, in respect of control and communications on the fire ground and, in particular, of the management of BA.

217 The fire was unique in the experience of most of the fire fighters attending the fire ground: the number of appliances, the scale and duration of the operation were greatly in excess of anything tackled previously, although it is by no means rare for a fire of such magnitude to occur nationally. Lack of experience locally of such a fire might have contributed to the identified failures to carry out designated fire ground tasks in accordance with set procedure although training and practice should have avoided such failures. It could also explain why, despite exemplary provision of equipment, there were widespread departures from established procedures for the use and maintenance of BA. We would expect the local Fire Service to learn from the experience and ensure that improvements are made. The Home Departments and particularly HM Chief Inspectors of Fire Services will wish to consider whether issues raised in this report and the lessons of this fire are applicable more widely in the Fire Services.

Health of firemen

218 Firemen might reasonably be expected to cope with some short-term exposure to smoke without undue adverse effect, but it was clear from the outset that this firefighting operation would be a long one. Consequently extra care should have been devoted to the use of breathing apparatus and the potential effects on the health of those involved. The health of the majority of the firemen examined through EMAS had been affected, in varying degrees of severity, by exposure to smoke and fume in the course of the firefighting operation. The standard of immediate treatment of firemen suffering ill health after fire ground experience generally followed the guidelines issued to fire authorities by the Home Departments: the general health surveillance also complied with the current Home Departments’ recommended standards, but not those recommended by HSE for employment generally. The FSMA was not readily accessible to firemen, nor in practice was he able to serve effectively as an adviser to the Fire Service on medical matters.

219 We suggest therefore that the Home Departments consider with EMAS how their recommendations might be brought into line with HSE guidance and whether the specific local advice from the EMA in Sheffield should be applied more generally. Meanwhile the South Yorkshire County Fire Authority and its medical adviser should together improve the effectiveness of the arrangements for providing medical advice.

Risk to the community

220 Subject to any revision resulting from the research work being undertaken, the evidence indicates that although immediate physical effects were felt for a time after the fire there was no perceived significant long-term risk to the health of the community from the asbestos fallout material or from the smoke plume.

--end--

Further information hoping to be identified and still to be located.

Known available source documents

No information identified to date and/or still to be located.

FRS Incident Report/s

No information identified to date and/or still to be located.

FBU Incident Report/s

No information identified to date and/or still to be located.

Health & Safety Executive (HSE) Incident Report/s

Health and Safety Executive (HSE). (1985). The Brightside Lane warehouse fire; a report of the investigation by the Health and Safety Executive into the effects of the fire at the National Freight Consortium warehouse building, Brightside Lane, Sheffield on 14th December 1984. [pdf] Available at; https://www.icheme.org/~/media/Documents/Subject%20Groups/Safety_Loss_Prevention/HSE%20Accident%20Reports/The%20Brightside%20Lane%20Warehouse%20Fire.pdf [Accessed on 15th August 2016].

Local Police Service or Constabulary Incident Report/s

No information identified to date and/or still to be located.

Ambulance Service Incident Report

No information identified to date and/or still to be located.

Building Research Establishment (BRE) Reports/investigations/research

No information identified to date and/or still to be located.

Coroner’s report/s and/or Rule 43 and/or Regulation 28 Notices etc.

No information identified to date and/or still to be located.

Dear Chief Officer Letters (DCOL), FRS Circulars, FRS Notices and/or Bulletins etc. and/or Related Government Correspondence

No information identified to date and/or still to be located.

Notifications from National Operational Learning User Group (NOLUG) and/or Joint Emergency Services Interoperability Principles (JESIP)

No information identified to date and/or still to be located.

Other information sources

Further information hoping to be identified and still to be located.

Service learning material

No information identified to date and/or still to be located.

Videos available

 No information identified to date and/or still to be located.

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