Incident directory

1987 - Ditchley Road

18/03/1987

Country:

  • Explosions

Severity:

Fatal

Description

Date of event

18th March 1987                 

Time of event

15:13 HRS (INITIAL CALL)

Name of premises

S. & J. Quarries Ltd.

Location

Ditchley Road, Charlbury, Oxfordshire.

Service area

Oxfordshire Fire Service (OFS) now Oxfordshire Fire and Rescue Service (OFRS).         

Nature of incident

Fire and explosion.

Property type

Single storey, detached approximately 15m x 7m with attached redundant explosives store approximately 1.7m x 1.7m opening into the main workshop area.

Premises use

Workshop for quarry.

Construction type and materials

Steel frame, with steel sheet cladding with part corrugated asbestos and PVC roof over an earth base.

Occupancy

Quarry staff.

Fire source and location of fire

Accidental ignition involving ‘hotwork’ (gas cutting equipment sparks) and combustible materials, spreading to Oxygen and Acetylene cutting equipment and the structure of the redundant explosives store.

Synopsis

Brief Synopsis

Oxfordshire Fire Service (OFS) were called to a fire at S & J Quarries, Ditchley Road on the 18th March at approximately 15:13, involving gas cylinders. 2 pumps were mobilised. The first appliance arrived at approximately 15:21 and found a fire involving a number of Oxygen and Acetylene cylinders within the rear, redundant, explosives store. A jet was immediately got to work via the front with a hose reel at the side also in use. The jet knocked down the fire and a hose reel was further used to attack the fire and cool the cylinders using the digger parked in the workshop as cover. It was observed that the gas hose, valve and gauge assembly was also burning on one of the cylinders (Karras & Hewlett, circa 1987).

At 15:30 the second appliance arrived and after transferring the pumps tank contents to the first pump, a second hose reel was got to work to cool the cylinders. After the fire had been extinguished and cooling had been carried out for a period of time the crews, including a Sub Officer (SubO) began to move the cylinders out of the explosives store and into the workshop area where they were put onto the floor. At approximately 15:40 an explosion occurred involving an Acetylene cylinder. SubO John Wixey was fatally injured and 6 other firefighters were also injured (Karras & Hewlett, circa 1987).

Photo 2

Pictures and images courtesy of Oxfordshire Fire and Rescue Service (OFRS).

 Photo 3

Layout of workshop prior to fire. Pictures and images courtesy of Oxfordshire Fire and Rescue Service (OFRS).

 Photo 4

Position of personnel and cylinders prior to explosion. Pictures and images courtesy of Oxfordshire Fire and Rescue Service (OFRS).

 Photo 5

Position of Sub O and cylinders following the explosion. Pictures and images courtesy of Oxfordshire Fire and Rescue Service (OFRS).

Photo 6

Pictures courtesy of Oxfordshire Fire and Rescue Service (OFRS).

  Photo 8

Pictures and images courtesy of Oxfordshire Fire and Rescue Service (OFRS).

 Photo 9

Pictures and images courtesy of Oxfordshire Fire and Rescue Service (OFRS).

 Photo 10

Pictures and images courtesy of Oxfordshire Fire and Rescue Service (OFRS).

 Photo 11

Pictures and images courtesy of Oxfordshire Fire and Rescue Service (OFRS).

 Photo 12

Pictures and images courtesy of Oxfordshire Fire and Rescue Service (OFRS).

 Photo 13

Pictures and images courtesy of Oxfordshire Fire and Rescue Service (OFRS).

 Photo 14

Pictures and images courtesy of Oxfordshire Fire and Rescue Service (OFRS).

 Photo 15

Pictures and images courtesy of Oxfordshire Fire and Rescue Service (OFRS).

Main findings, key lessons & areas for learning

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

Oxfordshire Fire Brigade (Now Oxfordshire Fire & Rescue Service) summary of main conclusions & recommendations

Taken from; Karras, G & Hewlett, A. (circa 1987). Incident investigation report, S. & J. Quarries Ltd, Town Quarry, Ditchley Road, Charlbury, Oxon. Oxfordshire Fire Service.

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1. CONCLUSIONS

10.1 It is considered that the cylinders were stored in an unsatisfactory manner. Oxygen and acetylene cylinders were together; there was no ventilation in the area; the store had a combustible lining and the cylinders were extremely difficult to move in the event of fire.

10.2 The use of the cutting equipment with the cylinders left in the store must be considered as bad practice. Any mishap during use which resulted in a fire was almost bound to affect all the cylinders. The coils of gas supply pipe on the floor of the store would have caused an accelerated fire and led to the cylinders being heated when the supply pipes became involved.

10.3 The operator should have turned off the gas supply at regulators as well as the at the torch when he stopped work for tea and bearing in mind he had just completed a cutting operation he should have checked the area to ensure no hot metal was in contact with any combustible materials and that the sparks from the cutting operation had not started any smouldering fire in the vicinity before leaving the building.

10.4 The initial fire fighting operation was basically correct. The fire was attacked by bringing a jet to bear onto it from outside the building and after the initial knock down of the flames the crew moved in cautiously with a hose reel jet from behind cover.

10.5 As the crew entered the building they were better able to see what was burning and the extent of the fire. Except for the involvement of the gas cylinders the fire would appear to have been of minor proportions. There were no visual signs such as blistered paint on the cylinders to indicate that they had been subjected to heat. (See App.2: Photographs of store).

10.6 It is therefore not unreasonable to suppose that the officer in charge considered that, except for the cylinder that was flaming off, there was little risk of the cylinders exploding. Indeed it is probable that in the circumstances he felt the cylinders, which did not appear to be involved, were a greater risk by being left with the cylinder that had been on fire than that created by moving them.

10.7 It was extremely difficult for the crew to remain outside the store and maintain a safe distance yet effectively cool the cylinders. The acetylene cylinders were being shielded by the wall of the store and being up against the wall meant that only one face of the cylinder was directly exposed to the application of water.

10.8 It was not readily apparent that the base of the acetylene cylinders had been subjected to considerable heating from gas burning from the supply pipes coiled on the floor impinging onto them. (See Appendix 2: photograph Nos. 8 & 9).

10.9 The confined space in the store would have made it extremely difficult to set up lashed branches to cool the cylinders to enable men to withdraw.

10.10 Bearing all these factors in mind it is believed that the option of withdrawing the fireman and leaving the cylinders to cool on their own was not considered because the officer in charge thought the cylinders were safe to move.

10.11 In the event this proved to be a mistake. However, there is no positive guidance from any authoritive source as to the lowest temperature at which a cylinder will start to decompose. Nor is there any guidance as to how long it will be before a cylinder explodes once decomposition has started, or how long a cylinder has to be subjected to heat before it becomes dangerous.

10.12 In the absence of such guidance the decision as to whether a cylinder is safe to move or not will, more often than not, be based on a Fire Officer's experience, expertise and the actual situation. Whilst all firemen are aware that compressed gas cylinders may burst if heated, not all of them fully appreciate that an acetylene cylinder can continue to self-heat after it has been removed from the fire.

10.13 In the event it is now obvious that the cylinders should have been cooled for a much longer period before being moved. Branches should have been lashed and the personnel withdrawn or at least directed the jets from behind cover, committing the minimum number of personnel into the building. However it can be postulated that had this been done and the cylinders still exploded then the force and flame front could well have been more directional (because of the robust construction of the former explosive storage area). As it was the force of the explosion dissipated because of the light cladding and structure of the main building itself.

10.14 Before any of the cylinders were moved provision should have been made for them to have been taken out of the building and immersed in water by providing a temporary dam or put into the lagoon behind the building. They should not have been left lying around on the workshop floor because this probably meant each cylinder was only cooled intermittently for a few moments at a time using only the water supply carried on the fire appliances. It must be noted that this whole report covers a short period of time and there is every reason to believe that immersion procedures would have been put in hand after the arrival of StnO 2.

10.15 When considering all the foregoing it must be borne in mind that in any fire there is an element of risk and a need to make rapid decisions during firefighting operations. In carrying out his duties of saving life and property a fireman accepts them. These are reduced by the provision of procedures and guidance but in the final analysis the fireman himself will judge if the risks are acceptable based on his own expertise and experience and the situation he faces. It would be totally against any fireman's nature and training not to get in and put the fire out. In view of this it is fair to say that most firemen would have tried to get into the building, extinguish the fire and then deal with the cylinders.

10.16 Following a previous incident in June, 1985, where an acetylene cylinder had exploded, Charlbury personnel were instructed in the procedures for dealing with cylinders involved in fire. This information is supported by a, now retired, Station Officer 4.

A letter from him giving a statement to this effect is awaited he is in Saudi Arabia.

However, the training record (TNG/17), in its current format does not specify the precise nature of training given for a particular training period but only coded headings which does not indicate in what format the training was given.

10.17 Although it cannot be determined from records who actually received the instruction, it is certain that two members of the Charlbury crew at this incident (Sub O Wixey and Fm 2) had attended the previous incident and would almost certainly have learned from their experience and had a reasonable knowledge of the procedures, as was portrayed by their early actions.

10.18 It would appear that the nearest officer to the incident was not mobilised. StnO 2 was mobilised from A.6 a distance of 11.3 miles from A.4. However, StnO 4 was in attendance at A.10, a distance of 7.3 miles from A.4.

The main reason for this mobilising error was due to control not being aware of the officers location due to incorrect radio procedures by both parties, in that, the control operator did not acknowledge the officers message due to the receipt of a fire call and the officers closed apparently without receiving an acknowledgement.

It should also be noted that once in Ditchley Road, StnO 2 required directions, from appliances in attendance, to the quarry and because of the inaccuracy of the response it caused further delay in his arrival, this is reasonable as StnO 2 was not familiar with the area, however, the local officer was aware of the location of the quarry. It is difficult to determine the actual time delay caused by these problems and impossible to say whether it would have affected the outcome of the incident.

1. RECOMMENDATIONS

11.1 Acetylene cylinders are in common use throughout industry. They can be found in most commercial or industrial premises and are on occasions encountered at incidents. However there is very little precise information as to how they will behave in a fire situation. Therefore it is very difficult to issue positive guidance to firefighters on how to deal with these cylinders bearing in mind the diverse situations likely to be experienced.

11.2 Manufacturers, distributors and technical experts in the field should be approached for as much information as possible regarding the properties of dissolved acetylene compressed in cylinders.

11.3 Where there is insufficient technical data, manufacturers, distributors etc., should be encouraged by the emergency services, and enforcing bodies such as the Health and Safety Exective to carry out a research programme to provide the information. This could well be a worthwhile project for the Home Office Scientific Research Department to take on, with an ultimate intention of reporting to the Joint Committee on Fire Brigade Operations and subsequently to the Central Fire Brigades Advisory Council.

11.4 The information gained from any research, together with existing information, should be promulgated as a Code of Practice to better advise users on the storage and use of oxygen and acetylene equipment. This code need not be unreasonable or inhibitive, but practical and with basic safety in mind.

11.5 Operations and Training note should be produced from the information currently available giving guidance as to the procedure that should be adopted at incidents involving acetylene cylinders. The procedures should be updated as further information becomes available.

11.6 Each station and watch should be given a lecture on the properties of acetylene and to reaffirm the dangers of dissolved acetylene cylinders and the procedures for dealing with them at incidents. This training should be confirmed by including the procedures in combined exercises and situation drills.

11.7 The revised training records which have been on trial, at certain stations throughout the Command for several months, and detail more specifically the type of training undertaken, should be implemented at the earliest opportunity. Supervisory Officers should be encouraged to ensure that stations undertake a balanced training syllabus to ensure that the risks they are likely to encounter in their areas, are adequately covered.

11.8 The benefits of using such equipment as the Thermal Imaging camera to try and detect if a cylinder is starting to decompose should be investigated. (See 11.3 above)

11.9 Inspecting Officers and enforcing agencies such as the Health and Safety Executive, Environmental Health Officers should be reminded of the dangers of dissolved acetylene cylinders and should ensure they are being correctly stored and used when found in any premises they inspect.

11.10 All personnel should be reminded of the use of basic, but vitally important, radio procedures particularly in the following areas.

1) Mobiles should not assume that any message has been received until it has been acknowledged by Control. If they have difficulties due to bad reception they should confirm their location by landline.

2) Control operators should acknowledge mobiles and record their location, particularly when other operators are free to accept fire calls.

3) Personnel giving directions should be precise, remembering that other mobiles responding may not be as familiar as they are with the area.

11.11 There appears to be no available statistics concerning the involvement and behaviour of acetylene cylinders in fire situations. The existing "requirement to report" the explosion of acetylene cylinders is restricted to incidents where fire is not involved. Thus the incidence of explosion in or after fire could be more frequent than the present limited information indicates. This should be rectified e.g. by the extraction of such information from FDR1 reports.

--end--

FBU summary of main findings, key lessons & recommendations

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

IFE Commentary & lessons if applicable

None produced at this time.

Known available source documents

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

FRS Incident Report/s

Karras, G & Hewlett, A. (circa 1987). Incident investigation report, S. and J. Quarries Ltd, Town Quarry, Ditchley Road, Charlbury, Oxon. Oxfordshire Fire Service.

FBU Incident Report/s

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

Health & Safety Executive (HSE) Incident Report/s and/or improvement notices

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

Thames Valley Police Incident Report/s

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

South Central Ambulance Service (previously Oxfordshire 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 regulation 28 notices

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

Other information sources

Johnson, M. V. (1987). Fireman killed while on duty. Fire. (May). Page 38.

 Photo 16

Johnson, M. V. (1987). Fireman’s death brings call for research into gas cylinders. Fire. (December). Page 7.

 Photo 17

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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