Incident directory

2010 - Lepperton



New Zealand

  • Building Fires


Near miss


Date of event

13th October 2010.

Time of event

Approximately 16:29 (INITIAL CALL).

Name of premises

Chicken Shed at Cross Road.


Lepperton, New Zealand.

Service area

New Zealand Fire Service (NZFS) now Fire and Emergency New Zealand (FENZ).

Nature of incident


Property type

Single storey, agricultural premises measuring approximately 100 m x 18 m.

Premises use

Agricultural and commercial chicken shed.

Construction type and materials

Steel (reinforced steel joist) frame with external cladding of painted corrugated iron sheets, with lining of fibreglass panels along the walls and ceiling with a fibre type insulation between them and outside panels. Floor covered with approximately 200 mm of dry wood shavings.


Approximately 20,000 chickens.

Fire source and location of fire

Accidental believed to be started involving a heater and wood shavings.


Brief Synopsis

The New Zealand Fire Service were called to a fire at an agricultural commercial chicken shed at Cross Road, Lepperton on the 13th October 2010 at 16:29. There was a ‘brisk south west wind blowing’ (Kinsella and Maunder 2010). ‘The building was used to house chickens that are raised from chicks to adult birds in approximately six weeks. The building would normally contain 20,000 birds and is insulated and heated to about 33° Celsius’ (Kinsella and Maunder 2010).

‘The fire was initially discovered by contractors who attempted to extinguish the fire using foam and dry powder extinguishers’.

On arrival crews encountered a series of small spot fires within the wood shavings. At 16:45 a ‘make pumps 3’ message was sent. A team of 2 breathing apparatus (BA) wearers was committed with a low pressure delivery supply (1 jet consisting of 2 x 70mm and 1 x 45mm length) and water available from the fire appliance tank supply. This attack continued until the tank was emptied and crews were withdrawn. The second appliance crew to arrive tried to get water from a nearby 30,000 litre tank but were unsuccessful and therefor augmented the first appliances tank with their own tanks supply. After this the second appliance relocated to a swimming pool (Kinsella and Maunder 2010).

‘Fire fighting operations continued on the premise that the incident involved a small series of fires in the wood shavings and that the fires were just about out’. ‘The incident management team did not review tactics even though information coming back from fire crews was indicating the fire was growing in intensity, with increased smoke volumes and colour changes, as well as a significant heat build-up’. (Kinsella and Maunder 2010).

At 16:50 a second alarm was transmitted.

Fire fighting operations continued intermittently as additional appliances arrived and fed their tank supplies to Waitara 471. A secure water supply was established by means of a 200 metre long feeder line with intermediate pumps (INGL647) and a base pump WAIT477 supplying water from a swimming pool to the south of building two. (Kinsella and Maunder 2010).

A second BA team of 2 was committed and made entry with a low pressure delivery supply (jet) about half way up the Western side of the building. This crew were subsequently relieved by another BA team of 2 crew from New Plymouth 614. While attempting to extinguish the main seat of the fire the crew found their water supply had been shut down. ‘Within 5-10 seconds this crew was engulfed by a roll over and smoke gas explosion which forced them to evacuate via a door some 40 metres from their entry point’. ‘Both crew members suffered serious burns to their backsides and backs as well as hands and arms. The crews were treated on site until ambulances removed them to hospital’. (Kinsella and Maunder 2010).

Water supplies to the fire ground pump via the feeder line were in place and secure at the time of entry and the only possible options to explain the loss of water on the delivery are:

1. The wrong delivery valve was shut down (two deliveries were in place from WAIT471 and only one was in use).

2. It was thought that the crew from Inglewood had exited and that the delivery was no longer required.

3. There were two different people operating the fire ground pump (Waitara 471) at times and this may have led to confusion and a subsequent communication breakdown. (Kinsella and Maunder 2010).

Further assistance messages were sent.

The fire was extinguished using defensive tactics and handed back to the owners at approximately 16:55 on the 15th October 2010. 65 fire fighters and 19 appliances and support vehicles had been involved in this incident which lasted over 48 hours (Kinsella and Maunder 2010).

Photo 1

Courtesy of Fire and Emergency New Zealand (FENZ) from Kinsella, O. & Maunder, J. (2010).

Photo 2

Courtesy of Fire and Emergency New Zealand (FENZ) from Kinsella, O. & Maunder, J. (2010).

Photo 3

Courtesy of Fire and Emergency New Zealand (FENZ) from Kinsella, O. & Maunder, J. (2010).

Photo 4

Courtesy of Fire and Emergency New Zealand (FENZ) from Kinsella, O. & Maunder, J. (2010).

Photo 5

Courtesy of Fire and Emergency New Zealand (FENZ) from Kinsella, O. & Maunder, J. (2010).

Photo 6

Incident at approximately 17:31. Courtesy of Fire and Emergency New Zealand (FENZ) from Kinsella, O. & Maunder, J. (2010).

Photo 7

Incident at approximately 17:48. Courtesy of Fire and Emergency New Zealand (FENZ) from Kinsella, O. & Maunder, J. (2010).

Photo 8

Image screen shot from command unit video camera footage. Courtesy of Fire and Emergency New Zealand (FENZ).

Photo 9

Image screen shot from command unit video camera footage. Courtesy of Fire and Emergency New Zealand (FENZ).

Photo 10

Courtesy of Fire and Emergency New Zealand (FENZ) from Kinsella, O. & Maunder, J. (2010).

Photo 11

Courtesy of Fire and Emergency New Zealand (FENZ) from Kinsella, O. & Maunder, J. (2010).

Photo 12

Courtesy of Fire and Emergency New Zealand (FENZ) from Kinsella, O. & Maunder, J. (2010).

Photo 13

Courtesy of Fire and Emergency New Zealand (FENZ) from Kinsella, O. & Maunder, J. (2010).

Photo 14

Courtesy of Fire and Emergency New Zealand (FENZ) from Kinsella, O. & Maunder, J. (2010).

Main findings, key lessons & areas for learning

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

Fire and Emergency New Zealand (FENZ) summary of main findings, conclusions, key lessons & recommendations

Taken from; Kinsella, O. & Maunder, J. (2010) Operational review F0797555 Lepperton 13th October 2010. [pdf]. New Zealand Fire Service.


Key Findings

1.  The fire extinguishers (Foam and Dry Powder) available to the contractors who made the initial fire attack were inappropriate for the situation and environment that is in place at this location. Whilst they are appropriate for the "Class of fire" they were not appropriate for the loosely packed aerated wood shavings on the floor of the building. The operation of Dry Powder extinguishers may have contributed to the spread of fire. A hose reel would have provided a more appropriate solution, with a CO2 extinguisher for any electrical threats.
2.  The fire was considered by the Incident Commander to be a small fire or series of fires that could be contained with little difficulty. However, at no time during the incident was it recognised that the fire had spread throughout the building by the circulating fans, and spot fires were burning beneath the wood shavings.
3.  Crew OIC's and the Incident Controller did not re-assess the situation and subsequently were unaware of the spread and extent of the fire
4.  The fires had been burning for 45 minutes contributing to a gradual build-up of heat and flammable gases within the structure. This contributed to a significant change in the fire environment and led to a hazardous compartment fire scenario developing.
5. Crews from Waitara and Inglewood appliances were exposed to unnecessary heat and prolonged operations due to being unable to complete extinguishing operations as the water supply was erratic and inadequate.
6.  Portable pumps could not be used to pump water from the tanks adjacent to the building due to the conical shape of the tank tops. If appropriate couplings had been fitted to the tanks a readily accessible water supply could have been utilised.
7.  The decision not to open the doors at the southern end of the building was appropriate in the initial stages as this prevented the escalation of the fire.
8.  Aggressive internal fire fighting requires a robust water supply to ensure the safety of crews working within the structure.
9.  Injured crew members lost water supplies at a critical time. Had an effective water supply been sustained, they may have been able suppress the main seat of the fire, or at a minimum, provided themselves with some protection to reduce exposure to heat and flame and support a safe withdrawal.
10.  The parking of fire appliances directly outside the doors of the structure involved in fire did not take into consideration the potential for fire growth.
11.  While ventilation of structures involved in fire initially adds to the intensity, more consideration should be given to ventilating to reduce the exposure of crews to very hazardous conditions. The decision not to open the southern double doors was tactically sound in the initial stages of the fire. Had a dynamic risk assessment approach been implemented the signs of a developing fire at the southern end would have become more apparent. The opening of these doors to ventilate should have been considered as this would have provided a safer work environment.
12.  Use of Thermal Imaging Camera (TIC) when operating a delivery. Consideration should be given to having a third person attached to the crew when using a TIC with a Low Pressure Delivery due to difficulties encountered when manoeuvring/operating low pressure deliveries.
13.  Had Fire Behaviour Training been completed, this may have minimised the Hazard to personal.


The findings of two other reports are attached as Appendices.

These are:

A Fire Investigation report completed by FSO Matt Crabtree, which indicated that the cause of the initial fire was due to the close proximity of the number three heater to the flammable wood shavings that covered the floor of the chicken shed and that subsequent fire spread and escalation led to the destruction of the number two building at 75 Cross Rd, Lepperton. This is attached as Appendix 4.

A Level 2 Accident Investigation report compiled by SSO Craig Gardiner. This is attached as Appendix 5.

Mobilisation and Notifications

All Comcen mobilisations and notifications were as per expected protocols.

Ambulance were notified on transmission of second Alarm as per standard procedure. Ambulance did not respond and self cancelled the event at 1741hrs.

Following the fire fighter injuries an assistance message was transmitted and a further Status Two message was transmitted two minutes later at 1744hrs. Ambulance responded two ambulances and an Officer to the scene.

Ambulance staff arrived on scene at 1804hrs (ambulance manager) and 1807hrs (Inglewood ambulance), 20/23 minutes respectively after the request was transmitted.

Injured staff were transported to hospital.

Details of all mobilisation, notifications and messages are attached in Appendix 1.

Command and Control

Initial Incident Controller was the SSO/OIC of Waitara 471. Command changed with the arrival of Waitara 477 and the Waitara CFO, who then became the Incident Controller. He remained Incident Controller until relieved by the AAM following the transmission of the fourth alarm at 1742hrs.

On the arrival the OIC of New Plymouth 614 placed his crew under the supervision of the Incident Controller, he then went to supervise the repositioning of New Plymouth 614 to the southern end of building one.

No incident action plan was evident. The fire was thought to be a small series of spot fires in wood shavings, this was understandable. However, as the incident developed and the conditions changed i.e. Increased temperatures, increasing smoke volumes and colour, as well as feedback from crews, no reassessment of strategic and tactical options was considered.

A major factor affecting the outcome at Lepperton was the failure of the IMT to apply the principles of Dynamic risk assessment. i.e. : Risk = Likelihood X Consequence.

Risk assessment is defined as ; Risk Assessment is a process in which hazards are identified and judgments are made as to whether the risks are high or low, acceptable or unacceptable."

"Dynamic risk assessment is where these judgments are continuously reassessed to take into account any changes in the situation :

This reassessment did not take place at the Lepperton incident and as such tactics remained the same even though the situation had changed significantly over the duration (60 minutes) of the incident.

Had this type of assessment been carried out, the decision to enter the crews may have not been made and alternative tactic could have been considered, an example being the possible redirection of the fire attack to the southern end where the main part of the fire was actually located, with an external attack through the large double doors.

Applying a dynamic risk assessment to this incident may well have minimised the hazard to the extent where the accident may not have occurred.

Incident ground (IGC) radio protocols are not in place, both FF had ICG radios and had an evacuation call or an "All Out" call been made, they may have been able act on the radio call rather than have to rely on hearing the siren form the outside. (Both made comment that they did not hear the siren until their exit from the building)

The current situation within the NZFs is that, there is not a national set of protocols for use with IGC radios, and subsequently no real distress process or "mayday" capability.

Across the NZFs its now fairly common for the majority of operational firefighters to have access too, or be in a team where one of the FF's is equipped with an IGC radio.

New firefighting PPE provides excellent protection from the hazards of heat and flame, but insulates the firefighter within flash hoods and helmets, all of which reduce the FF's ability to hear faint or distant sounds.

Effective IGC with appropriate equipment and a set of national protocols would provide an effective level of communications, with recognisable distress and emergency signals/words that would enable instant recognition and action upon receiving such a call.

International practice uses specific calls for distress, such as "mayday' to indicate a life threat etc.

International research indicates that one of the major causes of " Traumatic Firefighter Life Losses" is "inadequate communication". (

Crew Supervision

Internal fire fighting operations were under the supervision the OIC Waitara 471, who made entry into the building with crews wearing Level 2 protective clothing and Breathing Apparatus.

Breathing Apparatus Entry Control (ECO) was established at the staging point (north end building three) and was operating effectively.

The incident management structure consisted of OIC Fire (CFO Waitara), Operations Commander (OIC - Waitara 471) also performed the role of Sector Commander internal fire fighting operations, Safety Officer OIC Inglewood 641.

Supervision at the Lepperton incident was provided at a number of levels.

IC (Incident Commander/Controller) CFO Waitara overall command and responsibility

OPs commander: SSO Waitara 471 operational supervision of crews operating in active sectors.

Crew Commander: acting SO New Plymouth 614, responsible for direct supervision of his crew or ensuring that when handed over to another that this supervision would continue.


On arrival NEWP 614 SO gave control of his crew to the CFO/SSO of Waitara and then left to supervise the positioning and tasking of his appliance.

The crews were tasked by CFO/SSO to conduct interior firefighting operations via the main entry at the northern end of the building. The SSO went in with them a couple of times to assess the situation and it must be assumed to provide direct supervision. (This would be appropriate given that the Waitara CFO was outside and providing overall command and control.

When the crews (NEWP 614) relocated to the western entry portal, they spoke with the AAM who had just arrived and with CFO Waitara about making entry via the western portal. The SSO (OPS Cmdr) went with them and observed them making entry, he did not enter with them and subsequently returned to the northern entry point.

Shortly after entry the water was cut off and they had to exit after the delayed flashover or roll over.

IGC radio traffic records the Ops Cmdr (SSO Waitara) advising the AAM of injured FF and subsequently the actions taken to treat them.

The supervision levels would be considered normal at an incident of this size, the operational firefighters were of a rank and experience that meant that this crew would have an expectation that they were capable of making informed decisions in regard to their actions on entry or withdrawal.

The Operations Commander was providing consistent supervision , in that he was monitoring them regularly by making entry to check out their progress.

It appears that the assessment when they entered, was that it was within operating parameters even though the exiting crew had indicated an increase in heat. The SSO did not prevent then from entering and was at the entry point when they entered.

The SSO was one of the first on the scene upon the NEWP 614 exit.. not known whether or not he was near the entry portal after the escalation, but possibly should have been to aid the exit of the NEWP614 crew .

The IC (CFO Waitara) continued with incident command but was relieved of this upon fire escalation and the injuries to NEWP614 crew.


The BA Cylinder protective bag ignited and melted during exposure to heat and flame during the egress of New Plymouth 614 crew.

All other equipment performed to expectations and no failures were reported.

PPE Refer Level 2 report

First Aid Refer Level 2 report


Compartment Fire Behaviour Training (CFBT) has been implemented into the NZFS and is due to be implemented in Taranaki in early 2011. The extent of the delivery of this training is unknown

The report findings showed that often FF's were not aware enough of the behaviour and signs of fire leading up to flash over, nor were they aware of the risks associated with smoke explosions and other incipient signs of fire behaviour.

The incident in Lepperton was one where the change in fire behaviour should have resulted in a change in tactics. Continuing of operations without reviewing tactics was is a major contributing factor to the injuries received by the two New Plymouth Firefighters.

Had the IMT and the FF's involved had CFBT training they would have been in a far better situation to be able to assess the risk, observe the changes in Fire Behaviour and possibly make different tactical decisions based on this knowledge.

Refer OSM status Appendix 6

Operational Procedures/Policy

The following documents and Policies were considered relevant to investigations into this incident:

OI - RD1 - operational safety
OI - E6-2a - Multi-gas detectors
OI - G6 - Ventilation
OI - E3-2 - Breathing Apparatus
OS5 TRP/R - Operational Skills Maintenance (OSM)
M1 SOP - Command and Control - Procedure
M1 POP - Command and Control - Policy
M1 TM - Command and Control - Technical manual
M2 - Mobilisation
Safe person concept - Career/Volunteer Recruit module (Version 2, June 2010)
Training note - Thermal Imaging Cameras (TIC2)
Training note - Pump operation - B-Type
Training note - Pump operation - Water relay
Training note - Pump operation - Instructors manual
Health and Safety Manual, section three (Hazard management and control)
Standard - AS/NZS 4360:2004 Risk Management

Water Supplies

The inability to establish a secure water supply early on in the incident and having to rely on tank supplies being replenished by subsequent arriving appliances seriously hampered operations. A sustained fire attack could not be maintained and crews were operating intermittently as water came on and off and they were pulled out of the building until a new supply was available.

Two attempts to use B-Type ejector pumps were made into the 30,000 litre tank on the west side of building two (Fire Structure), the first attempt failed to get any water, while second did achieve a return but then overran the supply and emptied the appliance tank, and was unable to re-establish water supplies by this method.

A secure water supply was established from the swimming pool some 45 minutes from time of arrival and this supply was transferred to the fireground pump (471) via a long (200-250m) feeder working through a base pump (477) and an intermediate relay pump (647).

Additional water was also sourced from another 30,000 litre tank adjacent to building four, via a B-Type ejector after the fire had escalated.

Tankers also supplied water as per local arrangements with the Rural Fire Authority.

The water from the pool and subsequent tankers provided the main stay of water supplies for fire fighting subsequent to the escalation of the incident.

Risk Planning

The building did not meet the threshold for the development of a risk plan therefore no Risk Plan was required. 22 of 33 Operational review - F0797555 Lepperton Tuesday, 17 May 2011


1.   Fire Risk Management: Fire Risk Management Officers should be proactive in providing advice to rural property owners regarding:

  • Practicable means of accessing water supplies, e.g. tank connections.
  • Appropriate types of extinguishing medium appropriate for the risk.

2.Appliance parking: The parking of the appliance immediately outside the main northern double doors to the building, as well as directly downwind should be reviewed.

3.    Inappropriate PPE: Pump operators and other support staff who are in or are likely to be in immediate vicinity to any possible fire development are to be in Level 2 protective clothing as per the Operational Instruction N2 - National Dress Code for Uniformed Personnel.
4.    There was no formal hand over or documented/transmitted command change to the CFO of Waitara upon his arrival on the fire ground.
5.    B-Type ejector pumps: Knowledge of the operating profile, capacity and methods of get to work with B-type ejector pumps requires training and review.
6.    Research the parameters for the delivery of Fire Behaviour Training with a view to enhancing the recognition of changing fire conditions during fire development.
7.    Breathing apparatus: Compliance with the OI E3-2 Breathing Apparatus and subsequent training note; Volunteer Recruit Programme | Module 12: Breathing Apparatus (p.44-47) with reference to relief and rescue crews when Stage One or Two BA is set up.
8.    Water supplies: Effective and sustainable water supplies should be established as early as possible when committing crews to interior fire attack operations, intermittent use of tank supplies should not be used for internal fire attacks on large structures.
9.    Ventilation: Research of ventilation techniques and requirements as contained in operation instruction (G6) should be reviewed.
10.    Command and Control: The early development of an Incident Action Plan (IAP) and subsequent strategic and tactical planning needs to be developed so that operations are not reactive. Use of the Command and Control Field notebook as a guide should be encouraged.
11.  Command and Control: The appointment of an "Incident Safety Officer" (ISO) is required where 16 personnel (all agencies) are present. This number occurred at the latest, on the arrival of the third appliance, and the subsequent appointment should have been made much earlier than it was (on arrival of AAM and Command Unit). (Command & Control Technical Manual, M1 TM. 2009, sec 5.3.3)
12.   Risk assessment: Identifying the potential risks, i.e. 400m3 wood shavings within the chicken shed.
13.   Safe Person Concept: Dynamic risk assessment needs to be employed to enable Incident Management Teams (IMT) to develop dynamic tactics and to be aware of the risks and subsequent changes that these risks pose to any incident, no matter how small it my appear.
14.  Thermal Imaging Camera Procedures: Consider researching and developing procedures for the use of TICs when operating LPDs.
15.  Consideration should be given to developing a set of National IGC radio protocols and terminology for use on the incident ground, especially in the areas of emergency and distress calls.


It is recommended that the Fire Region Manager and DOT develop corrective actions where appropriate based on the Opportunities For Improvement (OFI's) identified in this report.


New Zealand Professional Firefighters Union (NZPFU) 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.

Known available source documents

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

Fire and Emergency New Zealand (FENZ) Incident Report/s

Kinsella, O. & Maunder, J. (2010) Operational review F0797555 Lepperton 13th October 2010. [pdf] . New Zealand Fire Service.

Gardiner, C. Ryburn, J. and Alding, M. (Unknown date). Level 2 investigation Lepperton fire. New Zealand Fire Service.

Crabtree, M. & Gallagher, P. (Unknown date). Fire investigation report Lepperton fire. New Zealand Fire Service.

McGill, P. (2011). National Notice x/2010 Lepperton fire, 13 Oct 2010. Findings and corrective actions. [pdf]. New Zealand Fire Service.

McGill, P. (2011). Corrective action plan task list. [pdf]. New Zealand Fire Service.

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

New Zealand Professional Firefighters Union (NZPFU) Incident Report/s

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

WorkSafe New Zealand Incident Report/s and/or improvement notices

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

New Zealand Police Incident Report/s

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

St. John’s Ambulance Service Incident Report

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

Building Research Association of New Zealand (BRANZ) Reports/investigations/research

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

Coroner’s report/s

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

New Zealand Fire Service. (2010). Footage from command unit video camera. [WMV]. Available here.

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

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